Before Back-to-School: Medicaid Financing of Early Childhood Home Visiting Programs

By Katharine Witgert
September 2012

It’s back-to-school time in many families, but kids – and moms – can benefit from teaching and learning much earlier in life, too. Home visits to new and expectant mothers help ensure that both mothers and children receive needed health services and can improve health and life outcomes in cost-effective ways. The Affordable Care Act (ACA) raised the profile of home visiting through the Maternal Infant and Early Childhood Home Visiting (MIECHV) program. Funding from MIECHV allows all 50 states to test home visiting models and expand those that meet standards of effectiveness. MIECHV’s $1.5 billion funding is available for five years. Medicaid is onepossible source of funding to help bring evidence-based home visiting programs to scale and ensure their long-term sustainability.

In a recent report, Medicaid Financing of Early Childhood Home Visiting Programs: Options, Opportunities, and Challenges, supported by the Pew Center on the States, NASHP explored the Medicaid financing mechanisms that are being or potentially could be used to support home visiting services. Five commonly used Medicaid financing mechanisms are:

• Targeted case management
• Administrative case management
• Enhanced prenatal benefits
• Managed care
• Traditional medical assistance services (fee-for-service)
  (For brief definitions of these terms, click here.)

The report’s case studies illuminate the mechanisms most commonly in current use. For example: Kentucky’s HANDS program uses Medicaid targeted case management to provide home visiting services to high-risk first-time parents. Illinois’ program, “Family Case Management,” uses administrative case management to finance home visits. And Michigan uses traditional fee-for-service billing to reimburse nurses and social workers who deliver home visits in the Maternal Infant Health Program. In addition, Washington’s First Steps program uses two mechanisms simultaneously: fee-for-services billing to provide home visiting services to mothers and targeted case management for home visiting services provided to infants.
Other Medicaid financing options may also lend themselves to funding services provided as part of a home visiting program. A NASHP-facilitated panel of federal, state, and non-profit sector experts, hosted by the Pew Home Visiting Campaign, concluded that some of the most likely options are:

• Section 1905(a) preventive services: Federal law allows states to provide broadly defined “preventive services” to Medicaid beneficiaries. A state could make the case that evidence-based home visiting programs can prevent negative health outcomes and should therefore be included as a preventive service.
• EPSDT: The Medicaid statute requires states to provide eligible children with periodic health screenings and with needed health care services identified through those screenings. In theory, a bundle of services could be created within EPSDT to be delivered through home visiting.
• §1915b Medicaid waiver: This waiver is most commonly used by states instituting Medicaid managed care. But, it can also be used by states to selectively contract with specific providers for specific services. Using a §1915b waiver, a state could define a home visiting service package and develop a set monthly payment for that package.

States that wish to support home visiting services through Medicaid must first choose the most appropriate financing mechanism for their circumstances – taking into consideration the population served, services offered, providers delivering services, and federal matching rates – and should work closely with CMS to develop the necessary state plan amendments (SPAs) or waivers. Medicaid may be one important source of financing to support home visiting services, but will likely need to be combined with other financing mechanisms to ensure all necessary home visiting services can be delivered to all families who could benefit from them. Home visiting programs and Medicaid agencies can work together to ensure that families get the early childhood health services that set them on the path to lifelong success.