Coverage of Maternal, Infant and Early Childhood Home Visiting Services

Research has shown that a quality home visit by a nurse, social worker, early childhood educator or other trained personnel during pregnancy and early parenting can improve the lives of families and their children both at an early age and well into adolescence and early adulthood. The Centers for Medicare and Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) have been working collaboratively to inform states about resources available to help them meet the needs of pregnant women and families with young children through evidence-based home visiting (EBHV) services. In March 2016, they released a Joint Information Bulletin on Coverage of Maternal, Infant, and Early Childhood Home Visiting Services.

A recent NASHP webinar featuring representatives from HRSA and CMS, along with a representative from South Carolina, a leading state in home visiting, and another policy expert addressed federal resources and opportunities, as well as state strategies for coverage of evidence-based home visiting services.

The Federal Home Visiting Program (also known as the Maternal, Infant, and Early Childhood Home Visiting Program or MIECHV) supports voluntary, evidence-based home visiting services for at-risk pregnant women and their young children from pregnancy to kindergarten entry. The program is built on decades of research showing that home visits by trained providers can improve maternal and child health, support positive parenting, prevent child abuse and neglect, and promote child development and school readiness. Research also shows that evidence-based home visiting can provide a positive return on investment to society through savings in public expenditures on emergency room visits, child protective services, special education, as well as increased tax revenues from parents’ earnings.

The Federal Home Visiting Program, administered by HRSA in partnership with the Administration for Children and Families (ACF), provides funds to states, territories, and tribal entities to implement home visiting programs in high-risk communities. It is important to note that the Federal Home Visiting Program offers targeted funds that are not necessarily statewide; therefore, in areas that are not targeted by the program, Medicaid may be the only payer for home visiting services. By law, state and territory awardees must spend the majority of their Federal Home Visiting Program grants to implement evidence-based home visiting models, with up to 25 percent of funding available to implement promising approaches that will undergo rigorous evaluation. Additionally, the Program monitors grantee performance and supports continuous quality improvement systems. States have flexibility to tailor the program to fit the needs of their at-risk communities, and work in collaboration with other local and state early childhood systems. This is particularly important given the program has designated high-risk priority populations; in 2015 nearly 80 percent of the families served by the Federal Home Visiting Program fell below 100 percent of the Federal Poverty Level (FPL).

When looking to expand and sustain the coverage of home visiting services, Medicaid engagement and collaboration can offer a variety of options for states. Currently, many states have seen success through Medicaid financing of evidence-based home visiting to enhance home visiting coverage and improve outcomes of Medicaid recipient populations. Under the Medicaid State Plan Authority there is no official benefit called “home visiting”; however, individual component services can be covered when Medicaid requirements are met. These services typically include: extended services to pregnant women, case management, preventive services, and the early and periodic screening, diagnostic, and treatment services benefit (EPSDT) among others. The overlap in services between those provided through EPSDT and Home Visiting offers an opportunity for EPSDT to be used as a permissible benefit pathway for the coverage of services.

State Medicaid agencies can also use various federal Medicaid authorities and approaches to help cover home visiting services including Health Homes (Section 1945 of Social Security Act), 1915(b) waivers, 1915(c) waivers, and 1115 waivers. Home Visiting can also be incorporated into Managed Care through new contract specifications. The previously mentioned ability to tailor evidence-based home visiting programs to meet local and state needs also applies when states are identifying opportunities through which they can work with Medicaid to cover and support these vulnerable populations.

South Carolina Nurse Family Partnership Pay for Success Project
In April 2016, South Carolina launched the nation’s first Pay for Success initiative focused on improving health outcomes for Medicaid eligible mothers and children.

The South Carolina Department of Health and Human Services, which administers Medicaid and the Pay for Success initiative, is using a 1915(b) Medicaid Waiver to expand and support the efforts of the Nurse Family Partnership (NFP) program. In Pay for Success (PFS) projects, funders provide upfront capitol to expand social services with payments tied to the achievement of pre-determined desired and measurable outcomes. The South Carolina Pay for Success initiative directed $30 million to expand the NFP’s evidence-based services to an additional 3,200 first-time low-income mothers across the state. Funding was provided by both philanthropic funders ($17 million) and through a Medicaid 1915(b) Waiver ($13 million). South Carolina chose to use a 1915(b) waiver as it allowed NFP to bill in real time for the cost of home visiting services, among other items. This program serves 30 of the 46 counties in South Carolina and is available for Medicaid-eligible, first-time mothers for nurse home visiting services ranging from no more than 28 weeks gestation to the child’s second birthday. The program is focusing on four outcome metrics for assessment of NFP’s impact. The South Carolina Department of Health and Human Services has $7.5 million available for success payments based on NFP’s performance on each metric. As of October 2016, the program has enrolled 811 mothers.

Looking Ahead
States have been using Medicaid to finance home visiting for over 20 years and continue to evolve in the approaches they use to provide coverage of these services for vulnerable mothers and children. To assist states in the development of polices and mechanisms needed to maximize Medicaid as a source of funding for home visiting, The Pew Charitable Trusts and the Heising Simons Foundation have funded the Medicaid and Home Visiting Learning Network. This network of 11 states provides peer-to peer learning among states and supports individual states’ policy goals regarding coverage of home visiting services. A new resource, highlighting the lessons learned from the Medicaid and Home Visiting Learning Network and including a checklist for states, is forthcoming and will be nationally disseminated.

If you are interested in more information about federal efforts related to home visiting, the Medicaid and Home Visiting Learning Network, or South Carolina’s Pay for Success program, please refer to the slides from the NASHP webinar or a recording of the presentations.