Medicaid anti-fraud plan blasted by developmental disabilities community

Family members would no longer be paid to provide personal care services under the latest update to a House plan targeting fraud in the Medicaid program.

That change and several others included in a substitute version of the proposal, as well as preserved provisions from a prior substitute bill, drew 77 opponents, largely from the intellectual and developmental disabilities community, to the House Medicaid Committee Wednesday. (Comp Doc)

Some witnesses, as well as Rep. Derrick Hall, D-Akron, further criticized the speed at which the bill is moving, with Hall questioning why the General Assembly has set an “arbitrary” deadline of June 10. (Hearing transcript & video)

Several witnesses also accused legislators of relying too heavily on Daily Wire reporting that brought focus to alleged Medicaid fraud in Ohio and using home healthcare as a scapegoat to make up for the $1 trillion cut to Medicaid by the One Big Beautiful Bill Act.

Chair Rep. Jennifer Gross, R-West Chester, opened the meeting by stating that the committee understands Medicaid’s purpose is to take care of the medical needs of people with disabilities, the elderly, children and the poorest Ohioans.

“We will move forward because fraud is happening,” she said. “That doesn’t mean that we will harm the [developmental disabilities] community. We do ask that you really understand that we will not be moving forward with business as usual when we have up to $60 billion of fraud in our system.

“When we spend the money that we shouldn’t be spending for people who should not receive services, a lot of the people in this room suffer because they don’t get the services they deserve.”

The latest substitute bill, adopted along party lines:

• Specifies no payments for personal care services are provided without prior authorization, while exempting personal care services provided under a Medicaid waiver component administered by the Department of Developmental Disabilities.
• Removes a proposed $10,000 cap for reporting fraud leading to recovery while maintaining the 10% reward under certain circumstances.
• Creates escalating mandatory fines for the offense of Medicaid fraud, ranging from $1,000 to $150,000.
• Removes a proposed requirement for the state auditor to establish an independent forensic audit and compliance framework for monitoring the Medicaid program
• Allows Managed Care Organizations to implement “reasonable and timely payment integrity actions” upon the identification of credible indicators of fraud, waste or abuse.
• Establishes new requirements for hospice care programs (HB 945).
• Expands the attorney general’s authority when conducting an investigation concerning Medicaid, nursing home or other long-term care facilities.
• Removes proposed provisions related to publicly funded child care contracts.

Sponsor Rep. Josh Williams, R-Sylvania Twp., told Amanda Lynch, a paid parent provider for her 24-year-old child with deaf-blindness, that lawmakers are in conversations about excluding particular developmental disabilities conditions from the bill.

“What we’re trying to address is the direct fraud that’s been investigated and convicted in Ohio and making sure we provide for taxpayer protections and program integrity,” he said. “It is fast moving. We’re talking about further amendments.”

Lynch responded: “We’re getting caught in the blender. You may not be trying to blend us in, but you are.”

Tim McCabe told the committee about his friend Justin Martin who has cerebral palsy and has struggled to put a care team together.

“There's a dire shortage of providers,” he said. “The only fix is getting new people into the field. And now, our government has frozen that lifeline for the next six months while they figure out how to save money on it.”

Rep. Bride Rose Sweeney, D-Westlake, said she was particularly concerned about the ban on family members providing care, regardless of how much additional oversight and regulations are included in the bill for non-family caregivers. She said that provision will remove 7,000 family providers from the system and asked what that would mean for the workforce and those looking for care.

“It would swallow up even more of this pool of people who have been unavailable,” he said.

Martin then addressed the committee, telling them that one of his providers was defrauding him.

“As angry as I feel, I understand why she felt the need to violate me: she was caring for her infant grandson and aging mother,” he said. “But what baffles and confuses me is why the governor, his party, and this committee would violate me a second time. Why my state, given the choice between putting together a blue-ribbon commission of actual disabled people to make changes to Medicaid or suddenly bowing to the fever-dreams of an out-of-town YouTuber, would choose door No. 2.”

Rep. Brian Stewart, R-Ashville, asked Martin: “Shouldn’t this committee want to make sure folks can’t defraud you going forward?”

Martin said he opposed the way lawmakers have chosen to stop fraud. He said the best way to counteract fraud is to have people with disabilities enmeshed in their communities, surrounded by family and friends who will report fraud when it happens. That is not possible without home healthcare, the elimination of which would force people to become “warehoused.”

He told Rep. Rachel Baker, D-Cincinnati, that he was defrauded by someone he found through an agency, not by a family member.

“I’m not saying don’t be concerned about fraud, but recognize that these allegations are part of a decades-long history of trojan horse cuts to Medicaid,” he said.

He said his community knows “that there are nine words in the English language much scarier than ‘I’m from the government, and I’m here to help.’ Try ‘Our government’s determined that your freedom is too expensive,’ ‘You were born prematurely; you don’t deserve my life,’ or perhaps: ‘The governor’s watching YouTube: go die in a warehouse.’”

Gross told Martin that she has not yet voted on the bill, and that even though she accepted the substitute, she does not support all aspects of the bill.

Responding to Rep. Desiree Tims, D-Dayton, Martin questioned lawmakers’ claims that they must protect the taxpayers.

“As if I’m not a taxpayer. I’m trying to work. I’m OK with protecting taxpayers, but let’s start with the ones who can’t shower and dress themselves,” he said.

Georgie Elson agreed fraud should be investigated and prosecuted.

“But what we are seeing right now is not a balanced effort to protect taxpayer dollars,” she said. “We are watching what appears like a coordinated political narrative that exaggerates and misrepresents data in order to justify cuts to Medicaid [home- and community-based services] and restrictions on family providers, all while giving far less attention to larger systemic sources of waste, fraud and abuse. The people who will pay the price are disabled Ohioans.”

She also said family caregivers are not the reason Ohio is in crisis. Instead, they are the reason the system has not fully collapsed.

She told Baker that the requirements for home caregivers are “pretty consistent” with independent providers, agency providers and self-directed care, as all require training, background checks and certification, among other requirements.

Jennifer Kucera of the Ohio Olmsted Task Force, said her community relies on personal care services, and cautioned lawmakers against making changes to a complicated system that includes waivers under the departments of Medicaid, Developmental Disabilities and Aging. She noted a simple carve out for DD waivers would not suffice, as many people with developmental disabilities are on a Medicaid or Aging waiver.

“You have to take time to look at the system, and this needs more time to be looked at in a more thoughtful way,” she said.

Sweeney asked Kucera about the consequences of rushing the process.

Kucera said each system uses different language and different laws.

“Yes, I want to get rid of fraud, and yes, I want the system to work smoother, and I’d love to see that, but you have to study the system, talk to the people who know the system,” she said, adding that the three-minute time limit imposed during the hearing was not enough. “It’s not a thing you can rush through because there will be human damage.”

She also told Rep. Anita Somani, D-Dublin, that lawmakers must also not broadly eliminate all family caregivers.

“If you do that, now we need thousands more paid providers,” she said. “Where are they coming from? Because they’re not in the system now.”

Matt O’Nesti, who is on a DD waiver, also urged lawmakers to take more time to achieve what they are looking to accomplish and to work with people with disabilities and the experts who work in the systems.

“The Medicaid and waiver systems are very complex so it seems reckless to try and build an entirely new infrastructure in a couple weeks,” he said.

He said his favorite part of the bill is the three lines that focus on keeping continuity of care intact.

“The assembly’s want for continuity of care must be equal if not in more detail than the new definitions of fraud,” he said.

He also urged lawmakers to fix the electronic visit verification system before adding more burden to it.

“It will never be able to handle these strict guidelines that are being proposed which can put an innocent person in line for fraud allegations and potentially leave a person with disability without care,” he said, earning a round of applause from the audience.

Rep. Ron Ferguson, R-Wintersville, said he believed many lawmakers’ intent is to “get it right” but added, “other people’s intent should be under more question.”