Ohio Medicaid collects $87.5M from families after loved ones’ death

By Nick Blizzard / July 29, 2023

Rebecca Miller said her father was on Medicaid for about two years and she served as his caretaker at his home after he was diagnosed in 2018 with Parkinson’s disease, from which he died last August.

About 30 days later while still mourning David Miller’s passing, the 36-year-old said she received a letter from the Ohio Attorney General’s Office stating her father owed $56,000 to Medicaid Estate Recovery.

The Medicaid collection program was foreign to the Clinton County woman, as it is to the vast majority of people, attorneys said.

The state notice was a jolt, informing Miller that her father’s house — for which she said the mortgage has been paid in full and is “the only real home that I’ve ever known” — was at risk, potentially leaving her homeless.

The AG’s letter stated “that they were going to take the place because of a $56,000 lien from Medicaid,” she said. “I’ve even called Medicaid myself to find out why — what kind of services are you saying (he owes) $56,000 for?”

Stories like Miller’s are “the classic Medicaid estate recovery” experience in the federally mandated program, one elder care and Medicaid planning south suburban Dayton attorney told the Dayton Daily News.

Ohio’s AG’s office — which collects the funds for the Ohio Department of Medicaid — has recovered more than $270 million since 2019, a year in which more than $730 million was collected nationwide, records show.

Washington Twp. attorney Ted Gudorf said he has a client who has been in a Kettering elderly care facility since last October.

“She’s run up a bill of $75,000. Her house is in Kettering. Her son is living in the house,” Gudorf said. “The facility has not applied for Medicaid yet … She’s going to go on Medicaid and when she dies, the state of Ohio will come back in and will seize that house, sell it … That happens on a regular basis.”

“No homes are seized,” Ohio AG press secretary Steve Irwin told this news organization. “Funds are recovered out of the sale of homes, but we do not take possession of a property.”

About estate recovery

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.

Estate recovery, which started in 1995, seeks to obtain repayment of the cost of benefits once a Medicaid recipient dies, according to the Ohio Department of Medicaid. Action is taken involving those who were either permanently institutionalized or 55 years or older, records show.

Among the instances when recovery occurs are after the death of the Medicaid recipient’s surviving spouse and when that the deceased recipient has no surviving children younger than 21, documents show.

“The AGO will send a notice of claim to the estate’s executor requesting payment for the cost of Medicaid benefits,” according to the state’s guidelines.

David Miller had retired and was receiving a modest monthly pension when he was approved for Medicaid benefits, his daughter said.

Rebecca Miller said she cared for her father at his home, he didn’t have a nurse and was never in a nursing home, so she was surprised at the attorney general’s letter seeking $56,000.

“A lot of people think they’re only going to take your place only if you’re in a nursing home or if you had full-time care,” Miller said “No. They’re going to take it just because you have Medicaid. Period.”

The Ohio Department of Medicaid “has made several changes to ensure Ohioans covered by Medicaid are notified of estate recovery,” according to its deputy director, Lisa Lawless.

The department has inserted a Medicaid Estate Recovery form in “all approval and change notices and updated the Ohio benefits self-service portal with additional information on the program,” she added.

But Gudorf said there is “very minimal” public knowledge about the collection program. Similar comments were made by the managing attorney for Pro Seniors Inc., a Cincinnati-based organization educating southwest Ohio older adults and their caregivers about the wide variety of legal and long-term care issues.

“It’s not until you apply for Medicaid that you receive any kind of notice,” Pro Seniors’ Miriam Sheline said. “And it’s usually included in a bunch of other notices. Although it’s there, that’s the first time anybody actually looks at it.”

Pro Seniors is advocating judicial changes in the program, she said.

“We’ve been challenging the way the estate recovery has been written. It’s been interpreted that just effectively upon death — even if property is transferred to a third party — that somehow (the state’s) claim can be converted to an automatic lien,” Sheline said.

“That’s not what the statute says. And there’s no due process or provisions for a third party to challenge it,” she added. “There’s certain exceptions to estate recovery lien — or even estate recovery in general — (but) there’s no mechanism for a third party to raise those issues until after there’s already a lien on their home.”

This news organization requested records on how many properties were impacted by the Medicaid estate recovery program statewide with breakdowns of southwest Ohio counties from 2017-2022. The Ohio AG’s office, however, could not provide them “due to the ongoing system upgrades,” Irwin said.

National, state numbers

In 2019, states nationwide reported collecting about $733.4 million from beneficiary estates. States return part of the money to the federal government based on their federal medical assistance percentage, according to a 2021 report from the Medicaid and CHIP Payment and Access Commission (MACPAC), an agency that advises Congress.

The amount each state collects annually varies widely. Hawaii’s Medicaid estate recovery program collected $31,000 in 2019 while Iowa recovered more than $26 million, according to the federal report.

“The five states with the largest estate collections — Massachusetts, New York, Pennsylvania, Ohio and Wisconsin — account for 38.5% of all recoveries in FY 2019,” the report stated.

Last year, more than $87.5 million was collected by Ohio, state records show. That total was “a peak” annual amount, Irwin said.

The Ohio AG’s office mainly uses outside counsel for collections in various regions for several reasons, Irwin said. Local attorneys have more direct knowledge of the courts in their region, and are familiar with estate filings and property records, he added.

Ohio’s Medicaid program and other creditors are paid before any assets are distributed to heirs or other beneficiaries, according to the Ohio Association of Area Agencies on Aging. If there is an undue hardship to a survivor, the right to immediate recovery may be delayed or waived. Undue hardship is determined on a case-by-case basis.

Miller said she became aware of the hardship exemption after the deadline to apply had passed following her father’s death. In the year since her father died, she has done everything she knows of to keep from losing the house, but isn’t hopeful it’ll work.

“I feel like now, I’m going to be homeless because of all of this. My dad didn’t know that,” she added.

Avoiding a ‘nightmare’

The 2021 MACPAC report urged Congress to bar states from collecting from families with meager assets, and to let states opt out of the effort altogether.

“The program mainly recovers from estates of modest size, suggesting that individuals with greater means find ways to circumvent estate recovery and raising concerns about equity,” the report states.

States can limit their collection practices. Massachusetts implemented changes in 2021 to exempt estates of $25,000 or less, according to a report from National Public Radio.

Sheline said Pro Seniors has not sought that type of change. Some states have sought other reforms.

Gudorf said he specializes in long-term care Medicaid, which has an asset test and an income test to determine eligibility.

Attorneys specializing in elder care and Medicaid planning can steer clients in directions in which they can protect about half — if not all — of their assets from the recovery program. Another option is to buy long-term care insurance to avoid relying on Medicaid, Gudorf said.

Miller said she was not aware of these options.

“I don’t know whether I’m going to be able to keep the place,” she said, noting about her father, “he worked his whole life and bought this place.”

Miller said wants to help others not experience what she has been through.

“I just feel like if I can help avoid this from happening to anybody else, I really would appreciate that because this is just a nightmare,” she said. “That’s not something that you want to happen right when you lose your parent and all of sudden you’re fighting to keep your home. It’s horrible, right after you lose a loved one.”