Chronically ill people on Medicaid won’t be bound by new work requirement rules that the latest Trump administration guidance requires in order to qualify for “medically frail” exemptions, a federal judge ruled Thursday.

US District Judge Richard Stearns in Boston gave a partial victory to a coalition of 25 states and the District of Columbia, which sued the Trump administration in June over the Centers for Medicare and Medicaid Services guidance linked to the One Big Beautiful Bill Act. The 2025 law instituted the first-ever federal work requirement in Medicaid.

The law says the definition of medically frail must include people who are blind or disabled, have substance use disorders or disabling mental disorders, have certain disabilities that significantly impair daily activities, or have serious or complex medical conditions. But the CMS rule went further, requiring people in those categories to show that their conditions also “significantly impair” their ability to comply with the law’s work requirements.

Issued in June, the rule took many states and advocates by surprise since CMS had not indicated in its informal guidance that it would take a harder line. States, already under a tight deadline to stand up the work requirement program by January 1, have been racing to get their systems ready. The medically frail interpretation required them to make additional changes, and the judge’s ruling will now force them to shift directions again.

Advocates had worried that the CMS rule would add major paperwork burdens to patients, who could have had to provide proof that their conditions prevent them from working. Further complicating matters was that the severity of these enrollees’ medical conditions — and the impact on their ability to work — can vary over time.

The provision could also have put doctors in a tough spot, since they may have been called upon to help determine whether someone is able to work, which would affect their patients’ coverage.

The plaintiffs argued that the stricter rule would prevent eligible Americans from accessing the care they need — and overstep the text of the law itself. The judge agreed that they met the burden of irreparable harm.

“Because enforcement of an unlawful definition of ‘medically frail’ may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care, the States (and public) face potential for great hardship in the absence of an injunction,” Stearns said.

The ruling is likely to mean some people will be able to obtain or keep coverage, said Morgan Henderson, an economist who studies Medicaid at the Hilltop Institute at the University of Maryland, Baltimore County.

“Those individuals who would have lost coverage because they’re sick but they’re not quite sick enough,” he said, “they might have their coverage preserved now.”North Carolina Health and Human Services Secretary Dr. Dev Sangvai said it would also help patients avoid some stressful situations.

“One of our top priorities is to make sure people can get the critical health care they need without facing confusing paperwork or the fear of losing coverage during treatment,” he said in a statement. “This decision allows us to focus on what matters most: delivering reliable health care to our state’s most vulnerable residents when they need it most.”But Stearns did not give the states a complete victory. He upheld two other federal restrictions on how states can verify medical frailty, including the requirement that states reject proof of patients’ medical frailty if the diagnosis is more than a year old. He also upheld a policy allowing states to accept only one self-attestation per continuous period of enrollment.

Explaining why he upheld the portions in favor of the government, Stearns said “the government provided a non-frivolous rationale for adopting each provision and explained why it did not find the States’ concerns of disenrollment compelling.”CMS declined to comment.

The new Medicaid restrictions are part of Trump’s big tax and policy law in 2025. The change affects those covered through an expansion in most states that gave more lower-income people access to the government’s safety net healthcare program.

Starting January 1, expansion enrollees ages 19 to 64 must show that they work or do community service at least 80 hours a month or are in school at least half the time. There are exceptions for those considered medically frail or in addiction treatment programs, among others. Some states, including Nebraska and Montana, have already started enforcing the mandate.

Some 5.3 million more people are expected to be uninsured in 2034 because of the work requirement, according to a Congressional Budget Office estimate from last summer.