Accountability Is Key to Medicaid's Home Care Future

Every day, hundreds of thousands of Americans receive care not in hospitals or nursing facilities, but in their own homes — help with medication, mobility, bathing, or preparing meals. For many seniors and people with disabilities, that support is what allows them to remain at home, rather than move into expensive institutionalized care.

As home- and community-based services continue to grow, they have become a central part of the national debate over Medicaid spending. That debate has become increasingly focused on fraud, waste, and abuse, with federal and state officials intensifying scrutiny of provider enrollment, billing practices, and program integrity. 

Washington is right to ask hard questions about Medicaid spending. Taxpayers deserve to know that public dollars are reaching the people they intend to serve. Beneficiaries deserve programs that are stable, well-run, and protected from bad actors. . 

In self-directed care models, Medicaid beneficiaries who qualify for home- and community-based services are permitted to select and employ their own caregivers, often people they trust, such as family members, rather than relying exclusively on traditional agency-based home care models. In many states, Medicaid programs have deliberately shifted away from institutional settings and toward home- and community-based services, which are less expensive and significantly life-enhancing for patients. 

The question is not whether Medicaid home care programs should be accountable. They must be. The more important question is what kind of infrastructure allows states to identify risk early, prevent fraud, waste, and abuse, and maintain access for people who depend on care at home. 

Large public programs cannot operate on trust alone. They require unified data systems, consistent compliance standards, and the ability to identify irregular billing patterns before they escalate into systemic fraud. That is precisely where a strong fiscal intermediary (FI) becomes essential, building the infrastructure that gives states a complete picture of caregivers who provided services, for how long, under what authorization, and whether program requirements were met.

An FI is a critical partner in enforcing program rules and supporting the long-term sustainability of the program. They help operationalize accountability by managing caregiver enrollment, payroll, tax compliance, documentation, authorization controls, participant support, and the reporting of suspected fraud, waste, and abuse to government authorities. Together, these functions make home- and community-based services traceable and subject to consistent rules and oversight.

Without centralized visibility, obvious red flags, such as overlapping work hours, impossible schedules, payments submitted while a patient is hospitalized, ineligible caregivers, or caregivers attempting to work beyond the patient’s authorized care hours, can be harder to detect. When bad practices like those slip through the cracks, they drain taxpayer resources and erode public confidence in programs designed to protect vulnerable populations. A strong FI gives states the operational line of sight to prevent many of those problems before they become enforcement cases.

States like New York have proven that billions in costs can be reduced while preserving quality of care and improving compliance. Standardized fee structures, electronic visit verification, real-time timekeeping, eligibility validation, authorization management, caregiver enrollment and hours worked controls, and integrated reporting systems distinguish between paperwork errors and genuine misconduct, allowing quick intervention when necessary.

With federal attention fixed on Medicaid spending, states must build systems that embed compliance into daily operations, not treat it as an after-the-fact exercise. The long-term success of Medicaid programs will depend on whether states use recent scrutiny to strengthen infrastructure rather than retreat from reform. 

The stakes are high. Home and community-based services represent a growing component of Medicaid spending. Most Americans, when given the choice, prefer to receive care at home rather than in institutional settings. But programs that cannot demonstrate disciplined oversight will face growing skepticism. Taxpayers rightly expect that every dollar appropriated for care reaches who it is intended to serve. Patients deserve the same assurance.

Medicaid is not simply a budget line. It is a public trust. Transparency strengthens that trust when it clarifies how funds are used and reinforces the safeguards that allow programs to operate. The task ahead is not to retreat from home-based care or treat every growing program as inherently suspect. Doing so risks undermining a model that helps people remain independent at home while controlling costs. Rather, we should pair the promise of choice with the discipline, data systems and a strong FI infrastructure that programs of this scale demand.