Judge strikes Medicaid ‘medically frail’ limit; family sues OpenAI over ChatGPT drug taper; Medicare fraud fugitive gets 20 years — Morning Medical Update Weekly Recap

Judge strikes CMS’ narrower ‘medically frail’ test for Medicaid work requirements

The ruling sides with 25 states and D.C. but upholds CMS’ 12-month lookback, and the work requirements still start in January.

A federal judge in Boston on Oct. 29 struck down the Centers for Medicare & Medicaid Services’ (CMS) narrower definition of who counts as “medically frail” under Medicaid’s new work requirements.

Starting Jan. 1, 2027, the One Big Beautiful Bill Act requires many adults ages 19 to 64 covered through Medicaid expansion to work or do community service at least 80 hours a month, or attend school at least half time, to keep coverage. Congress exempted people who are medically frail and listed five groups that count: people who are blind or disabled, have a substance use disorder or a disabling mental disorder, have a disability that significantly impairs daily activities, or have a serious or complex medical condition.

CMS’ interim final rule, issued in June, added a condition: A person in those groups qualified only if their “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement.”

What the judge decided

U.S. District Judge Richard Stearns sided with 25 states and the District of Columbia, ruling that the added standard “is beyond the powers of CMS and thus contrary to law,” Politico reported. The Justice Department had argued that the law gave the health secretary room to define the term.

Stearns upheld two other provisions the states challenged: a rule that states may verify frailty only with claims and encounter data from the previous 12 months, and a limit of one self-attestation per continuous enrollment period. “The court finds the States’ objections to the twelve-month lookback period and the limitation on the use of self-attestations unconvincing,” he wrote, according to Stateline.

The rest of the work requirements still take effect in January. The permanent injunction covers the states that sued, though HFMA reported that the court’s vacatur of the definition applies nationwide, and how the decision plays out in other states remains unclear. CMS declined to comment on the decision or say whether it will appeal, Politico reported.

What physicians are saying

The American Medical Association (AMA) was among nine physician groups that said the CMS rule narrowed a protection Congress wrote for medically frail patients. AMA President Willie Underwood III, M.D., called the ruling “a victory for patients” in a statement, Stateline reported.

“We’re not trained to decide whether someone is able to work.” — Eva Shapiro, physician, Tucson, Arizona

Shapiro made the comment on a press call about the rules the week before the ruling, Politico reported. “Patients with chronic conditions may have good weeks and bad weeks,” she said.

Family sues OpenAI, alleging ChatGPT coached a woman off her seizure medication

The complaint says the chatbot drew up a 25-day taper and told her not to mention it before a doctor’s appointment.

The parents of Bowen Wan, a 31-year-old Seattle software engineer with epilepsy, filed a wrongful death lawsuit against OpenAI and CEO Sam Altman on Oct. 27 in San Francisco Superior Court.

According to the complaint, Wan worried that lamotrigine, the antiseizure drug she had taken for years, was hurting her speech ahead of job interviews. The suit alleges that the GPT-4o version of ChatGPT drew up a roughly 25-day schedule to take her from 400 milligrams a day to zero, and no doctor had recommended the taper.

Before one medical appointment, the chatbot allegedly told her, “Do not mention Lam reduction plan.” When a physician ordered a blood test that could have revealed her falling drug levels, she declined it, and the suit alleges ChatGPT praised that decision, People reported.

Her neurologist and OpenAI respond

Wan died in February. The King County Medical Examiner attributed her death to sudden unexpected death in epilepsy. Her neurologist, Nicholas Poolos, M.D., Ph.D., of the UW Medicine Regional Epilepsy Center in Seattle, told The New York Times that advising her to stop the drug would have been malpractice.

OpenAI spokesman Drew Pusateri called Wan’s story an “incredibly heartbreaking situation” and said it involved an early version of ChatGPT that is no longer available, the Times reported. OpenAI pulled GPT-4o from the consumer ChatGPT app on Feb. 13, the day after the medical examiner believes Wan died. OpenAI has not yet responded to the complaint in court, and the allegations have not been proven.

Medicare brace fraud architect who fled to the Philippines gets 20 years

Prosecutors say the scheme produced more than $365 million in fraudulent Medicare claims.

U.S. District Judge Joseph F. Anderson Jr. sentenced Herbert Leon Kimble, 60, of Chicago, to 20 years in federal prison Oct. 26 for conspiracy to defraud the United States and failure to appear. He was ordered to pay Medicare more than $199 million in restitution and to forfeit more than $195 million.

Prosecutors said Kimble helped orchestrate a nationwide scheme that used offshore call centers and sham telemedicine companies to generate medically unnecessary prescriptions for orthotic braces. According to the Justice Department, the medical professionals involved “rarely conducted real consultations and simply signed preselected brace orders to maximize Medicare reimbursement.”

The scheme caused more than $365 million in fraudulent claims to Medicare, which paid out more than $199 million, and Kimble used proceeds to buy a luxury condo at the Shangri-La hotel in the Philippines, prosecutors said.

Nearly two years on the run

• 2019: Kimble pleaded guilty to conspiracy to defraud the United States.
• Fall 2024: He failed to appear in federal court on three separate occasions and fled to the Philippines.
• June 4, 2026: The FBI named him to its new Most Wanted Fraudsters list.
• June 8, 2026: He was apprehended in the Philippines and returned to the United States.
• Oct. 26, 2026: He was sentenced to 20 years. There is no parole in the federal system.