Ohio Medicaid Concerns Grow Amid Funding Cuts

Amanda Lynch, a mother advocating for her 24-year-old daughter who is deaf and blind and faces multiple disabilities, recently spoke against House Bill 795 before the Ohio House Medicaid Committee. This bill proposes stricter regulations for certain Medicaid providers and increases penalties for those committing Medicaid fraud. A key point in her testimony was a new requirement for specific providers to implement electronic visit verification.

The heightened focus on Medicaid fraud in Ohio seems to coincide with the program’s rapid growth, which serves over 3 million residents. However, it’s facing looming funding cuts amounting to billions. Medicaid funding comes from both federal and state sources, with recent federal contributions covering around 64% to 69% of Ohio’s Medicaid program expenditures.

Costs have surged approximately 52.9% since fiscal year 2020, jumping from $28.2 billion to an expected $43.2 billion in fiscal year 2025. During fiscal years 2024 and 2023, Medicaid spending was estimated at $38.9 billion and $36.1 billion, respectively. In the earlier pandemic year of fiscal 2021, expenditures were around $31.7 billion.

Changes to the program since 2020 have emphasized areas such as children’s behavioral health and care coordination. Some of the key initiatives include:

• OhioRISE, which provides services for children with complex behavioral health needs, offering options like intensive residential treatment.

• A revamped managed care system, set for full implementation by 2023, will adopt a more personalized approach involving a single pharmacy benefit manager.

• The updated MyCare Ohio aims to unify benefits for those eligible for both Medicaid and Medicare.

• Postpartum Medicaid coverage has been expanded from 60 days to a full year for mothers to improve health outcomes.

During the pandemic, states were required to maintain continuous enrollment for Medicaid members, ensuring care without interruptions.

Projected Losses and Provider Tax Implications

The ongoing discussions about Medicaid fraud and funding increases come on the heels of a projected $33 billion loss in funds for Ohio’s Medicaid program over the next decade. This is mainly due to the recent HR1 legislation, which alters how states fund their Medicaid programs, significantly impacting provider taxes.

Brian O’Rourke, a health policy analyst, emphasized that the state could lose substantial revenue as these taxes—levies on healthcare providers—are reduced or eliminated under new provisions. Disability advocates suggest that the current emphasis on fraud might be a strategy to identify cuts to offset funding losses.

Lynch remarked, “We’re looking for solutions to different problems,” highlighting the struggle many face for sustainable support.

Home Medical Care and Its Challenges

There’s a growing sentiment that Medicaid-funded home health assistance might be both a challenging area for potential fraud and an opportunity for cutting costs. Ohio’s Home and Community-Based Waiver System enables individuals to avoid institutional care by receiving necessary services at home.

Amy Loring McGee, director at the Health Policy Institute of Ohio, pointed out that, historically, the options were limited to nursing home care for individuals with long-term needs. Now, many prefer to stay in their homes, which can be more economical.

She explained, “Before these waivers, long-term care effectively meant nursing home placements.” To qualify for the waiver, individuals must meet residency, citizenship, and certain care level requirements. Although nursing home care is sometimes still necessary for those requiring around-the-clock support, many are choosing home-based care to manage their needs more flexibly and often at lower costs.

In fact, Ohio reportedly spends around $12,000 less per year on home care per enrollee compared to institutional care. In light of positive health outcomes and impressive cost savings, there’s been a noticeable shift: the percentage of Ohio Medicaid enrollees over 60 receiving care at home has spiked from 9% to 61% over the past three decades, showing a clear trend towards home-based support.