Why Ohio Home Health Agencies Face Heightened Medicaid and Medicare Scrutiny in 2026

Introduction

Few states have seen as much home health enforcement activity in 2026 as Ohio. In the space of a few weeks in May and June, CMS imposed a nationwide moratorium on new Medicare home health and hospice enrollments, the Ohio Department of Medicaid (ODM) imposed its own Medicaid moratorium on new home health and hospice providers, Governor Mike DeWine issued an executive order allowing ODM to immediately suspend payments to high-risk providers, and ODM suspended payments to dozens of home health providers. Federal and state prosecutors announced new charges, and state legislators debated new anti-fraud legislation.

Ohio home health agencies also operate under the Medicare Review Choice Demonstration (RCD), which has applied in Ohio since 2019, and Ohio has required electronic visit verification (EVV) for home health services in Medicaid.

For legitimate agencies, this environment means more audits, more data monitoring, more revalidation, and less tolerance for documentation gaps. This article explains why Ohio agencies face heightened scrutiny, what actions federal and state agencies have taken in 2026, and what agencies can do to protect themselves. It is educational and does not replace legal or professional advice. Because these developments are changing quickly, agencies should check official sources for the latest information.

The Federal Backdrop: The 2026 Medicare Enrollment Moratorium

On May 13, 2026, CMS announced six-month nationwide moratoria on new Medicare enrollment of home health agencies and hospices. CMS stated that the moratoria cover initial enrollment applications and certain changes in majority ownership, that currently enrolled providers may continue to serve Medicare beneficiaries, and that CMS would intensify targeted investigations, use advanced data analytics, and accelerate removal of providers suspected of fraud. The home health moratorium was published in the Federal Register as Document 2026-09717 and was scheduled to run six months, through November 13, 2026, with CMS able to extend it in six-month increments by notice in the Federal Register.

CMS's announcement also listed Ohio among the states subject to heightened oversight of newly enrolled hospices and among the states in the pre-claim and postpayment review demonstration for home health claims. CMS encouraged state Medicaid programs to consider their own moratoria.

Ohio's Medicaid Enrollment Moratorium

ODM announced that, in accordance with CMS-6101-N and 42 CFR 455.470, it implemented a moratorium on the enrollment of home health and hospice providers effective May 14, 2026 through November 14, 2026. According to ODM, during this period it will not accept new Medicaid enrollment applications for:

• Hospices.

• Home health agencies, including Medicare-certified and other accredited agencies.

• Waiver individuals and organizations.

• Private duty nurses.

• Personal care aides.

• Home care attendants.

The Ohio Department of Aging informed providers that Ohio planned to pause new enrollment for six months while existing providers undergo a program integrity review, and that the state was working with CMS to revalidate high-risk providers. The Aging department's notice stated that the moratorium does not apply to assisted living providers or PACE organizations.

Agencies should watch for official announcements about whether the moratorium will end as scheduled or be extended.

Executive Order 2026-02D and Payment Suspensions

Governor DeWine announced new Medicaid fraud prevention initiatives on May 13, 2026. Among them, ODM was directed to request the statewide new provider moratorium, and the governor said he would issue an executive order allowing ODM to adopt emergency rules for more frequent revalidation of providers identified as higher risk.

The governor then issued Executive Order 2026-02D, which aligned Ohio's Medicaid payment suspension process with CMS's approach and allowed ODM to suspend payments upon determining a credible allegation of fraud. On June 4, 2026, ODM announced its first enforcement actions under the order: suspending payments to 49 high-risk Medicaid home health providers whose billing patterns raised potential fraud concerns, identified through upgraded data analytics. ODM later announced suspensions of additional newly identified high-risk providers.

Under federal Medicaid rules at 42 CFR 455.23, state Medicaid agencies must suspend payments to a provider after determining there is a credible allegation of fraud for which an investigation is pending, unless the state determines that good cause exists not to suspend or to suspend only in part. States must also refer such cases to the state's Medicaid Fraud Control Unit.

Federal and State Prosecutions

In June 2026, federal officials announced charges in Ohio fraud cases as part of the Department of Justice's 2026 National Health Care Fraud Takedown, and the Ohio Attorney General's Medicaid Fraud Control Unit announced state charges against Medicaid providers, including home health aides accused of billing for services not provided. The Ohio Attorney General has continued to announce Medicaid fraud indictments throughout 2026, many involving home health and in-home services. Federal prosecutors in Ohio have also announced convictions and sentences in home health Medicaid fraud cases in recent years.

These actions show close coordination among the U.S. Attorneys' Offices, HHS-OIG, the FBI, ODM, and the Ohio Medicaid Fraud Control Unit.

The Review Choice Demonstration in Ohio

Ohio has participated in the Medicare Home Health RCD since September 30, 2019. Ohio HHAs that bill Palmetto GBA must choose between pre-claim review and postpayment review for every billing period until they reach a 90 percent affirmation or claim approval rate, after which they may choose reduced review options. CMS extended RCD for five years effective June 1, 2024.

In the current environment, an agency's RCD performance is a visible indicator of compliance. Low affirmation rates and frequent non-affirmations may draw additional attention.

Electronic Visit Verification

Ohio was an early adopter of EVV for home health services, and state officials have noted that Ohio became the first state to implement EVV in home health care in 2018. EVV verifies visit details such as the date, time, location, provider, and service. In its 2026 initiatives, the state highlighted EVV as a tool against fraud, and ODM has phased in EVV as a requirement for payment.

EVV data can also be used by investigators to identify visits billed without matching verification, overlapping visits, or visits at implausible times or locations.

Why Ohio? Factors Behind the Scrutiny

Several factors contribute to the heightened attention:

• Growth in Medicaid home and community-based services billing and in the number of providers.

• Allegations of concentrated fraudulent billing in certain areas, which public officials and media reports have discussed, though not all allegations have been confirmed.

• Ohio's participation in federal initiatives such as RCD and the national moratorium.

• Upgraded state data analytics capable of identifying unusual billing patterns.

• Strong coordination between federal and state enforcement agencies.

• Legislative attention, including proposed anti-fraud legislation debated in the Ohio General Assembly in 2026.

What Investigators and Analysts Look For

Based on the government's public statements and common program integrity practices, Ohio home health agencies should expect scrutiny of:

• Services billed without matching EVV records.

• Overlapping visits by the same caregiver or for the same patient.

• Caregivers billing more hours than plausible in a day.

• Billing for services while patients were hospitalized, traveling, or deceased.

• Caregivers billing while working other full-time jobs.

• Sudden increases in billing or patient counts.

• New providers with unusually high billing soon after enrollment.

• Family caregiver arrangements that do not meet program rules.

• Referral patterns and patient recruitment.

• Medicare indicators such as homebound status, skilled need, OASIS scoring, and coding outliers.

• Ownership links among providers, especially providers that were suspended or terminated.

Steps Ohio Home Health Agencies Should Take Now

1. Monitor Official Sources

• Check ODM's website for moratorium updates, provider notices, and revalidation requirements.

• Monitor CMS announcements and the Federal Register for the Medicare moratorium's status.

• Review Palmetto GBA RCD updates.

• Track Ohio Department of Aging and Department of Developmental Disabilities provider memos if you serve waiver programs.

2. Prepare for Revalidation

• Confirm that enrollment information for Medicare and Medicaid is current and accurate, including ownership, managing employees, practice locations, and contact information.

• Gather required documentation ahead of any revalidation request.

• Respond to revalidation requests promptly and completely.

3. Strengthen EVV Compliance

• Make sure every Medicaid visit that requires EVV is verified.

• Investigate and correct EVV exceptions promptly, with documented reasons.

• Monitor caregiver schedules for overlaps and implausible hours.

• Train caregivers on EVV procedures.

4. Audit Medicaid Billing

• Compare billed hours with EVV records, timesheets, and care plans.

• Check for billing during hospitalizations or absences.

• Review caregiver hours and other employment.

• Review family caregiver arrangements against program rules.

5. Audit Medicare Documentation

• Focus on homebound status, face-to-face encounters, certifications and plans of care, OASIS accuracy, coding, and visit documentation.

• Track RCD affirmation or approval rates and analyze every non-affirmation and denial.

6. Review Referral Relationships

• Inventory physician arrangements, marketing practices, and relationships with facilities and community organizations.

• Make sure arrangements comply with the federal Anti-Kickback Statute, the physician self-referral law, and Ohio law.

7. Strengthen the Compliance Program

• Update policies and procedures.

• Train staff on fraud, waste, and abuse.

• Promote and monitor the compliance hotline.

• Conduct regular internal audits and track corrective actions.

• Report and return identified overpayments under federal and state rules.

8. Prepare for Payment Suspensions and Investigations

• Know who to call: identify healthcare counsel in advance.

• Have a document preservation process ready.

• Maintain cash reserves where possible.

• Understand the rebuttal process for Medicare payment suspensions and the Medicaid suspension process under 42 CFR 455.23 and Ohio rules.

9. Plan for Growth and Transactions Carefully

• Recognize that new Medicaid enrollments, new Medicare enrollments, new branches, and some ownership changes may be blocked while moratoria are in effect.

• Expect heightened screening for new enrollments after moratoria end. CMS has indicated that providers enrolling soon after the moratorium ends may face high-risk screening.

Understanding the Medicaid Payment Suspension Process

Medicaid payment suspensions differ from Medicare suspensions in several ways.

• Under 42 CFR 455.23, the state must send notice of the suspension, generally within five days of taking action unless law enforcement requests a delay, and the notice must explain the general allegations, state that the suspension is temporary, and describe the provider's right to submit written evidence and any administrative review rights under state law.

• The suspension continues until the state or prosecuting authorities determine there is insufficient evidence of fraud, or legal proceedings are completed.

• States may find good cause not to suspend or to suspend only in part, for example when a suspension would jeopardize beneficiary access or when law enforcement requests it.

• States must refer the case to the Medicaid Fraud Control Unit.

Ohio providers should review the specific notice, Ohio Administrative Code provisions, and any administrative review process the notice describes, and involve counsel immediately.

Medicaid Managed Care

Many Ohio Medicaid members receive services through managed care organizations. Agencies should expect managed care plans to:

• Conduct their own audits and reviews.

• Share information with ODM and the Medicaid Fraud Control Unit.

• Act on state suspensions and terminations.

• Require EVV and documentation consistent with state rules.

Agencies should review their managed care contracts for audit, recoupment, and reporting provisions.

Overlap Between Medicare and Medicaid Findings

Many Ohio agencies serve both Medicare and Medicaid patients. Findings in one program can lead to actions in the other:

• A Medicaid payment suspension based on credible allegations of fraud may be shared with federal partners.

• A Medicare revocation can lead to Medicaid termination, and state termination can affect Medicare enrollment.

• Investigations by the Medicaid Fraud Control Unit and federal agencies are often coordinated.

Agencies should treat compliance in both programs as one integrated responsibility.

Questions Ohio Agency Leaders Should Ask

• Do we know our EVV exception rate and the reasons behind it?

• Could we explain every caregiver's daily hours if asked?

• Are our ownership and managing employee records current in both programs?

• What is our RCD affirmation or approval rate, and what drives non-affirmations?

• Do we have any referral arrangements that would concern an investigator?

• Do we have counsel identified and a suspension response plan?

• Do we have enough cash to operate if payments were suspended for several months?

• Have we audited Medicaid and Medicare billing in the past six months?

Proposed Legislation and Policy Changes

State legislators debated anti-fraud legislation in 2026, including proposals for stronger oversight of Medicaid providers. Agencies should monitor the Ohio General Assembly and ODM rulemaking, because new requirements for enrollment, revalidation, EVV, and reporting may follow. Emergency rules authorized under the governor's initiatives, such as more frequent revalidation for higher-risk providers, may also take effect with little notice.

Patient Access Considerations

State and disability advocates have raised concerns that the Medicaid moratorium may make it harder for some Ohioans to find caregivers, particularly when an existing aide leaves. Legitimate agencies can help by maintaining staff, communicating with care coordinators, and planning carefully for transitions. Agencies should continue to follow program rules for patient choice and care continuity.

A Hypothetical Example

An Ohio agency that provides both Medicare skilled home health and Medicaid waiver services reviews its operations after the June 2026 suspensions. An internal EVV audit finds that about 3 percent of Medicaid visits were billed with manual EVV entries lacking documented reasons, and two caregivers had overlapping visits. The agency corrects billing where needed, reports and returns identified overpayments, retrains staff on EVV, and adds a weekly exception review.

On the Medicare side, the agency's RCD affirmation rate has hovered around 85 percent. An analysis shows most non-affirmations involve face-to-face documentation from two referral sources. The agency educates those practices and adds an intake check. It also updates its enrollment records, prepares documentation for possible revalidation, and engages counsel to review its medical director agreement. When ODM later sends a revalidation request, the agency responds within days.

A 30-Day Action Plan for Ohio Agencies

• Week 1: Confirm enrollment information in Medicare and Medicaid, identify counsel, and review the latest ODM and CMS notices.

• Week 2: Run an EVV exception report and a caregiver hours analysis, and correct issues.

• Week 3: Audit a sample of Medicare periods for homebound status, face-to-face documentation, certifications, OASIS, and coding, and review RCD non-affirmations.

• Week 4: Inventory referral arrangements, update compliance training, prepare a suspension response plan, and report results to leadership.

Agencies can repeat this cycle quarterly while enforcement remains intense.

Documentation Habits That Matter Most in Ohio Right Now

• Every Medicaid visit verified through EVV, with exceptions explained.

• Timesheets and care plans that match billed hours.

• Clear records of patient hospitalizations and absences.

• Complete Medicare certification, face-to-face, and plan of care documentation.

• Accurate ownership and managing employee records.

Staying Calm and Compliant

Heightened scrutiny does not mean every agency is under suspicion. Legitimate agencies that document care accurately, verify visits, and respond quickly to requests are well positioned.

Key Takeaways

• Ohio agencies face overlapping federal and state moratoria, suspensions, and investigations in 2026.

• ODM can now suspend payments quickly based on credible allegations of fraud.

• EVV data is a central tool for identifying questionable Medicaid billing.

• RCD performance remains a visible measure of Medicare compliance.

• Accurate enrollment records and quick revalidation responses matter.

• Agencies should audit both Medicaid and Medicare billing and review referral relationships.

• Every agency should have counsel identified and a suspension response plan ready.

Frequently Asked Questions

What is the Ohio Medicaid home health moratorium?

ODM announced a moratorium on new Medicaid enrollment of home health and hospice providers, including several related provider types, effective May 14 through November 14, 2026.

Does the moratorium affect existing providers?

It blocks new enrollments. Existing providers may continue to serve members, but the state has said existing providers are undergoing program integrity review and high-risk providers may be revalidated.

What is Executive Order 2026-02D?

An executive order issued by Governor DeWine that aligned Ohio's Medicaid payment suspension process with CMS's approach, allowing ODM to suspend payments based on credible allegations of fraud. ODM used it to suspend payments to 49 high-risk home health providers in June 2026.

Is the Medicare home health moratorium still in effect?

CMS's moratorium was scheduled to run through November 13, 2026, and CMS may extend it by Federal Register notice. Check CMS and the Federal Register for the current status.

What should Ohio agencies focus on first?

Accurate enrollment information, EVV compliance, Medicaid billing audits, Medicare documentation audits, referral relationship reviews, and a ready response plan for suspensions and investigations.

Conclusion

Ohio home health agencies are operating in one of the most intense enforcement environments in the country. Federal and state moratoria, immediate payment suspensions, upgraded data analytics, EVV requirements, the Review Choice Demonstration, and active prosecutions all mean that documentation gaps and billing errors are more likely to be found and acted on. Agencies that keep enrollment information accurate, verify every visit, audit Medicaid and Medicare billing, review referral relationships, strengthen their compliance programs, and prepare for revalidation and possible suspensions will be in the best position to continue serving Ohioans while demonstrating that they are legitimate, compliant providers.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps Ohio home health agencies prepare for heightened scrutiny through EVV and Medicaid billing audits, Medicare documentation and RCD support, referral relationship reviews, compliance program assessments, revalidation preparation, and suspension response support alongside legal counsel. If your Ohio agency wants to strengthen its position in 2026, please get in touch with us. We will be happy to help you with this topic.

References

• Ohio Department of Medicaid. Home Health Services and Provider Enrollment Moratorium Notice. https://medicaid.ohio.gov/FOROHIOANS/Programs/HomeHealthSrvs.aspx

• Ohio Department of Medicaid. Provider Enrollment Moratorium. https://medicaid.ohio.gov/home/odm-moratorium

• Ohio Department of Medicaid. Ohio Medicaid Initiates First Provider Suspensions Under Governor DeWine's Anti-Fraud Executive Order (June 4, 2026). https://medicaid.ohio.gov/news/press-release/ohio-medicaid-initiates-provider-suspensions

• Office of Ohio Governor Mike DeWine. Governor DeWine Announces New Medicaid Fraud Prevention Initiatives (May 13, 2026). https://governor.ohio.gov/media/news-and-media/governor-dewine-announces-new-medicaid-fraud-prevention-initiatives

• Ohio Department of Aging. Provider Memo: Important Updates to Ohio Medicaid Fraud Prevention Requirements (May 15, 2026). https://aging.ohio.gov/see-news-and-events/provider+memos/provider-memo-may-15-2026

• Ohio Attorney General. Six Medicaid Providers Facing Fraud, Theft Charges (June 23, 2026). https://ohioattorneygeneral.gov/Media/News-Releases/June-2026/Six-Medicaid-Providers-Facing-Fraud-Theft-Charges

• Centers for Medicare & Medicaid Services. CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria (May 13, 2026). https://www.cms.gov/newsroom/press-releases/cms-announces-aggressive-nationwide-crackdown-fraud-six-month-hospice-home-health-agency-enrollment

• Federal Register. Announcement of Nationwide Temporary Moratoria on Enrollment of Home Health Agencies (Document 2026-09717). https://www.federalregister.gov/d/2026-09717

• Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/review-choice-demonstration/review-choice-demonstration-for-home-health-services

• Electronic Code of Federal Regulations. 42 CFR 455.23, Suspension of Payments in Cases of Fraud. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-A/section-455.23

• Electronic Code of Federal Regulations. 42 CFR 455.470, Temporary Moratoria. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-E/section-455.470

• U.S. Attorney's Office, Southern District of Ohio. Home Health Care Companies Owner Sentenced to More Than 3 Years in Prison for $5.7 Million Medicaid Fraud. https://www.justice.gov/usao-sdoh/pr/home-health-care-companies-owner-sentenced-more-3-years-prison-57-million-medicaid

• Centers for Medicare & Medicaid Services. Electronic Visit Verification. https://www.medicaid.gov/medicaid/home-community-based-services/guidance/electronic-visit-verification-evv/index.html