A federal court ruled in a memorandum and order published October 29 that a portion of a Centers for Medicare & Medicaid Services (CMS) rule is contrary to law. The decision addresses limitations placed on the definition of "medically frail" individuals under the implementation of H.R. 1.
In the decision, U.S. District Judge Richard G. Stearns found that CMS exceeded its authority by adding a requirement that individuals must demonstrate their condition significantly impairs their ability to comply with community engagement requirements to qualify as medically frail. The court ruled that the agency lacked the power to exclude any subset of individuals within the five subcategories delineated by Congress, which include individuals who are blind or disabled, have a substance use disorder, have a disabling mental disorder, have a physical, intellectual, or developmental disability that impairs daily activities, or have a serious and complex medical condition.
The court also addressed the States' challenges to a twelve-month lookback period for claims and encounter data used to verify medical frailty, as well as restrictions on self-attestations. The judge found these specific provisions were not arbitrary or capricious, as the government provided a non-frivolous rationale for their adoption. The court noted that the government's rationale for the twelve-month period was that older information might not reflect an individual's current condition.
The ruling grants the states a permanent injunction to prevent the enforcement of the unlawful definition. To allow states time to adjust their verification systems before the Congressionally mandated January 1, 2027, implementation deadline, the court issued a six-month stay of enforcement regarding any determinations of medical frailty status under H.R. 1.
The litigation involves a challenge by several states, including Massachusetts, California, New Jersey, Arizona, Colorado, Connecticut, Delaware, the District of Columbia, Hawai‘i, Illinois, Kentucky, Maine, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, and Wisconsin. The plaintiffs argue that the government violated the Administrative Procedure Act and the Spending Clause of the U.S. Constitution.
