States have long-standing programs and investments that support home visiting for women, children and their families. Public insurance financing is a key part of these efforts in many states. A recent national report found that approximately 20 states use Medicaid and CHIP to finance home visiting services.[9] Several policy questions persist concerning the use of public insurance financing and braiding the array of federal, state, and private funding options available to states:
- Limited awareness about which elements of home visiting Medicaid and CHIP can reimburse for;
- Varying knowledge levels among home visiting stakeholders about how to navigate the Medicaid program;
- The administrative burden around tracking and reporting the impact of home visiting services on health outcomes;
- The need for integration and alignment among home visiting services and other child-serving systems; and
- The variability among states’ policy, programmatic, and system considerations resulting in the need for tailored and targeted financing strategies.
State health leaders who participated in the federal/state meeting (see Appendix B) identified the following policy areas that need additional focus and support relating to public insurance financing of home visiting services.
How can states ensure that home visiting programs are fully funded, particularly given the looming fiscal crises, to meet the needs of all eligible families. This requires complex braiding of federal, state, and private funding streams. Home visiting programs provide an array of services and supports to pregnant women, infants, and children, not all of which are Medicaid- and CHIP-reimbursable. Therefore, home visiting programs must be supported by multiple federal and state funding streams. State health leaders expressed the need to ensure that the full array of services (e.g., health services, social supports, home visitor transportation, provider training) are provided through home visiting programs, while leveraging financing of those services that can be covered by Medicaid and CHIP.
Limited awareness about public insurance financing options and the use of federal authorities in Medicaid and CHIP can hinder the use of these options in states. State Medicaid, MIECHV, and Title V MCH programs, and other stakeholders that administer home visiting services expressed the need for additional information and technical assistance about public insurance financing options and how to use and leverage them in states. Home visiting is not a mandated benefit or fully defined set of services under the federal Medicaid program. States must leverage one or more categories of benefits (e.g., case management, preventive services, and home health services) in order to use federal Medicaid and CHIP funds for home visiting services.[10] To leverage them effectively requires an in-depth understanding of the financing options available under Medicaid and CHIP, knowing which services are reimbursable, and strong cross-sector partnerships among state Medicaid and public health programs.
Complexities in state Medicaid and managed care plan rate setting can lead to variability in reimbursement rates for home visiting services among states. Rate setting for Medicaid is a complex process that involves ensuring rates are actuarially sound based on economy, efficiency, and quality.[11] State Medicaid agencies set their own rates for services through an actuarial process that takes into account base utilization, medical trend inflation, and risk adjustment.[12],[13] The actuarial process used to set Medicaid payment rates takes into account cost savings and the benefits of a service over a period of time. In the case of home visiting services, cost savings may not be realized until years after the service is delivered. Additionally, low usage of services can result in lower projected costs for the service, and therefore a lower baseline for the service when determining the overall capitation rate. Home visiting rates for select states underscore this variability – in Oregon, reimbursement is $355 per visit for home visiting delivered through targeted case management, in Minnesota public health nurses are able to bill $140 per visit, and in South Carolina, Medicaid reimburses $176 per visit.[14]
In addition to overall rate setting, state Medicaid agencies also must negotiate rates for home visiting services provided by managed care plans, in states that serve Medicaid beneficiaries through Medicaid managed care. Negotiating rates with managed care plans can be a challenge for several reasons. First, a wide range of services are provided in home visiting, making it difficult to establish a rate that fully covers all components of a home visit. Also, the benefits of home visiting services, like school readiness, reduced crime or domestic violence, and improved parent-child relationships,[15] may not be fully realized while a Medicaid beneficiary is a member of the Medicaid managed care plan and Medicaid enrollees often transition on and off of coverage over time, resulting in a potential disincentive for health plans to invest in services.
Medicaid and CHIP reimbursement rates can impact the availability of home visitors. Because home visiting is not a discrete service, reimbursement rates may be lower than what is needed to cover a full home visit, which includes costs for transportation for the home visitors and assistance in accessing non-Medicaid related services. Reimbursement levels can hinder the ability of states and community-based organizations to hire and retain professionals (e.g., public health nurses and other health and social service professionals) who deliver home visiting services. In a national survey of home visiting program managers, low salary was the most common reason (51 percent) for staff turnover.[16] Home visitor workforce shortages can lead to an inability for programs to fully reach and support the large population of families that need and can benefit from services.
Navigating state Medicaid billing policies and billing codes when providing services using a two- generation approach requires dedicated staff time. Home visiting programs are intentionally designed using a two-generation approach – a model that promotes caring for the mother and child together as one unit. In this case, determining correct codes for billing can be complicated and also depend on state Medicaid policy for Medicaid reimbursement of two-generation services. Federal guidance allows states to reimburse for services to a Medicaid-eligible mother or a Medicaid-eligible child for services that actively involve the child, are directly related to the needs of the child and such services must be delivered to the child and mother together, but can be claimed as a direct service for the child.[17] Given the different funding streams used to support services, administrators need to know what types of providers can be reimbursed by which funding streams (e.g., Medicaid or MIECHV) and the appropriate billing codes and procedures for all of the different services that home visitors provide.
Rules governing qualified provider requirements in Medicaid state plan amendments can limit which home visitors are reimbursed. Evidence-based home visiting models vary in their requirements for who qualifies as a home visitor.[18] Some programs require that nurses conduct a home visit, while other programs promote the use of community health workers or other trained staff. Federal Medicaid law[19] allows states to set reasonable standards relating to qualifications of providers under Medicaid.[20] Depending on the benefit, services can be provided by unlicensed practitioners who meet qualifications established by a state. Such benefits include the case management benefit, preventive services, and rehabilitative services benefit. Examples of reasonable standards states must set for providers include the ability to perform the service in a professionally competent manner and the infrastructure to bill.[21] State policies vary regarding terms for qualified providers for home visiting. Some states set the qualified provider based on the home visiting model being used (e.g., nurse family partnership), while others may use local health departments or other community-based organizations that already have qualified providers to deliver services.[22] The types of providers a state deems to be an eligible qualified provider may not always include the provider who is the home visitor. Additionally, in most cases the qualified provider rendering the home visiting service is not the same as the qualified billing provider (e.g., a physician, local implementing agency, or health department), which can add another layer of complexity to Medicaid reimbursement.
Navigating federal Medicaid authorities such as waiver requirements can impact the use of some Medicaid strategies. Federal Medicaid Section 1115 demonstration project authorities provide states with additional flexibility to design policy initiatives and programs that improve health care for Medicaid beneficiaries. The federal Section 1115 Medicaid waiver, for example, is a research demonstration waiver that is approved for an initial five-year period, and can be extended for up to an additional three to five years depending on the populations served.[23] A few states (e.g., Maryland and Vermont) have used Section 1115 waivers to support home visiting through Medicaid.[24] However, states at the meeting discussed that due to the intricacies of the federal waiver process this strategy is not commonly used to support home visiting services. One factor may be that states are required to demonstrate budget neutrality over the life of the demonstration project, usually lasting just a few years. While some home visiting outcomes, like those for pregnant women and newborns, may be more immediate, other health outcomes may not be evident until several years after the service is provided. Because of this states can experience challenges in demonstrating cost savings to continue to use Medicaid dollars through the 1115 demonstration waiver.[25]
Lack of alignment across federal and state data reporting requirements adds to complexities in demonstrating the impact of home visiting programs. States must submit separate federal program reports for different performance measures and indicators across the programs that support home visiting, creating challenges for state performance reporting. States often have to implement planning processes and dedicate resources to integrate home visiting efforts, create data tracking and reporting systems that align measures across an array of programs, and ultimately, build a statewide integrated home visiting program from multiple federal and state funding sources. These challenges are compounded by a lack of staff capacity to report on data, inadequate state reporting systems, and lack of comparability of data and reporting measures across federal programs including Medicaid and CHIP. Most states have few-to-no home visiting data tracking and reporting systems that fully capture home visiting data and thus, ease the reporting process as it relates to home visiting.