Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and parenting women in the United States, and they have far-reaching consequences for the health and well-being of women and their children. Integrated care models that support pregnant and parenting women’s physical and behavioral health and social service needs can improve outcomes for women and children and reduce health care costs.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) is working with states to support and advance innovative policy initiatives that improve access to quality health care for pregnant and parenting women.
As part of the MCH PIP initiative, NASHP is convening a two-year policy academy including eight state teams made up of representatives from state Medicaid agencies, public health agencies, mental health/substance use agencies, and other state stakeholders. States selected to participate in the first cohort of the NASHP policy academy include:
- New Jersey
- South Carolina
Over the next two years, these states will identify, promote, and advance innovative, state-level policy initiatives to improve access to care for Medicaid-eligible pregnant and parenting women with or at risk of SUD and/or mental health conditions. NASHP will work with the states to identify high-priority policy issues, challenges, and opportunities through targeted technical assistance, peer-to-peer learning, analyses of policy issues, and development of policy briefs and other resources that will be disseminated nationally.
While many states have identified pregnant and parenting women as a priority population for their SUD and behavioral health efforts, challenges and opportunities persist. NASHP recently published two Issue Hubs that provide valuable resources, including information on the Centers for Medicare & Medicaid Services’ Maternal Opioid Misuse (MOM) Model. They are available at:
- Resources to Help States Improve Integrated Care for Pregnant and Parenting Women: This Issue Hub provides valuable resources for states interested in using the Maternal Opioid Misuse (MOM) model and others to improve access to comprehensive and coordinated care and implement innovative payment and care delivery models for pregnant and parenting women eligible for Medicaid.
- Resources to Help States Improve Integrated Care for Children: This Issue Hub provides valuable resources for states interested in the Integrated Care for Kids (InCK) Model and others working to implement payment, coverage, and cross-agency strategies to improve for integrated care coordination of behavioral, physical and health-related social needs for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
People living with HIV (PLWH) are living longer due to advances in antiretroviral therapies and disease management. In 2016, 47 percent of PLWH in the United States were over age 50. This population often needs long-term services and supports at an earlier age due to increased risk of dementia, chronic illness, and the social isolation still associated with HIV infection. This aging population’s unique health care service and support needs are ushering in a new wave of state initiatives that work both within and outside traditional systems.
At the National Academy of State Health Policy’s annual conference earlier this year, state leaders met during a daylong preconference, Covering the Waterfront: Innovative State HIV Policy Approaches, from Prevention to Aging in Place, to share the strategies and challenges they face as they work to support PLWH across their lifespans.
New York and South Carolina have longstanding Medicaid that provide home- and community-based services (HCBS) to an aging PLWH population. Policymakers from those states described how these programs address the needs of their older :
South Carolina, whose HIV/AIDs 1915(c) waiver dates back to 1988, has made changes to its waiver benefits to better support an older population, including enhanced prescription drug coverage and self-directed, in-home services. Waiver benefits also include and home modifications, which state officials noted was key to keeping aging PLWH living independently for as long as possible. While South Carolina adapted its HIV/AIDS waiver to meet these needs, state officials noted that fewer PLWH are accessing waiver services in recent years because they no longer meet institutional level-of-care criteria. Attendees noted that states may need to consider other strategies to address the needs of PLWH who still need long-term care in their homes or communities, but no longer qualify for waiver programs. Policymakers suggested that over time older adults with HIV may be best served through other, non-HIV-specific HCBS waivers.
New York has operated its AIDS Adult Day Health Care Program (ADHCP) under its Medicaid state plan since 2007. ADHCPs are long-term care programs that provide eligible PLWH and people at risk for HIV with services and supports in a community setting. In addition to core services, such as nursing visits, mental health treatment, and support for daily living activities, clients can also participate in group meals, yoga classes, and socialization services. State policymakers view these investments as effective tools to reduce the isolation commonly experienced by PLWH, encourage engagement in treatment, and ultimately reduce the cost of care for PLWH who can be successfully supported in their homes and communities for longer periods of time.
While PLWH are living longer and often able to age in place in their communities, many will eventually need care from long-term care facilities. Officials expressed concern that these facilities may be ill-equipped to handle this population — a 2015 scan of state long-term care facility regulations found that very few states require these facilities to train their staff in how to care for PLWH. State policymakers discussed the need to enhance provider and staff training and address the persistent stigma associated with HIV infection often found among long-term care facility staff as key priorities for future work.
For more information about how states are working to improve the lives of PLWH, including older adults, explore NASHP’s Toolkit: State Strategies to Improve Health Outcomes for People Living with HIV.
Additional resources from the Health Resources and Services Administration’s HIV/AIDS Bureau:
HRSA Care Action: The Graying of HIV
Aging with HIV: Care Challenges
Engaging and Retaining Older Adults in HIV Care
Home visiting programs have a long track record of improving health and life outcomes of children and families, such as increasing school readiness and reducing hospitalizations, while generating long-term savings. States use home visiting to target interventions for some of their most vulnerable populations and utilize multiple private and public funding streams, including Medicaid, to support these programs. This issue brief, developed with support from the Alliance for Early Success, highlights Medicaid and other funding sources available to support these services and explores opportunities to integrate home visiting into state health reform efforts. The brief also features examples of how states use Medicaid to finance home visiting programs.
Learn more about Community Health Workers: Policy Opportunities for Population Health and Patient-Centered Health Care at NASHP’s 30th Annual State Health Policy Conference Oct. 23-25, 2017, in Portland, OR.
Discover how states are designing, implementing, and funding their community health worker programs across the nation at NASHP’s community health worker interactive map.
Wednesday, October 25th
Under a new Administration, there has been increased focus on the need for more flexible federal funding for state health programs. This session examines the implications of braiding, blending, or block granting traditional Medicaid and public health funding streams to support population health goals. Speakers share their own states’ braiding and blending experiences, and discuss innovations and strategies to capitalize on a federal drive toward increased cross-program integration and flexibility. Examples include Louisiana’s Permanent Supportive Housing initiative, South Carolina’s Nurse-Family Partnership Pay for Success initiative, and Vermont’s Supports and Services at Home. This session is presented in partnership with the de Beaumont Foundation.
- Bryan Amick, Acting Deputy Director for Health Programs, South Carolina Department of Health and Human Services
- Ana Novais, Executive Director of Health, Rhode Island Department of Health
- Jenney Samuelson, Associate Director, Vermont Blueprint for Health
- Robin Wagner, Deputy Assistant Secretary, Office of Aging and Adult Services, Louisiana Department of Health
Presented in partnership with the de Beaumont Foundation
Related NASHP Resources:
- Webinar: Braiding and Blending Funds to Meet Health-Related Social Needs: Lessons from Louisiana and Virginia
- Publication: Braiding Funds to House Complex Medicaid Beneficiaries: Key Policy Lessons from Louisiana
- Publication and Infographic: Pooling and Braiding Funds for Health-Related Social Needs: Lessons from Virginia’s Children’s Services Act
- Publication and Infographic: Braiding and Blending Funding Streams to Meet the Health-Related Social Needs of Low-Income Persons: Considerations for State Health Policymakers
Preterm birth, which accounts for approximately 11.5 percent of all births and 50 percent of pregnancy-related costs, is the largest cause of infant morbidity and mortality. This creates a significant burden on the U.S. healthcare system. A leading strategy for decreasing infant morbidity and mortality related to preterm birth is for states to use perinatal regionalization, a designation system where infants are born in or transferred to specific facilities based on the amount of care needed.
Regionalization of perinatal care is characterized by a tiered system of risk-appropriate care delivery whereby hospitals choose or are given specific designations based on the level of care they can provide. The system’s purpose is to ensure that high-risk mothers and infants are cared for at appropriate level facilities. For example, evidence suggests that an infant born at less than 32 weeks gestation or weighs less than 1500g should be cared for at a Level III facility with a neonatal intensive care unit. Perinatal regionalization has been shown to improve maternal and neonatal outcomes, and to be cost effective.
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization.
Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system.
A new joint issue brief by the National Academy for State Health Policy (NASHP) and NICHQ explores Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered.
For more information, download and read the new issue brief.
State Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
For example, California has identified transportation as a critical element to its perinatal regionalization system and, more broadly, the health of high-risk mothers and infants. The provision of transportation can be challenging due to both the structure of their perinatal regionalization system and the different modalities used for providing transportation under the Medi-Cal Benefit (e.g. Local County Agreements and/or Fee-for-service and Medicaid managed care systems). In regards to transportation services, Medi-Cal currently serves as the payer of last resort. However, when Medi-Cal eligible individuals need coverage for transportation services, Medi-Cal will cover the cost from either fee-for-service or managed care delivery systems. Transportation to a hospital as well as transfer between hospitals is also a common benefit in health plans available under the California Medi-Cal Access Program. Medi-Cal’s Comprehensive Perinatal Services Program also partners with the California Perinatal Transport Systems and Regional Perinatal Programs of California to promote and cover services integral to perinatal regionalization. These two programs are supported by the state Title V Maternal and Child Health Services Block grant.
The Georgia Medicaid Program plays a key role in funding the Georgia Regional Perinatal Care Network (GRPCN) along with state general revenue funds appropriated to the Georgia Department of Public Health (DPH). GRPCN is managed under the DPH. GRPCN is made of up six regional care centers for the treatment of high-risk mothers and infants. These six centers are designated based on regional need and available funding. The GRPCN’s funding comes from Medicaid, state funds appropriated to the DPH and state matched funds. Available funding is intended to support costs associated with cost of care, and regional center administrative costs for outreach, education and transportation services. Georgia also uses the state Title V Maternal and Child Health Services Block grant to support a range of programs and initiatives focused on preventing infant mortality, including perinatal regionalization.
 Anne Rossier Markus, Elie Andres, Kristina D. West, Nicole Garro, and Cynthia Pellegrini, “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform,” Journal of Women’s Health Issues 23, no.5 (2013): e273, doi:10.1016/j.whi.2013.06.006
New issue brief
California Case Study
Georgia Case Study
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization. Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system. This chart includes selected state initiatives and highlights Medicaid as a key partner in financing perinatal regionalization systems.
For more information on Medicaid funding opportunities in support of perinatal regionalization systems, read the blog post and issue brief that further explore Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered. Case studies of California and Georgia demonstrate how state Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
This resource was developed by NASHP in partnership with the National Institute for Children’s Health Quality (NICHQ) as part of the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
|California||The Regional Perinatal Programs of California (RPPC) were established in 1979 due to the need for a more comprehensive network of healthcare providers within specific geographic areas to promote access to high quality levels of maternal and infant care.[ii] Today, the RPPC has divided California into 9 separate regions, each of which include between 18-38 hospitals each.[iii]The California Perinatal Transport Systems (CPeTS) act of 1976 appropriated funds for the development of a dispatch service to facilitate transportation of mother and infants to NICUs.[iv] It also provides collection and analysis of perinatal and neonatal transportation data.|
|Florida||Developed in the 1970’s, Florida’s eleven Regional Perinatal Intensive Care Centers (RPICCs) provide access to high-risk perinatal care and are managed by FL’s Department of Health. Each facility provides community outreach education, and consultative support to other obstetricians and Level II and III NICUs in their areas, in addition to inpatient and outpatient services.[x]|
|Georgia||The Georgia Regional Perinatal Care Network Project (GRPCN) is a statewide initiative funded by the state Medicaid agency and state general funds appropriated to the Georgia Department of Public Health. Georgia’s six regional care centers are designated based on regional need and available funding.[xiii]|
|Illinois[xv]||First adopted in 1976, Title 77 created a perinatal regionalization system through Illinois Administrative code. [xvi] The Illinois Department of Public Health oversees the system and works with a Perinatal Advisory Committee (PAC) that offers recommendations relating to perinatal care. Today, Illinois’ perinatal regionalization system includes 10 administration Perinatal Centers that supervise 122 obstetric hospitals. In additional to a supervisory role, each Regional Perinatal Center has both clinical and administrative responsibilities.[xvii]|
|South Carolina||Established in the 1970’s, South Carolina’s regionalized perinatal system of care, is now made up of five perinatal centers in four regions that contract with the SC Department of Health. Key elements of the system include early risk assessment and referral to appropriate care; coordination and communication between hospitals and community providers; monitoring systems through data; and ensuring access to services from preconception through the first year of life.[xx]|
|California||Medi-Cal works with a variety of different partner programs to ensure coverage and access to services for pregnant women and neonates. These programs include the California Children’s Services Program (CCS),[v] The California Medi-cal Access Program (CMAP),[vi] and the Comprehensive Perinatal Services Program (CPSP).[vii] Through these programs, Medi-cal provides a variety of benefits, but the most notable is reimbursement for transportation services.[viii]|
|Florida||All RPICC Program patients are potential Medicaid Recipients. RPICC Medicaid reimbursement is inclusive for all services provided by the neonatology or obstetrical groups. [xi] The Agency for HealthCare Administration pays claims for inpatient-only services provided to Medicaid recipients by neonatologists and obstetricians enrolled in RPICC with Medicaid funds.|
|Georgia||Georgia Department of Public Health services for Medicaid members include: Perinatal Health Partners (PHP), Perinatal Case management, and Presumptive Eligibility Determination. [xiv]|
|Illinois[xv]||Two main programs offering coverage are available for pregnant women: Medicaid Presumptive Eligibility (MPE) which offers immediate temporary coverage for pregnant women who meet income requirements (outpatient care) and Moms & Babies, which covers healthcare during pregnancy and 60 days post-partum (inpatient, outpatient, and transportation).[xviii] Illinois’ Medicaid managed care plans are required to pay for and ensure the same level of care for pregnant women as in the fee-for-service benefit package.|
|South Carolina||Overall, the ability to link and contract with Medicaid providers has been difficult due to variations in policies and services of the Medicaid managed care plans. [xxi]|
|California||Funding for the RPPC and CPeTS is provided via Federal Title V Maternal and Child Health (MCH) Block Grant Funds.[ix]|
|Florida||The RPICC program is funded through a combination of Federal Title V MCH Block Grant Funds and Medicaid dollars. [xii]|
|Georgia||GRPCN is jointly funded by Georgia Medicaid and the Georgia Department of Public Health.|
|Illinois[xv]||IDPH allocates state funds to target preventative services, and provide grants to designated APCs responsible for the administration and implementation of the perinatal program.[xix]|
|South Carolina||Majority of the funding is through SC Department of Health and Hospitals. Additional funds are provided by the Title V MCH Block Grant.[xxii]|
|California||There is a neonatal transportation policy and it includes maternal transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Florida||There is a neonatal transportation policy and it includes maternal transportation and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Georgia||There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants, and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Illinois[xv]||There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants and mothers, and inter-hospital transportation.|
|South Carolina||There is a neonatal transportation policy and it includes maternal transportation, back-transportation for infants, and inter-hospital transportation.|
[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[ii] “Regional Perinatal Programs of California Fact Sheet,” California Department of Public Health, Accessed August 24, 2016, https://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/RPPC.aspx[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[iii] California Department of Public Health- Maternal, Child, and Adolescent Health Program – Epidemiology, Assessment, and Program Development Branch, “Regional Perinatal Programs of California (RPPC),” October 2015, https://www.cdph.ca.gov/programs/rppc/Documents/RPPC_Regions_Oct2015.pdf
[iv] California Perinatal Transport System, “California Perinatal Transport System,” Accessed August 24, 2016, https://www.perinatal.org/
[v] California Department of Health Care Services, “Program Overview – California Children’s Services,” Accessed August, 29, 2016, https://www.dhcs.ca.gov/services/ccs/Pages/ProgramOverview.aspx
[vi] California Department of Health Care Services, Medi-Cal Access Program, “What Services are Covered in MCAP?,” Accessed August 24, 2016, https://mcap.dhcs.ca.gov/Services/?lang=en
[vii] County of Los Angeles Public Health, “Comprehensive Perinatal Services Program,” Accessed August 24, 2016, https://publichealth.lacounty.gov/mch/cpsp/CPSPwebpages/cpsp_rev.htm
[viii] “Medical Transportation – Ground,” in: California Code of Regulations, 2015, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi7_PmV7trOAhXDHx4KHScUBtkQFggeMAA&url=https%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart2%2Fmctrangndcd_a05.doc&usg=AFQjCNFzBYxIjWfYOw5gAKxm32BkzRkHug&sig2=QFlVSnGrnpIL6_Y7Sjbd2Q
[ix] California Department of Public Health, “Maternal and Child Health Services Title V Block Grant – California,” 2015, https://www.cdph.ca.gov/programs/mcah/Documents/Title%20V%202016%20Application%202014%20Report%20final.pdf
[x] Children’s Medical Services (CMS), “Regional Perinatal Intensive Care Centers,” Accessed August 29, 2016, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/rpicc.html
[xi]Florida Department of Health, Regional Perinatal Intensive Care Centers Handbook, August 2010, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/documents/rpicc_handbook.pdf
[xiii] National Perinatal Information Center, “Medicaid Funding – The Georgia Regional Perinatal Care Network, Accessed August 24, 2016, https://www.npic.org/projects/MedicaidFunding.php
[xiv] Georgia Department of Community Health, “Georgia Public Health Services Available for Medicaid Members,” Accessed August 29, 2016, https://dch.georgia.gov/sites/dch.georgia.gov/files/Georgia_Public_Health_Services_for_Medicaid_Members.pdf
[xv] Bruce Rauner, Felicia F. Noorwood, and Teresa Hursey, Report to the General Assembly, January 2016 – Public Act 93-0536, (2016), https://www.illinois.gov/hfs/SiteCollectionDocuments/perinatalreport2016.pdf
[xvi] Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640: Regionalized Perinatal Health Care Code, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/07700640sections.html
[xvii] Illinois Department of Public Health, “Perinatal Regionalization,” Accessed August 29, 2016, https://www.dph.illinois.gov/topics-services/life-stages-populations/infant-mortality/perinatal-regionalization
[xviii] Illinois Department of Healthcare and Family Services, “Moms and Babies,” Accessed August 29, 2016, https://www.illinois.gov/hfs/MedicalPrograms/AllKids/Pages/MomsAndBabies.aspx#momsbabies
[xix]Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640, Section 640.80: Regional Perinatal Networks – Composition and Funding, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/077006400000800R.html
[xx] Association of State and Territorial Health Officials, “South Carolina’s Perinatal Regionalized System of Care: Reducing Premature Births and Infant Mortality,” (2013), https://www.astho.org/Presidents-Challenge-2013/SouthCarolina/
[xxi] South Carolina Department of health and Environmental Control, Healthy Mothers, Healthy Babies: South Carolina’s Plan to Reduce Infant Mortality & Premature Births, (October 2013), https://www.scdhec.gov/library/cr-010842.pdf
[xxii] The Title V Maternal and Child Health Block Grant funded components include: obstetric and neonatal outreach education, transport coordination, and physician consult and follow-up.
Association of Maternal and Child Health Programs, “South Carolina – Maternal and Child Health Block Grant 2016 State Profile,” Accessed August 29, 2016, https://www.amchp.org/Policy-Advocacy/MCHAdvocacy/Documents/South%20Carolina%202016.pdf
NASHP recently brought together a group of state and federal policy leaders to discuss the Medicare-Medicaid Financial Alignment Initiative, D-SNP health plans, and other programs and resources aimed at aligning health care payment and delivery to improve care for dual eligibles. See a report from the meeting and sign up for a webinar on state contracting with D-SNP plans, a strategy that meeting participants described as an underutilized tool that states can use to advance positive change.
Read the full report here.
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.
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.
State agencies across the country, from Medicaid to public health, to social services and corrections, are deeply engaged in multi-sector initiatives to reduce infant mortality. And for good reason — the United States ranks 25th among industrialized countries in infant mortality with a disproportionate number of being African Americans.
Despite the gravity of the problem, infant mortality is responsive to policy and prevention strategies. There are recognized risks including smoking, limited pre/interconception care, unsafe sleep practices, and pre-term birth as well as evidence-based interventions that require a multi-sector approach.
NASHP’s 29th Annual State Health Policy Conference a session on infant mortality featured a snapshot of three state approaches: Colorado, Indiana, and South Carolina. Each of these states has developed a public/private partnership committed to comprehensive strategies that address both medical and social factors related to infant mortality. Each has participated in HRSA’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), identified state policy levers, and documented success stories.
Colorado’s Nurse-Family Partnership (NFP) has produced many positive outcomes. In fact, cumulative data as of December 31, 2015 shows that in 61 of the 64 counties served by the program, 90 percent of babies were born at a healthy weight and 91 percent of babies were born at full term . Because the NFP serves only first-time mothers, Health First Colorado, the state’s Medicaid program, offers Prenatal Plus to provide case management, nutrition counseling, and psychosocial services to all pregnant women at risk for negative maternal and infant health outcomes. These negative outcomes may be due to numerous lifestyle, behavioral, and non-medical factors that could affect pregnancy including a lost job or excessive debt, partner in jail, or prior low birth rate infant.
Health First Colorado has also devised strategies to ensure the accessibility of Long-Acting Reversible Contraception (LARC). The program pays full purchase price for LARC and a fee schedule rate for insertion at a physician’s office. Federally Qualified Health Centers (FQHC) are reimbursed through a Prospective Payment System (PPS) encounter rate based on full-costs for LARC devices and insertion. Health First Colorado received approval from CMS to pay free standing Rural Health Clinics (RHC) a separate payment for LARC devices because their PPS is not based on full cost methodology. The insertion of LARCs at an RHC is still paid at their PPS encounter rate. The state is also working with providers to reduce the rate of C-sections in low-risk, first time moms, and is considering options to provide physicians with information on their own C-section rates to encourage quality improvement.
Indiana’s Perinatal Quality Improvement Collaborative recognizes the value of multi-sector partnerships and data-driven evidence-based strategies. Through a public/private partnership, the state Medicaid agency was able to establish a policy for nonpayment for early elective delivery. A Management and Performance Hub collects information from a variety of state data sources, including Medicaid, the Department of Corrections, and multiple State Department of Health sources including HIV/STD and Maternal and Child Health. This collection of data sources has assisted the state in identifying three distinct high-risk subpopulations that account for only 1.6 percent of the sample population but nearly 50 percent of infant deaths. This information has enabled the state to target interventions. These high-risk subpopulations include low birthweight, preterm birth, and limited access to prenatal care, the most significant factor identified.
As a demonstration of state commitment, the Safety PIN (Protecting Indiana’s Newborns) grant program enacted by the Indiana Legislature in 2015 appropriates $13.5 million to reduce infant mortality: $2.5 million will support development of a two-way app for pregnant women to encourage better prenatal care and $11 million will be distributed through a competitive grant program to nonprofit organizations, local health departments, and health care entities for innovative approaches to address infant mortality.
South Carolina’s Birth Outcomes Initiative is a public/private partnership of payers, providers, and other partners. Among its achievements are a dramatic reduction in early elective deliveries partly as a result of Medicaid nonpayment policies. Additionally through the initiative the state saw a 110 percent increase in LARC insertions in the past two years, and a decrease in infant mortality of 23 percent among non-white populations, and a 9 percent decrease overall.
South Carolina is the first state to initiate a pay for success model for birth outcomes, developed through a 1915(b) waiver in partnership with its NFP and the Children’s Trust. The program will enroll approximately 4,000 additional mothers in NFP evidence-based home visiting services over a four-year period. The waiver allows for “non-statewideness,” enabling the program to focus on communities most at risk. Through a combination of philanthropic support and Medicaid funding, the program provides upfront capital to expand services. Full success payments begin only if an independent randomized controlled trial finds that the NFP can meet the outcome targets: a reduction in preterm births by 15 percent, reduction in child injuries by 26 percent, and an increase in birth spacing by 20 percent. Other success payments will be made only if at least 65 percent of those enrolled reside within a set of targeted rural and underserved communities.
These states provide a snapshot of policy and financing levers that, as part of a comprehensive strategy, can make an impact on infant mortality. Questions remain about how best to capitalize on the momentum and develop complementary policy and programmatic approaches. For instance, what approaches can reduce the significant disparities as evidenced by an African American infant mortality rate that is two to three times higher than for the white population in each of the three states profiled? What are the most effective strategies for engaging African American communities in efforts to develop patient- and community-centered approaches? Some communities may be distrustful of LARC interventions unless they know the state policies for removal of the devices. In two of the three states profiled, Medicaid policies place limits on when removal is covered. In South Carolina they are covered when medically indicated and in Colorado coverage is provided when the medical provider and client are currently enrolled in the Medicaid program at the time of the LARC removal. What interventions are most effective in addressing social factors that contribute to infant mortality? Lessons will continue to emerge as all states continue to innovate and wrestle with these questions.