Home visiting programs play a critical role in improving the health and well-being of women, children, and their families by delivering voluntary health, educational, and social services.[1] States support home visiting services through a complex arrangement of public and private funding, with additional federal funds recently authorized by the 2023 Consolidated Appropriations Act.
These investments have helped to dramatically increase the number of women and children served by home visiting programs over the past decade.[2] Despite these investments, many states’ home visiting programs only reach a fraction of eligible families due to insufficient resources and funding.[3]
Most individuals participating in home visiting programs are enrolled in Medicaid.[4] As of 2022, at least 28 states offer home visiting services within their Medicaid programs to better address the unique needs of their beneficiaries. This analysis details how states structure Medicaid reimbursement for home visiting services across a diverse array of federal authorities, benefit categories, and financing mechanisms.
History of Medicaid Financing of Home Visiting
Home visiting is a long-standing strategy that states use to improve the health and well-being of women, children, and their families, particularly for those living in underserved or historically marginalized communities. While there are differences across home visiting programs, common home visiting services include case management and care coordination, screenings for physical and social-emotional needs, and family support and counseling.[5] The benefits of home visiting services are well-documented and are associated with improved outcomes and demonstrated cost savings due to reductions in avoidable health service utilization.[6, 7]
Financing of home visiting services is essential for ensuring access to high-quality services for eligible individuals. States finance home visiting services through public and private funding streams, including state general revenue, public insurance financing (e.g., Medicaid), and federal funding from the Maternal and Infant Early Childhood Home Visiting (MIECHV) program — the largest federal funding source supporting home visiting. Despite these investments, only an estimated 15 percent of the more than 465,000 eligible families receive MIECHV services.[8] Over 70 percent of MIECHV participants in fiscal year 2021 were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).[9] As such, the strategic use of public insurance financing is a critical strategy to help expand access to home visiting services.
While federal Medicaid law does not allow for the full scope of home visiting services to be covered by state Medicaid programs, states may seek federal approval to support common home visiting services, including screening, case management, and family support and counseling.[10] The extent to which states may leverage federal Medicaid dollars to support home visiting is affected by many complex factors, including limited awareness about which elements of home visiting Medicaid can support, administrative burdens for fulfilling Medicaid reimbursement and reporting requirements, and variability among states’ broader home visiting systems needed to support effective cross-sector financing.[11] (See NASHP’s brief “Public Insurance Financing of Home Visiting Services: Insights from a Federal/State Discussion” for more information.)
Despite these challenges, states are increasingly implementing Medicaid reimbursement for home visiting services. A 2019 report identified 20 states using Medicaid financing to support home visiting, with several states having federal authorization to do so since the 1990s (e.g., Oklahoma and Wisconsin).[12] A separate 2020 report indicated at least 26 states provide Medicaid reimbursement specifically for prenatal or postpartum home visits.[13] NASHP’s analysis identified at least 28 states that provide Medicaid reimbursement for at least some home visiting services (see Table 1), consistent with previous analyses. Among these states, there is significant variation in how they structure Medicaid reimbursement for home visiting. While most states support Medicaid financing of home visiting through a broad range of state plan benefit categories (e.g., targeted case management), eight states do so via a Medicaid program waiver authority. Similarly, the scope of allowable home visiting services eligible for Medicaid reimbursement differs across states. Some states offer reimbursement for a wide range of home visiting services that align with specific Home Visiting Evidence of Effectiveness (HomVEE) models, whereas other states cover only case management-related home visiting services.
Methodology
This policy brief is based on a 50-state analysis of state Medicaid programs that provide home visiting services. NASHP analyzed the following program features:
- The structure of allowable home visiting services, including the federal authority and benefit category
- The provision of allowable services and eligible populations
- The requirement for alignment with evidence-based HomVEE models
NASHP reviewed publicly available Medicaid policy documents, including Medicaid policy manuals, provider updates, and managed care contracts. State Medicaid and MIECHV officials were provided an opportunity to review their state’s information for accuracy. For state-specific information referenced in this brief, see the companion 50-state chart, Medicaid Reimbursement for Home Visiting Services.
Medicaid Federal Authorities and Benefit Categories for Home Visiting
A specific home visiting benefit does not exist under Medicaid. States may cover home visiting under their Medicaid program using individual service components (e.g., case management or screening) that can be rendered in a home setting. As such, state Medicaid programs often structure home visiting services through an array of federal Medicaid authorities and benefit categories — each offering unique administrative and/or programmatic criteria to best fit a state’s needs. The Centers for Medicare & Medicaid Services requires states to receive federal approval to provide Medicaid reimbursement for home visiting services either through their state plan or a Medicaid program waiver (see text box). Most states (22 states) that cover home visiting services under their Medicaid program do so under their state plan, whereas eight states use a Medicaid program waiver (see Table 2).[14]
This analysis identified at least seven different Medicaid state plan benefit categories supporting home visiting. The most common benefit categories include targeted case management (TCM) (10 states), extended services to pregnant women (five states), and early and periodic screening, diagnostic, and treatment (EPSDT) (three states). Most states support home visiting under an optional Medicaid benefit category (e.g., TCM or extended services to pregnant women).
Among states that use a Medicaid program waiver to reimburse home visiting services, six states administer a Section 1115 demonstration waiver, and two states use a Section 1915(b) freedom of choice waiver (see Table 2). At least two states (Arkansas and Massachusetts) support home visiting services through a CHIP health services initiative — which are available for Medicaid and CHIP beneficiaries in both states. At least four states use more than one federal authority and/or benefit category, which may allow these states to support a broader range of home visiting services, target populations, and/or administrative flexibilities.
Overview of Federal Medicaid Authorities
Medicaid State Plan: A Medicaid state plan is a formal agreement between the state and federal government describing how the state administers its Medicaid program. The state plan must align with and abide by federal Medicaid laws to claim federal matching funds. The state plan outlines who will be covered, the benefits covered, criteria for reimbursing providers, and administrative activities.[15] Under Medicaid law, there are mandatory and optional Medicaid benefits — each state approaching coverage of these benefits in a different way.
Medicaid Program Waiver: Medicaid program waivers allow states to test new approaches to service delivery by “waiving” certain Medicaid state plan requirements or federal Medicaid laws. Waivers are typically time-limited and often used to offer specialized benefits to a subset of Medicaid beneficiaries, to restrict enrollees to a specific group of providers, or extend coverage to certain individuals.[16] Common Medicaid program waivers include Section 1115 demonstration waivers and Section 1915(b) freedom of choice waivers.
Scope of Allowable Home Visiting Services under State Medicaid Programs
There is considerable variation in the scope of home visiting services supported by state Medicaid programs. Some states allow Medicaid reimbursement for an extensive range of home visiting services, whereas other states reimburse only one or two specific service components (e.g., case management). As of 2022, assessment is the most common home visiting service under Medicaid, with at least 20 states offering reimbursement (see Table 3). Given the differing terminology used by states, assessment is categorized as any physical, behavioral, or environmental (e.g., home safety) examination to discern the health status of the beneficiary for the purposes of this analysis. For example, an assessment may include a structured tool to assess a child’s needs for health, mental health, or social resources (e.g., food and transportation). Alternatively, some states specify an assessment as a physical examination of the child.
At least 19 states cover some form of skill building and education, including breastfeeding education, parenting skills, nutritional information, family planning, or developmental milestones, among others. Other commonly supported Medicaid home visiting services identified in this analysis include:
- Case management (eight states)
- Development of a care plan (10 states)
- Referral to services (17 states )
- Monitoring and follow-up activities (eight states)
- Screening (10 states)
- Health promotion and counseling (10 states)
Enhanced Home Visiting Services Reimbursed by Medicaid
Home visiting programs deliver high-quality, comprehensive services to improve the well-being and health of women, children, and their families. While home visiting often includes health-focused services, such as screenings or health promotion activities, home visiting services often provide much more. At least 15 states provide reimbursement for enhanced home visiting services beyond those commonly covered by Medicaid. These enhanced services often align with certain evidence-based home visiting programs. Among state Medicaid programs offering enhanced home visiting services, eight states offer maternal depression screening, nutrition education, and/or breastfeeding support. Other notable enhanced home visiting services under Medicaid include:
- Stress management (six states)
- Intimate partner violence screening and/or education (six states)
- Sexually transmitted infection prevention education (five states)
- Tobacco use screening and cessation education (five states)
- Connection to oral health care (five states)
States Requiring HomVEE Models for Medicaid Reimbursement
Nearly half of states (13) require the provision of a specific HomVEE recognized model(s) to receive Medicaid reimbursement (see text box). The most common HomVEE model required by state Medicaid programs is Nurse Family Partnership (11 states) followed by Parents as Teachers (six states) and Healthy Families America (four states). One state (Kentucky) requires Health Access Nurturing Development Services for Medicaid reimbursement (see Table 4). At least three states (Arkansas, Pennsylvania, and Vermont) provide reimbursement for both HomVEE-required models and non-HomVEE home visiting services (e.g., case management). While state Medicaid programs that require specific HomVEE-recognized models generally offer expansive home visiting services, many states that do not require HomVEE-recognized models provide a similar range of benefits.
Home Visiting Evidence of Effectiveness (HomVEE) Models
The Health Resources and Services Administration launched Home Visiting Evidence of Effectiveness (HomVEE) to conduct systematic reviews of early childhood home visiting programs and provide an assessment of the evidence of effectiveness for home visiting models that target families with pregnant women and children from birth through age five. MIECHV requires implementation of specific HomVEE models to receive federal MIECHV grant funds. Select HomVEE models include Nurse Family Partnership, Parents as Teachers, Healthy Families America, and Health Access Nurturing Development Services, among others.
State Medicaid Payment and Delivery Systems for Home Visiting
State Medicaid programs offer benefits through two primary payment mechanisms: fee-for-service (FFS) and per member per month (PMPM) or capitated payments. FFS payments operate by reimbursing providers for each service provided. PMPM payments are generally risk-based payments to managed care organizations on a periodic (typically monthly) basis to provide a defined set of benefits, which may include home visiting. Many states implement both FFS and PMPM payment systems by enrolling Medicaid beneficiaries in managed care organizations to oversee the majority of their health care needs and carving out specific services (e.g., home visiting) to be paid for on a FFS basis.
Nearly 80 percent of states that finance Medicaid home visiting services use FFS, whereas nine states integrate home visiting as part of a PMPM payment (see Table 5). At least six states (Arkansas, Michigan, New Hampshire, Ohio, Pennsylvania, and Vermont) use both FFS and PMPM payments to support home visiting. At least one state (Massachusetts) relies on certified public expenditures to reimburse for home visiting services. Selection of a payment system may depend on the benefit category and scope of allowable home visiting services, the participation of managed care organizations(s) versus community-based providers, and/or the target population. There are no significant differences in reimbursement trends between states that require the provision of a HomVEE model and states that do not. Relatedly, state Medicaid programs that require HomVEE models structure their payment systems nearly evenly between FFS and PMPM.
Populations Eligible to Receive Medicaid-supported Home Visiting Services
All states providing Medicaid reimbursement for home visiting services have specific eligibility criteria. Nearly all states (26) that provide Medicaid reimbursement for home visiting services have eligibility criteria specific to pregnant and/or postpartum people, with some states extending eligibility for home visiting services to parents or caregivers in general. The majority of pregnant or postpartum-specific home visiting programs are available to beneficiaries from the prenatal period to the postpartum period. The duration that home visiting services are available during the postpartum period varies across states. Most states provide home visiting services for 12 to 24 months postpartum, whereas other states limit services to two weeks postpartum. Nineteen states have eligibility criteria specific to children, infants, or newborns. The duration of home visiting services available to children, infants, or newborns varies across states as well. Some states offer these services to newborns within 72 hours after discharge, while other states offer home visiting services to children up to age 21.
Considerations for States Exploring Medicaid Financing of Home Visiting
Medicaid financing of home visiting services is a complex endeavor that looks different in each state. States need to decide which strategy works best and aligns with their specific needs and broader home visiting system. As states explore how to refine or adapt their Medicaid programs to support home visiting, they can consider the following:
- Selecting a Medicaid Federal Authority and Benefit Category: State Medicaid programs support home visiting using a variety of federal authorities and benefit categories. Selection of a particular federal authority and benefit category depends on a complex set of factors, including the scope and duration of the home visiting service(s) offered, the targeted population (e.g., Medicaid-enrolled pregnant people and/or children), and the longevity of the home visiting benefit. While benefits offered under a Medicaid state plan are indefinite, those offered under a waiver are time-limited and require periodic reauthorization. Additionally, state Medicaid programs will also want to consider which federal authority and/or benefit category will best support their existing landscape. For example, a state with a more limited managed care framework may opt to select an authority that allows services to be rendered in a broader network.
- Structuring Effective Reimbursement Mechanisms: Designing effective reimbursement mechanisms for home visiting is multifaceted, in part because of the breadth of home visiting services and availability of multiple public funding streams (e.g., MIECHV grants). Because home visiting is not a discreet service, it is important to calculate a reimbursement rate that reflects the full cost of the home visit, which is often driven by the scope of allowable services and provider type. States may also consider how Medicaid funding can complement other available funding streams for home visiting, particularly MIECHV. A critical component of this work is ensuring staff are trained to navigate complex fiscal requirements and reimbursement structures across funding streams. States may also consider amending their financial systems to track and report on the specific funding source used (e.g., MIECHV versus Medicaid). In doing so, states can work toward building cross-sector financing of home visiting to strengthen access to needed services.[17]
- Aligning Medicaid Home Visiting with a HomVEE Model: As state Medicaid programs implement home visiting services, they will want to consider if, and to what extent, to align with HomVEE model(s). Some state Medicaid programs require the provision of a HomVEE model for Medicaid reimbursement. Other states offer more flexibility by identifying a particular HomVEE model in their Medicaid policy guidance or by providing specific reimbursement rates for a HomVEE model. Other states provide limited or no guidance on the matter. The extent to which Medicaid-supported home visiting services align with a HomVEE model may be influenced by the level of partnership with the state’s MIECHV program and the availability of established HomVEE programming throughout the state. Aligning Medicaid-support home visiting benefits with broader state maternal and early childhood efforts can help to support better coordination of both services and resources.
Conclusion
States are increasingly implementing home visiting services within their Medicaid programs through a diverse array of federal authorities, Medicaid benefit categories, and financing mechanisms. As states continue to explore opportunities within their Medicaid programs to address the unique needs of children and their families through home visiting services, state Medicaid programs will want to consider, in conjunction with their MIECHV partners, how Medicaid policy levers (e.g., benefit categories and reimbursement) can be operationalized to complement the broader home visiting landscape. In doing so, states can optimize available resources, thereby improving access to needed home visiting services and strengthening integration across child-serving systems.
Endnotes
- U.S. Department of Health and Human Services, Health Resources and Services Administration, Centers for Medicare & Medicaid, “Coverage of Maternal, Infant, and Early Childhood Home Visiting Services,” Joint Informational Bulletin, March 2, 2016. www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-02-16.pdf.
- Health Resources and Services Administration, Maternal & Child Health, “Home Visiting Program: State Fact Sheets.” https://mchb.hrsa.gov/programs-impact/programs/home-visiting/state-fact-sheets#:~:text=In%20FY%202021%2C%20HRSA%2Dsupported,children%20in%201%2C065%20U.S.%20counties.
- U.S. Department of Education and Department of Health And Human Services, “Collaboration and Coordination of the Maternal, Infant, And Early Childhood Home Visiting Program and the Individuals with Disabilities Education Act Part C Programs,” Joint Policy Statement, January 19, 2017. www2.ed.gov/about/inits/ed/earlylearning/files/ed-hhs-miechv-partc-guidance.pdf.
- Johnson, K. “Medicaid Financing for Home Visiting: The State of States’ Approaches,” Johnson Group Consulting, January 2019. https://ccf.georgetown.edu/wp-content/uploads/2019/01/Medicaid-and-Home-Visiting.pdf.
“Coverage of Maternal, Infant, and Early Childhood Home Visiting Services,” 2016.
The Potential Cost Savings from Home Visiting due to Reductions in Child Maltreatment, Casey Family Programs, March 2014. www.casey.org/media/evidence-based-home-visiting.pdf.
Michalopoulos, C., et al., “Evidence on the Long-term Effects of Home Visiting Programs: Laying the Groundwork for Long-term Follow-up in the Mother and Infant Home Visiting Program Evaluation,” OPRE Report, September 2017. https://files.eric.ed.gov/fulltext/ED579153.pdf.
Herzfeldt-Kamprath, R., et al., “Medicaid and Home Visiting Best Practices from States,” Center for American Progress, January 2017. www.americanprogress.org/article/medicaid-and-home-visiting/.
“2022 Home Visiting Yearbook: An Overview,” National Home Visiting Resource Center, 2022. https://live-nhvrc.pantheonsite.io/wp-content/uploads/NHVRC-Yearbook-Summary-2022.pdf.
“Coverage of Maternal, Infant, and Early Childhood Home Visiting Services,” 2016.
“Public Insurance Financing of Home Visiting Services: Insights from a Federal/State Discussion,” National Academy for State Health Policy, November 6, 2020. https://nashp.org/public-insurance-financing-of-home-visiting-services-insights-from-a-federal-state-discussion/#toggle-id-8.
“Medicaid Financing for Home Visiting: The State of States’ Approaches,” 2016.
Medicaid and CHIP Payment and Access Commission, “Report to Congress on Medicaid and CHIP,” June 2020. www.macpac.gov/wp-content/uploads/2020/06/June-2020-Report-to-Congress-on-Medicaid-and-CHIP.pdf.
- Several states use more than one federal authority to provide Medicaid reimbursement for home visiting services. As a result, the specified figures are greater than the total number of states with Medicaid financing of home visiting.
Centers for Medicare & Medicaid Services, “Medicaid State Plan Amendments,” www.medicaid.gov/medicaid/medicaid-state-plan-amendments/index.html.
Medicaid and CHIP Payment and Access Commission, “Medicaid Waivers 101,” www.macpac.gov/medicaid-101/waivers/.
- “Managing Multiple Funding Sources to Support Home Visiting Programs,” Maternal, Infant, & Early Childhood Home Visiting Technical Assistance Center, https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/managing-multiple-funding.pdf.
Acknowledgements
This policy brief was written by Veronnica Thompson and Anoosha Hasan. Karen VanLandeghem also contributed to the brief through input, guidance, or draft review. NASHP wishes to thank state Medicaid and home visiting officials, as well as officials at the Health Resources and Services Administration, Maternal and Child Health Bureau, for their review.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. 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.
