States implement home visiting services to improve the health and well-being of women, children, and their families. The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, administered by the Health Resources and Services Administration (HRSA) in partnership with the Administration for Children and Families (ACF), is the primary source of federal funding for evidence-based home visiting programs. States also leverage other state and federal funding, including public insurance financing (Medicaid and the Children’s Health Insurance Program, or CHIP), to support select home visiting services. Medicaid eligible home visiting services may include screening, case management, family support, counseling, and skills training for pregnant people and parents with young children. Public insurance financing can enhance access to home visiting services, especially for families with incomes below the federal poverty level. NASHP worked with states such as Alabama and Montana to provide targeted technical assistance on how their Medicaid programs can expand coverage of home visiting services.
Medicaid plays a significant role in providing coverage to children and pregnant people. As of September 2022, over 41 million children were enrolled in Medicaid and CHIP combined, which is approximately 50 percent of the total Medicaid and CHIP enrollment. Medicaid is the largest single payer of pregnancy-related services, financing 42 percent of all U.S. births in 2019. According to HRSA, in fiscal year 2021, 72 percent of MIECHV participants were enrolled in Medicaid or CHIP. In addition, 8 out of 10 mothers, infants, and children participating in home visiting programs are enrolled in Medicaid, representing a unique opportunity to establish sustainable funding for home visiting programs. An estimated 26 states cover home visiting services for pregnant people, new parents, or infants through Medicaid, and at least 20 states provide Medicaid coverage of home visiting programs, with several other states pursuing similar efforts.
Alabama is implementing its recent statewide extension of its Nurse-Family Partnership (NFP) program as a targeted case management benefit under its Medicaid program. NFP is an evidence-based, community health program delivered by nurses who visit first-time mothers, starting in pregnancy and continuing until the child turns two years old. Under the targeted case management benefit, NFP nurses assess the individual’s medical, educational, and social needs and refer them to providers to address those needs, schedule appointments for the individual, and develop and monitor the individual’s specific care plan. The NFP program, which began as a regional pilot program, has extended statewide with the goal of providing home visiting services to first-time mothers and high-risk pregnant Medicaid beneficiaries until the child turns two years old to reduce infant and maternal mortality.
Montana is exploring covering home visiting services under its Medicaid program through a state plan amendment. The state is also considering recruiting community health workers to aid in outreach and referrals to home visiting services. Montana is exploring reimbursing non-nurse home visitors through the preventive counseling current procedural terminology, or CPT, code. Because most home visitors work under multiple home visiting models, there can be confusion in submitting claims at different rates. To alleviate this administrative burden, the state is exploring an approach involving cross-disciplinary training across different models to average the cost of a home visit. As part of this work, Montana is engaging in a coordinated state evaluation that includes plans to survey home visitors under MIECHV to assess what credentialed provider types make up the home visiting workforce.
Key Considerations for Leveraging Public Insurance Coverage and Financing of Home Visiting Services
These states identified the following key considerations and opportunities to strengthen public insurance financing of home visiting services:
Workforce
Many states, especially those with large rural areas, are currently experiencing a health care workforce shortage, which has created challenges in recruiting nurses and other health care professionals to provide home visiting services. As states pursue opportunities to build a sustainable home visiting workforce, some are recruiting a broader array of Medicaid-eligible non-nurse provider types, such as community health workers, to provide home visiting services. Expanding the home visiting workforce to include non-nurse providers can establish a robust and sustainable workforce for providing home visiting services to families.
Addressing Administrative Burden
Administrative burdens such as extensive training requirements and billing challenges can limit the opportunity for home visitors to submit claims to Medicaid for services. To alleviate administrative challenges for nurse home visitors, states may consider streamlining Medicaid billing processes by differentiating between case management and clinical services to ensure separate claims are filed for each of these services.
Strategic Use of Multiple Funding Sources
To maximize the reach of home visiting services, it is critical to leverage available funding sources to support home visiting. While Medicaid funding is a key lever for supporting home visiting, diverse public and private funding streams and financing strategies can also be considered to support capacity building in historically marginalized and underfunded communities. States can benefit from being aware of all home visiting services provided by different state agencies, in part, by forming strong cross-agency relationships to align public insurance financing of home visiting services efforts. States can integrate this priority within a broader leadership agenda for early childhood initiatives, such as the statewide vision and plan currently being developed by Early Childhood Comprehensive Systems awardees.
As an initial step, states may consider exploring whether any early childhood focused fiscal mapping, or innovative health system financing efforts are underway. States may also consider conducting an analysis of Medicaid-funded home visiting programs to assess key service delivery elements, such as who is receiving the service and which services are being delivered. The findings may help to inform cross-agency efforts to target and/or expand home visiting services across the state and guide where public insurance financing can be best leveraged.
NASHP will continue to monitor state Medicaid innovations to support home visiting at both the state and federal level.
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 U.S. government.
