Home visiting is an important and long-standing strategy for improving the health and well-being of women, children, and their families. Home visiting programs deliver and help connect individuals to critical social, health, and educational services. They can include screenings for physical, social-emotional, and developmental issues, case management services, and family support and counseling. Studies have shown that home visiting programs can reduce child maltreatment and intimate partner violence and improve maternal and child health outcomes, including positive parenting and child development. These programs also show long-term cost savings, with benefits exceeding costs by an amount as high as 200 percent. Other areas of savings include a reduction of unnecessary emergency department visits and decreased use of public assistance programs such as Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Medicaid.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is the primary source of federal funding for home visiting programs and is administered through the Health Resources and Services Administration (HRSA). HRSA awarded approximately $341 million in September 2020 to 56 states, territories, and nonprofit organizations to support the provision of voluntary, evidence-based home visiting services.
In addition to MIECHV, states leverage multiple state and federal funding streams to finance home visiting programs. Prominent sources of funding include Medicaid and the Children’s Health Insurance Program (CHIP), TANF, the state Title V Maternal and Child Health (MCH) Services Block Grant, state general revenue funds, and private foundation support. In addition to these sources, the Family First Prevention Services Act authorized new optional funding under Title IV-E of the Social Security Act for prevention services for mental health, substance abuse, and in-home parent skill-based programs, and may also serve as a prominent source of funding in the future.
At least 20 states use Medicaid to support home visiting programs. Targeted case management is the most common federal Medicaid authority that states use to support these programs. In a 2016 Joint Informational Bulletin on Coverage of Maternal, Infant, and Early Childhood Home Visiting Services, the Centers for Medicare & Medicaid Services (CMS) and HRSA encouraged states to use Medicaid and other federal and state funding sources to support home visiting programs. In 2019, the National Academy for State Health Policy, with support from the Maternal and Child Health Bureau, HRSA, convened state and federal Medicaid, public health, and home visiting leaders to discuss key opportunities, challenges, and innovative approaches to enhance public insurance financing of home visiting services. Participating states identified many questions and considerations for use of Medicaid to cover home visiting services. These considerations include:
- how to best integrate public insurance financing as part of state health reform efforts in Medicaid and CHIP, including strategies to move towards value-based payment (VBP);
- how to best braid multiple private, state and federal funding sources including Medicaid; and
- how to ensure providers meet qualified provider requirements in Medicaid programs, while still maintaining fidelity to the specific home visiting model.
Highlights of Approaches to Medicaid Financing in Seven States
NASHP reviewed Medicaid state plans, state Title V MCH Services Block grant applications and annual reports, state MIECHV program applications, and appropriation bills in seven states (Colorado, Kentucky, Michigan, Minnesota, New York, Oregon, and Wisconsin) in May 2021 to further understand and describe selected states’ approaches to Medicaid financing of home visiting programs. These states were selected for their geographic diversity, length of history using Medicaid to support home visiting programs, and publicly available information. Key highlights of the Medicaid financing approaches in the seven states are below.
- Five states (CO, KY, NY, OR, WI) support home visiting programs through Medicaid targeted case management, and two states (MI and MN) finance these programs through an extended service for pregnant women or an ‘Other practitioner services’ benefit. Medicaid targeted case management (TCM) services often do not cover the full costs of a home visiting program. Medicaid TCM services entail a comprehensive and periodic assessment, development of a specific care plan, referral and follow-up as needed, and activity monitoring. The Extended Services for Pregnant Women authority is another avenue by which states can reimburse for home visiting services. A state can, under federal regulation 42 CFR 440.250(p), provide a greater amount of services in scope, duration, and amount for pregnant women compared to other Medicaid beneficiaries. Michigan used this authority, which broadly allowed for more services offered by a home visiting program/provider to be reimbursed compared to the targeted case management benefit. ‘Other practitioner services’ is an optional benefit allowable under Medicaid that can also be used to support home visiting programs. Minnesota used this benefit to cover prenatal and postpartum home visits by a Public Health Nurse or a registered nurse under the supervision of a Public Health Nurse.
- Five of the seven states (MI, MN, NY, OR, WI) reimburse for home visiting services as part of capitated payments under Medicaid managed care (MMC) and two states (CO and KY) do so through direct payments to providers under fee-for-service arrangements. State Medicaid programs determine the service delivery system in which home visiting services are provided, which can have implications for implementation and delivery. For example, a state can require Medicaid managed care organizations to refer eligible enrollees to home visiting programs approved by the state Medicaid agency as part of the state MMC contract.
- The seven states describe specific provider qualifications in their Medicaid state plan, as is outlined in federal regulation. States can set reasonable standards relating to qualifications of providers and often do to meet home visiting model provider requirements. This includes degree requirements (e.g., bachelor’s or master’s degree, certification), licensure requirements, professional qualifications (e.g., social worker, registered nurses, early childhood development specialist), and/or infrastructure to bill Medicaid. There are some exemptions to these qualifications when someone is not available in a geographic area or community.
- The seven states leverage a variety of public and private funding sources, in addition to MIECHV and Medicaid, to support home visiting programs. These sources include but are not limited to Tobacco Master Settlement Agreement revenue, state school aid, the Child Abuse and Prevention and Treatment Act (CAPTA) funds, and TANF. In many cases, the selected states also use state general revenue funds.
The following table summarizes Medicaid financing approaches in the selected seven states. This information is not meant to be an exhaustive list of all home visiting programs in the state. It includes state information on Medicaid authorities and benefit categories, services eligible for Medicaid reimbursement, the state’s qualified provider requirements, other sources of funding, the state’s delivery system approach, and other relevant information that can inform state efforts to enhance Medicaid support for home visiting programs.
- State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 368 § (2009). https://www.colorado.gov/pacific/sites/default/files/Colorado%20Medicaid%20State%20Plan%20-%20February%2026%2C%202020.pdf.
- State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 368 § (2009). https://www.colorado.gov/pacific/sites/default/files/Colorado%20Medicaid%20State%20Plan%20-%20February%2026%2C%202020.pdf.
- State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 368 § (2009). https://www.colorado.gov/pacific/sites/default/files/Colorado%20Medicaid%20State%20Plan%20-%20February%2026%2C%202020.pdf.
- Nurse Home Visitor Program (Targeted Case Management) § (2019). https://www.colorado.gov/pacific/sites/default/files/CMS1500_NHVP%20v1_3_0.pdf.
- State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 368 § (2009). https://www.colorado.gov/pacific/sites/default/files/Colorado%20Medicaid%20State%20Plan%20-%20February%2026%2C%202020.pdf.
- MEDICAL ASSISTANCE – SECTION 8.749 NURSE HOME VISITOR PROGRAM § (n.d.). https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=6687.
- Kentucky State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg 728 § (n.d.). https://chfs.ky.gov/agencies/dms/Documents/StatePlanr1.pdf.
- Kentucky State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg 729-730 § (n.d.). https://chfs.ky.gov/agencies/dms/Documents/StatePlanr1.pdf.
- Kentucky State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg 730-731 § (n.d.). https://chfs.ky.gov/agencies/dms/Documents/StatePlanr1.pdf.
- Health Access Nurturing Development Services (HANDS) Program – PT (15). Health Access Nurturing Development Services (HANDS) Program – PT (15) – Cabinet for Health and Family Services, n.d. https://chfs.ky.gov/agencies/dms/provider/Pages/HANDS.aspx.
- Health Access Nurturing Development Services (HANDS) Program – PT (15). Health Access Nurturing Development Services (HANDS) Program – PT (15) – Cabinet for Health and Family Services, n.d. https://chfs.ky.gov/agencies/dms/provider/Pages/HANDS.aspx.
- Maternal and Child Health Bureau, Maternal and Child Health Services Title V Block Grant Kentucky FY 2021 Application/ FY 2019 Annual Report, Pg. 20, 43 § (2020). https://mchb.tvisdata.hrsa.gov/uploadedfiles/StateSubmittedFiles/2021/KY/KY_TitleV_PrintVersion_FY21.pdf.
- Maternal, Infant and Early Childhood Home Visiting Grant Program (X10), Kentucky § (2020). https://data.hrsa.gov/tools/find-grants?program=All HRSA Program Areas&programName=Maternal| Infant and Early Childhood Homevisiting Grant Program (X10)&fiscalYear=All Awarded Grants&state=Kentucky.
- Energy and Environment Budget, Pg. 185 § (n.d.). https://osbd.ky.gov/Publications/Documents/Budget%20Documents/2020-2021%20Budget%20of%20the%20Commonwealth/2020-2021%20BOC%20Volume%20I%20-%20FINAL%20-%20(Part%20B).pdf.
- Maternal and Child Health Bureau, Maternal and Child Health Services Title V Block Grant Kentucky FY 2021 Application/ FY 2019 Annual Report, Pg. 20 § (2020). https://mchb.tvisdata.hrsa.gov/uploadedfiles/StateSubmittedFiles/2021/KY/KY_TitleV_PrintVersion_FY21.pdf.
- Maternal and Child Health Bureau, Maternal and Child Health Services Title V Block Grant Kentucky FY 2021 Application/ FY 2019 Annual Report, Pg. 43 § (2020). https://mchb.tvisdata.hrsa.gov/uploadedfiles/StateSubmittedFiles/2021/KY/KY_TitleV_PrintVersion_FY21.pdf.
- Maternal Infant Health Program For Families. Maternal Infant Health Program – For Families, n.d. https://www.michigan.gov/mihp/0,5421,7-311-66377—,00.html.
- Department of Community Health, Michigan State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 457 § (2009). http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf.
- Department of Community Health, Michigan State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 457 § (2009). http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf.
- Department of Community Health, Michigan State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 457 § (2009). http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf.
- Maternal Infant Health Program (MIHP) – New Provider Inquiry Meeting § (2020). https://www.michigan.gov/documents/mihp/MIHP_New_Provider_Inquiry_presentation_July_8_2020_Final_696002_7.pdf.
- Department of Community Health, Michigan State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 882 § (2009). http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf.
- 2019 Michigan Home Visiting Report § (2019). https://www.michigan.gov/documents/mdhhs/Home-Visiting-Legislative-Report-FY2019_720781_7.pdf.
- NFP eligibility: First-time mothers that is pregnant 28 weeks or less with varying income eligibility requirements.
- Health Families America eligibility: Varies by local sites
- Family Spirit eligibility: Any woman who is pregnant or a caregiver with a child who is less than 3 years old can receive the Family Spirit Program
- Family Connects eligibility: Often times, eligibility is only restricted to a certain geographic area
- State Plan Amendment (SPA) #: 18-0001 Page 8: https://mn.gov/dhs/assets/18-01-spa_tcm1053-354420.pdf
- State Plan Amendment (SPA) #: 18-0001 Page 2: https://mn.gov/dhs/assets/18-01-spa_tcm1053-354420.pdf
- Public Health Nurse Registration. Minnesota Board of Nursing, n.d. https://mn.gov/boards/nursing/licensure/licensure/public-health-nurse-registration.jsp.
- Community Health Workers – Minnesota Dept. of Health, n.d. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/index.html.
- State Plan Amendment (SPA) #: 18-0001 Page 2, 8: https://mn.gov/dhs/assets/18-01-spa_tcm1053-354420.pdf
- Reckinger, Dawn. How States Leverage Medicaid and MIECHV to Support Home Visiting Services. NASHP Public Insurance Financing of Home Visiting Services State Policy Institute. Lecture, 2021.
- Reckinger, Dawn. How States Leverage Medicaid and MIECHV to Support Home Visiting Services. NASHP Public Insurance Financing of Home Visiting Services State Policy Institute. Lecture, 2021.
- Maternal, Infant and Early Childhood Home Visiting Grant Program (X10) § (2020). https://data.hrsa.gov/tools/find-grants?program=All HRSA Program Areas&programName=Maternal| Infant and Early Childhood Homevisiting Grant Program (X10)
- Minnesota Department of Health. Family Home Visiting – Funding and Grants Management, n.d. https://www.health.state.mn.us/communities/fhv/grant.html#Example1.
- New York State Department of Health, New York State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 802 § (n.d.). https://www.hcrapools.org/medicaid_state_plan/DOH_PDF_PROD/nys_medicaid_state_plan.pdf.
- New York State Department of Health, New York State Medicaid Program Comprehensive Medicaid Case Management: Policy Guidelines § (n.d.). https://www.emedny.org/ProviderManuals/CMCM/PDFS/CMCM_Policy.pdf.
- New York State Department of Health, New York State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 802 § (n.d.). https://www.hcrapools.org/medicaid_state_plan/DOH_PDF_PROD/nys_medicaid_state_plan.pdf.
- Maternal, Infant and Early Childhood Home Visiting Grant Program (X10), New York § (2020). https://data.hrsa.gov/tools/find-grants?program=All HRSA Program Areas&programName=Maternal| Infant and Early Childhood Homevisiting Grant Program (X10)&fiscalYear=All Awarded Grants&state=New York
- Oregon State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 491-492 § (2020). https://www.oregon.gov/oha/HSD/Medicaid-Policy/StatePlans/Medicaid-State-Plan.pdf.
- Oregon State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 496 § (2020). https://www.oregon.gov/oha/HSD/Medicaid-Policy/StatePlans/Medicaid-State-Plan.pdf.
- Oregon Administrative Rule 410-138-0060 Targeted Case Management Program Provider Requirements § (n.d.). https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=268911.
- Maternal, Infant and Early Childhood Home Visiting Grant Program (X10), Oregon § (2020). https://data.hrsa.gov/tools/find-grants?program=All HRSA Program Areas&programName=Maternal| Infant and Early Childhood Homevisiting Grant Program (X10)&fiscalYear=All Awarded Grants&state=Oregon
- Calsyn, Maura, Rachel Herzfeldt-Kamprath, and Thomas Huelskoetter. Medicaid and Home Visiting: Best Practices from States. Center for American Progress, January 25, 2017. https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/.
- Wisconsin State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 25 § (1987). https://www.dhs.wisconsin.gov/mandatoryreports/mastateplan/3-1a-case.pdf.
- Wisconsin State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 25 § (1987). https://www.dhs.wisconsin.gov/mandatoryreports/mastateplan/3-1a-case.pdf.
- Wisconsin State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 25 § (1987). https://www.dhs.wisconsin.gov/mandatoryreports/mastateplan/3-1a-case.pdf.
- Wisconsin State Plan Under Title XIX of the Social Security Act Medical Assistance Program, Pg. 25 § (1987). https://www.dhs.wisconsin.gov/mandatoryreports/mastateplan/3-1a-case.pdf.
- Calsyn, Maura, Rachel Herzfeldt-Kamprath, and Thomas Huelskoetter. Medicaid and Home Visiting: Best Practices from States. Center for American Progress, January 25, 2017. https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/.
- Prenatal Care Coordination. Wisconsin Department of Health Services, April 9, 2021. https://www.dhs.wisconsin.gov/mch/pncc.htm.
- Wisconsin Family Foundations Comprehensive Home Visiting Program. Wisconsin Department of Health Services, March 23, 2021. https://www.dhs.wisconsin.gov/mch/homevisits.htm.
- Maternal, Infant and Early Childhood Home Visiting Grant Program (X10), Wisconsin § (2020). https://data.hrsa.gov/tools/find-grants?program=All HRSA Program Areas&programName=Maternal| Infant and Early Childhood Homevisiting Grant Program (X10)&fiscalYear=All Awarded Grants&state=Wisconsin
- Wisconsin Targeted Case Management Policy, Pg. 112 § (2019). https://www.forwardhealth.wi.gov/kw/archive/CaseManage020119.pdf.
Acknowledgments: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. 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 US government.
