Chronically ill Medicaid recipients will not have to satisfy a stricter federal test to qualify for exemptions from new work requirements, after a judge blocked part of the Trump administration’s guidance Thursday.

US District Judge Richard Stearns in Boston granted a partial victory to 25 states and the District of Columbia. The coalition sued the Trump administration in June over Centers for Medicare and Medicaid Services guidance connected to the One Big Beautiful Bill Act.

The 2025 law created the first federal work requirement for Medicaid. It 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.

CMS went beyond that language by requiring people in those groups to show that their conditions also “significantly impair” their ability to comply with the work requirements. Stearns blocked enforcement of that stricter interpretation.

The rule was issued in June and surprised many states and advocates because CMS had not signaled the tougher interpretation in its informal guidance. States already faced a tight deadline to establish their work requirement programs by January 1.

States had been moving quickly to prepare their systems when the medically frail interpretation demanded additional changes. The judge’s decision will require those states to change direction again as they continue preparing for implementation.

Advocates warned that the stricter CMS rule could impose major paperwork burdens on patients. People might have been required to produce evidence showing that their medical conditions prevented them from working.

The severity of an enrollee’s condition, along with its effect on the person’s ability to work, can change over time. The provision also could have placed doctors in the difficult position of helping determine whether patients were able to work, potentially affecting their coverage.

The states argued that the policy would keep eligible Americans from receiving needed care and would go beyond the law’s text. Stearns agreed that the plaintiffs had demonstrated the threat 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.

Morgan Henderson, an economist who studies Medicaid at the Hilltop Institute at the University of Maryland, Baltimore County, said the ruling likely means some people will obtain or retain coverage. The decision particularly affects people whose illnesses might not have satisfied the stricter standard.

“Those individuals who would have lost coverage because they’re sick but they’re not quite sick enough,” Henderson said, “they might have their coverage preserved now.”

North Carolina Health and Human Services Secretary Dr. Dev Sangvai said the decision could spare patients from confusing and stressful circumstances. He emphasized access to care and continuity of coverage during treatment.

“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,” Sangvai 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.”

Stearns did not hand the states a complete victory. He upheld two other federal restrictions governing how states may verify that someone is medically frail.

One restriction requires states to reject evidence of medical frailty when the diagnosis is more than one year old. The judge also upheld a policy allowing states to accept only one statement from an enrollee attesting to medical frailty during each continuous enrollment period.

Explaining those decisions, 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.”

The Medicaid restrictions are part of Trump’s 2025 tax and policy law. They affect adults covered through Medicaid expansion programs in most states, which extended access to the government healthcare safety net to more people with lower incomes.

Starting January 1, expansion enrollees ages 19 through 64 must demonstrate that they work or perform community service for at least 80 hours each month, or that they attend school at least half the time. Exceptions include people considered medically frail and those participating in addiction treatment programs.

Nebraska and Montana are among the states that have already begun enforcing the mandate. A Congressional Budget Office estimate from last summer projected that the work requirement would leave an additional 5.3 million people uninsured in 2034.