Dive Brief:
- A new lawsuit is challenging upcoming Medicaid work requirements, arguing they don’t make enough exemptions for medically frail people and would cause millions to lose health insurance.
- The lawsuit, filed Friday on behalf of five individual Medicaid enrollees and a swath of provider groups, says guidance released by the CMS would create onerous steps for beneficiaries to prove they are too frail to satisfy the 80-hour work, education or volunteer hours needed to stay enrolled in Medicaid.
- The plaintiff providers also say the guidance would force them to determine Medicaid coverage for enrollees by verifying their medical frailty status, which would be beyond the scope of the patient-provider relationship. The lawsuit seeks to stay CMS’ policy.
Dive Insight:
The One Big Beautiful Bill Act, signed into law last year, enacted billions in cuts to Medicaid and mandated the nation’s first work requirement in the safety-net insurance program. When passed, the law also offered blanket exemptions for people who were too medically frail to satisfy the work requirements, which begin in 2027.
The CMS provided more guidance to states in June on how to implement the requirements, issuing an interim final rule that sparked outcry from some corners of the industry. Physician groups, such as America’s Physician Group, said the interim final rule contained a more narrow definition of medical frailty than included in the original law, pointing out that members must now regularly meet with a provider to prove that they are too frail to work.
The latest lawsuit, filed by provider groups including the American College of Physicians and American Academy of Pediatrics plus five Medicaid enrollees whose chronic conditions they’ll have to prove to maintain coverage, challenges the interim final rule, arguing it requires medically frail people to take the additional step of proving that their chronic conditions prevent them from engaging in work requirements.
According to Jane Perkins, litigation director at the National Health Law Program, one of the law groups representing the plaintiffs, this change puts coverage — and lives — at risk.
“The statute does not require medically frail people to prove that their conditions are so debilitating that they cannot meet the work requirement,” Perkins said in a statement. “The statute exempts the medically frail from work requirements and does not authorize CMS to re-introduce it through the backdoor with the new rule.”
The lawsuit also argues that the process by which enrollees must prove medical frailty is too burdensome.
The CMS said that enrollees and states could use claims data to prove medical frailty, but those claims can be no older than 12 months, a limit intended to fully capture the enrollee's current health status.
However, the plaintiffs argued in the lawsuit that the 12-month lookback period would cut more people from the exemptions who would otherwise be eligible if states reviewed over a 24-month period.
How providers verify medical frailty is also at issue. The plaintiff provider groups argue that, under the final rule, clinicians will be responsible for determining whether a health condition would exempt individuals from the work requirements. That oversteps the typical therapeutic relationship between patients and providers, they said.
“As physicians, we are trained to diagnose and treat our patients' medical conditions, not to conduct assessments about a given patient's ability to work,” Jan K. Carney, president of ACP, said in a statement. “Forcing doctors into the position of making these assessments diverts their time away from providing needed and life-saving health care to patients.”
Similar lawsuits challenging the medical frailty exemptions have failed in court. Earlier this summer, a judge dismissed a lawsuit brought by 25 states and Washington, D.C., that also alleged the CMS used a narrower definition of medically frail.
