The Ohio Department of Medicaid has announced that, for six months, it will freeze disenrollments from three Ohio Medicaid Waiver programs regarding people it alleges no longer meet the “level of care” required to participate in the program. Why is this important?
In Ohio, Medicaid Waiver programs allow people with serious care needs to receive care outside of an institution. For instance, a person can stay in their home instead of a group home or nursing facility. This allows people to have her needs met in the community, usually at a cost savings to the state.
The three waiver programs with the freeze in disenrollments are: 1) the Ohio Home Care Waiver, 2) the Passport Waiver, and 3) the Assisted Living Waiver. The Ohio Home Care Waivers serves individuals with physical disabilities and unstable medical conditions who are under the age of 60.1 The Passport serves people 60 and older in a community setting such as their home or a loved one’s home.2 The Assisted Living Waiver provides funding to pay for an individual age 21 or over to live in an assisted living facility.3
Many families over the past year have received shocking news that a loved one who receives care in their home or in another setting, like an apartment, is being disenrolled from the Medicaid Waiver program. Each year, to remain in the Waiver program, an individual has a new assessment. This year, across the state, families have received notices saying that their loved one no longer qualifies for the Waiver. The usual reason for this is some variation that the person no longer meets the “level of care” to be in the program. In almost all of these cases, the person’s condition has not changed. Instead, the way that the Ohio Department of Medicaid looks at these people has changed.
The consequences to the people and families can be severe. Many of these individuals have very serious medical conditions, such as being completely ventilator-dependent or conditions which could result in serious injury or death. The treating doctors are often perplexed and exasperated that their patient is facing disenrollment. Our firm has handled several of these cases on appeal with a high degree of success. However, many people have not appealed or were unsuccessful on their appeal. As a result, these families are left with the choice to either risk their loved one’s health or place their loved one into an institution away from home.
Many of the individuals who have been disenrolled from these Ohio Department of Medicaid “ODM” Waivers appear to be people who might also be served by the “DD system” – the Ohio Department of Developmental Disabilities and the county boards and provider agencies. There are also Waivers in the DD system, such as the I/O Waiver, which could meet these individuals’ needs, if available. However, someone disenrolled from the ODM Waivers does not necessarily qualify for these DD Waivers.
The exciting development is that both the Ohio Departments of Medicaid and Developmental Disabilities will work together over the next several months to find a solution. Their goal is to create a protocol for those who may be disenrolled and transferred to the DD system so that services will be uninterrupted as they transition from one Waiver to another. This is very good news for families.
What is not covered by this freeze, however, are those who have already been disenrolled and who did not appeal or lost their appeal. It is not clear that there will be a fix for these people. Also, we are seeing many cases where there is a reduction in hours of needed services, such as nursing or personal care. If there’s a disagreement, these cases will still need to be appealed.
As we learn more about the efforts at the state level, we will post an article to update the community.
Stayed tuned for more details to follow.