As Ohio targets Medicaid fraud, elderly Ohioans and those with disabilities fear losing their independence

COLUMBUS, Ohio -- Allegations that Medicaid is losing billions of dollars to fraud have sent Ohio Republicans racing to overhaul the state’s home-care system before their summer break.

But as conservatives rush forward with a sweeping reform bill, critics are questioning whether lawmakers are moving too quickly to understand how the changes could harm elderly and disabled Ohioans who depend on this kind of care to live independently.

“No member really had a chance to look at the bill,” said Rep. Jason Stephens, a Lawrence County Republican and former House speaker. “I think we need to take a lot more time to discuss this. There is no way we can get anything done that’s worthwhile.”

The 177-page rewrite of House Bill 795 was released around 10 a.m. Wednesday, hours before the House Medicaid Committee began taking testimony. And Stephens barely had time to read through it.

“That’s not a good way to legislate, in my opinion,” he said.

One of the biggest changes in HB 795 would prohibit family members from receiving Medicaid reimbursement for providing personal care services.

The bill would also tighten oversight of home care by requiring prior authorization for services, limiting approvals to 90 days and increasing penalties for providers accused of billing violations.

Other provisions would expand electronic monitoring requirements, impose new restrictions on hospice operators and classify Medicaid fraud as a form of “corrupt activity,” giving prosecutors access to additional enforcement tools.

What’s in the bill?
Amanda Lynch, whose adult daughter receives services through Medicaid, said she was on her way to Columbus when the bill became public.

“We’re prepared for a game that has changed,” Lynch told lawmakers. “We prepared for soccer, you guys are playing rugby.”

House Medicaid Committee Chair Jennifer Gross, a Butler County Republican, said lawmakers cannot continue “business as usual” while investigating claims that Medicaid may be losing billions of dollars to fraud.

Those allegations stem from reporting by the conservative news outlet The Daily Wire, which alleged immigrants and home-health providers exploited weaknesses in Ohio’s Medicaid system.

“We have a fraud, waste and abuse problem in Ohio,” Gross said. “Our goal of this committee is to find the biggest areas that we can stop the bleeding to save the services for those that are the most frail, infirm, poorest among us, and those that Ohioans desire to help.

The Ohio Department of Medicaid has opened an investigation into the allegations.

Gov. Mike DeWine’s spokesman, Dan Tierney, said some of the providers identified in the reporting are no longer active Medicaid providers and others were already under investigation before the articles were published.

Care behind closed doors
Medicaid is the nation’s largest payer of long-term care, and more than half of that spending now goes toward home- and community-based services.

About 132,000 Ohioans received home care services in 2023, a number that has remained largely unchanged for years.

The programs were created to help people remain in their communities. Federal officials began allowing states to offer the services through Medicaid waivers decades ago, provided states could show home-based care cost less than nursing homes or other institutional care.

Ohio officials say it often does.

The Health Policy Institute of Ohio estimated caring for someone at home costs about $12,000 less per year than caring for them in an institution.

DeWine has cited those savings when defending the program, saying the waiver system saves Ohio $600 million annually.

The very thing that makes home care appealing is also what makes it difficult to monitor.

Unlike a doctor’s office or hospital, much of the care takes place behind closed doors. Aides or paid family members help people bathe, dress, prepare meals and complete other daily tasks. That makes it harder for state officials to verify services were actually provided.

“It’s hard for us to control a system where it’s an unlicensed person in an unsupervised setting providing a service that’s very nebulous,” Dr. Mehmet Oz, administrator of the U.S. Centers for Medicare and Medicaid Services, said last week in Columbus. “How can you ask law enforcement to govern that? It’s not fair.”

Oz said the system needs clearer rules and stronger safeguards to ensure Medicaid dollars are being spent appropriately.

Gross and HB 795 sponsor Rep. Josh Williams, a Lucas County Republican, said the legislation is intended to provide those guardrails through things like mandatory electronic monitoring that will prove caregivers are at least inside these homes.

“We have so many problems with our EVV system as it stands right now,” said Rep. Crystal Lett, a Columbus Democrat whose son receives services through a Medicaid waiver program.

Caregivers testified that spotty cell service can make it difficult to clock in and out in rural areas, and benign timecard edits can be flagged for fraud.

If a caregiver stays past an authorized shift because a patient falls, for example, they may adjust their timesheet to avoid billing for unauthorized overtime. But with no way to explain the edit, those corrections can trigger fraud alerts and, under HB 795, subject providers to additional scrutiny.

Caregiver shortage
Across the country, demand for home health aides is soaring as the population ages. The work can be physically demanding, emotionally taxing and relatively low paying.

Nationally, the Bureau of Labor Statistics estimates home health and personal care aides earn, on average, $34,900 a year.

Ohio lawmakers approved funding increases in recent years to boost wages and stabilize the workforce, but they still earn less than nursing home workers.

“I have been seeking care for my daughter, but I cannot find it,” Lynch told lawmakers Wednesday. “I never wanted to be a paid care provider. The situation on the ground is that there aren’t paid caregivers left.”

Ohio’s Department of Medicaid doesn’t track the familial relations of its caregivers, but spokesperson Stephanie O’Grady said there are about 19,000 registered and 2,000 active “live-in” caregivers.

Disability advocates warned lawmakers that removing those people from the system before solving the workforce shortage could leave thousands of Ohioans with nowhere to turn.