Early in Washington’s Medicaid and early childhood home visiting collaboration, it was clear we needed a common understanding of home visiting services compared to home-based Medicaid services. As it happens, there are some significant differences! Although the Centers for Medicare and Medicaid Services (CMS) does not authorize home visiting models in their entirety, they do encourage states to pair Medicaid, state dollars, and private resources to create and fund a home visiting benefit package.

To create such a benefit package, policymakers, funders, advocates, and service providers need to be grounded in shared knowledge. Generally speaking, the two worlds differ in the following ways:

Even with that grounding, it’s still important to dig a bit deeper to answer the question of just what it means when someone reports Medicaid is funding home visiting in a certain state. Just as each state’s Medicaid plan is different, they also coordinate and finance maternal and early childhood home visiting in different ways. It’s important to differentiate between:

• A set of discrete, allowable home visiting services provided by proprietary models such as NFP, PAT, or Family Connects.
• A maternal-infant case management program developed by the State’s Medicaid agency, such as WA’s First Steps Maternity Support Services and Infant Case Management program or Michigan’s Maternal and Infant Health Program.
• A maternal-infant case management program developed by the State’s Medicaid agency that also meets the Department of Health and Human Services’ Home Visiting Evidence for Effectiveness (HOMVEE) criteria for Maternal, Infant, and Early Childhood Home Visiting (MIECHV).

Understanding the type of program can help avoid confusion and get to the heart of the question: To what level and how is Medicaid funding those programs?

Fully Medicaid-funded maternal and infant case management programs are developed by states within their Medicaid State Plans and approved by CMS. Program funding limits are determined by the amount of allocated state match. These programs are quite different from proprietary home visiting models. Some states have invested in modernizing their maternal and infant case management programs, been determined evidence-based, and are now also eligible for Maternal Infant Early Childhood Home Visiting (MIECHV) funding.

States accessing Medicaid for proprietary home visiting mostly use Targeted Case Management (TCM) to cover allowable services. TCM services typically include helping families identify and access medical, social, educational, or other needed community services and may include screenings, assessments, referrals, and care plan development. Additionally, TCM allows states to expand the provider pool beyond licensed and credentialed health care providers. This is critical for home visiting models that focus on provider education, trusted community connections, and model-specific training.

Likewise, the use of Medicaid waivers allow a greater latitude in provider type. Waivers also give states the chance to fund proprietary home visiting models through selective contracting. The goal is to show medical cost-savings through home visiting services. However, waivers are time-limited, and states must still identify funds to cover services not authorized by CMS.

States vary in their Medicaid payment approaches. Some use fee-for-service by timed unit or per visit. Some develop encounter rates. Some assign a cost per enrollment slot based on a prospective payment approach and reconcile services and payments at the end of their fiscal year. Managed care integration as a payment mechanism is an emerging approach, but it’s more typical to see coordination and referrals required across systems. In Washington, there’s an extra consideration as federal and state funds allocated to home visiting must sit within the Home Visiting Services Account (HVSA) under RCW 43.216.130.

And where has all this research led Washington State in their journey to developing Medicaid financing strategies for home visiting?

In 2018, Washington state legislation required the Health Care Authority (HCA) to provide recommendations building upon research and strategies identified in earlier work. Accordingly, HCA and the Department of Children, Youth and Families (DCYF) conducted a series of community workshops to help inform policy and funding decisions. Not surprisingly home visiting providers across the state consistently expressed the need for Medicaid financing to flow through the centralized HVSA administrative and reporting structure. Therefore, a key strategy remains the proactive alignment across Medicaid and early childhood home visiting to best leverage, maximize, and ensure the non-duplication of limited resources.

Based on community input and discussion reflected in the 2019 legislative report, HCA and DCYF are developing a joint funding proposal for the 2020 Washington state legislative session to fund home visiting services through:

• A state plan amendment to reimburse targeted case management services provided by DCYF home visiting programs funded through the Home Visiting Services Account (HVSA).
• Medicaid managed care contracting for reimbursement of home visiting services provided by HVSA-funded programs which could include clinical, behavioral health, and case management services.

Stay tuned for updates as HCA and DCYF begin their work to determine fiscal impacts for Medicaid federal financial participation, and develop their joint legislative budget proposal. What an exciting time to take on cross-sector policy and financing work that can so positively impact the lives of so many!