Home visiting programs can play a critical role in improving the health and well-being of women, children, and their families by delivering voluntary health, educational, and social services. States support home visiting services through a complex arrangement of public and private funding, including federal Maternal and Infant early Childhood Home Visiting (MIECHV) and Medicaid funding. This case study explores Alabama’s Medicaid coverage of the Nurse-Family Partnership (NFP) program and its coordination with MIECHV as one opportunity to leverage available federal funding for home visiting.
Overview of Medicaid Financing for Home Visiting
While there are differences across state home visiting programs, common home visiting services include case management and care coordination, screenings for physical and social-emotional needs, and family support and counseling. The benefits of home visiting services are well documented and are associated with improved outcomes and demonstrated cost savings due to reductions in avoidable health service utilization.
Financing of home visiting services is essential for assuring access to high-quality services for those served by the program. States finance home visiting services through public and private funding streams, including state general revenue, public insurance financing (e.g., Medicaid), and federal funding from the MIECHV program — the largest federal funding source supporting home visiting. States receiving MIECHV funding must implement evidence-based home visiting programs, as designated by the Home Visiting Evidence of Effectiveness (HomeVEE). Despite these investments, only an estimated 15 percent of the more than 480,000 eligible families in FY23 receive MIECHV services in the U.S. Over 80 percent of children receiving home visiting services in FY24 were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP). As such, the strategic use of public insurance financing is a critical strategy to help expand access to home visiting services.
Summary of Medicaid Financing of Home Visiting Services
Many state Medicaid programs have an important role in covering home visiting services in states. While federal Medicaid law does not allow for the full scope of home visiting services to be covered by state Medicaid programs, states may seek federal approval to cover common home visiting services, including screening, case management, and family support and counseling, or specific HomeVEE models. NASHP completed an analysis of state Medicaid programs providing home visiting services, Medicaid Reimbursement for Home Visiting: Findings from a 50-State Analysis. As of 2023:
- 28 states cover some type of home visiting service under Medicaid
- 22 states support home visiting services under a Medicaid state plan amendment
- 13 state Medicaid programs require the use of an evidence-based approved HomVEE model (e.g., NFP)
Alabama’s Home Visiting Landscape
In 2023, Alabama’s MIECHV program served 3,256 participants across 1,503 households under its two HomVEE models: NFP and Parents as Teachers (PAT). Approximately 60 percent of families served had income at or below 100 percent of the federal poverty line. Many families served by MIECHV are Medicaid-eligible. In 2022, the Alabama Medicaid Agency received federal authorization via a state plan amendment to provide statewide Medicaid reimbursement for NFP as a targeted case management benefit to improve health outcomes for women and babies.
Overview of Nurse-Family Partnership
NFP is an evidence-based, HomVEE-approved home visiting program that focuses on low-income, first-time pregnant women and their children. Participating families receive one-on-one home visits from a registered professional nurse. Services often begin early in the client’s pregnancy (with program enrollment no later than 28 weeks into pregnancy) and conclude when the client’s child turns two years old.
Summary of Alabama’s Medicaid Coverage of Home Visiting Services
Alabama’s Medicaid-covered NFP services are available to Medicaid-eligible women who are first-time mothers and/or who have a high-risk pregnancy (e.g., diabetes, high blood pressure) through their child’s second birthday. Covered services include: a comprehensive health assessment, development of a care plan, referrals and related coordination activities (e.g., scheduling appointments), monitoring and follow-up activities, and services in the care plan. Alabama does not reimburse for other HomeVEE models or individual home visiting services delivered by a non-NFP provider.
NFP services are reimbursed once per month for each participating family in the amount of $765.47 to enrolled NFP providers. A minimum of two visits per month, with one of those visits being conducted face-to-face, is required for the monthly reimbursement. In addition to being a registered nurse, participating providers must have certification by the National Service Organization (NSO) and enroll with the Alabama Medicaid Agency as a targeted case management provider.
Implementation of Statewide Medicaid Coverage of NFP and Coordination with MIECHV
To coordinate across home visiting models, the Alabama Medicaid Agency and the Alabama Department of Early Childhood Education (ADECE) have an agreement in which ADECE administers the PAT program, and NFP is overseen by Alabama’s Medicaid agency. Alabama currently has three NFP providers enrolled in Medicaid. Since their enrollment in 2022, one of these Medicaid-enrolled NFP providers expanded into four additional counties and another expanded into ten additional counties — resulting in approximately half the state (33 counties of 67 total) having access to Medicaid-funded NFP services. Of these three Medicaid-enrolled NFP providers, two use other funding sources, including MIECHV, to support non-Medicaid beneficiaries and non-Medicaid home visiting programs. The other NFP provider uses only Medicaid funding, meaning that it serves only Medicaid beneficiaries.
While Alabama has seen an increase in NFP providers since implementing Medicaid reimbursement for the home visiting model, there have been some administrative challenges, including providers being unfamiliar with the documentation requirements to enroll and receive reimbursement under Medicaid. There have also been operational considerations as NFP expands statewide, including the extent to which all NFP visits can be provided virtually. Some NFP providers are interested in providing all required NFP services via telehealth – an area that the state Medicaid agency is still exploring in terms of feasibility and potential impact on outcomes.
As Alabama continues to expand its Medicaid-funded NFP program, state officials have learned several lessons during the first several years of implementation. These lessons include: (1) the need to establish more clarity from the NSO early on to fully understand how NFP providers are certified to ensure alignment with the state’s credentialing system and expectations, (2) the importance of enforcing number of visits per month, and (3) the need to develop specific guidelines related to documentation requirements for practicing as an NFP provider under Medicaid to reduce confusion and administrative challenges.
Conclusion
Alabama’s statewide Medicaid-funded NFP program has made significant progress since its inception in 2022, with families in half of the state having access to NFP services to date. With at least 28 states providing Medicaid reimbursement for home visiting services, Alabama’s unique approach may inform other states’ efforts to strengthen cross-sector financing and improve access to needed home visiting services for women, children, and their families.
Acknowledgments
This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC54191; $396,167. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.
NASHP wishes to thank Dr. Travis Houser, John Majors Barry Cambron, and Linda White from Alabama for their time and insights.
