Medicaid Financing of Early Childhood Home Visiting Programs: Options, Opportunities, and Challenges

PEW CENTER ON THE STATES | NATIONAL ACADEMY FOR STATE HEALTH POLICY HOME VISITING JUNE 2012

The Pew Center on the States is a division of The Pew Charitable Trusts that identifies and advances effective solutions to critical issues facing states. Pew is a nonprofit organization that applies a rigorous, analytical approach to improve public policy, inform the public, and stimulate civic life.

The Pew Home Visiting Campaign partners with policy makers and advocates to promote smart state investments in quality, voluntary home-based programs for new and expectant families.

The National Academy for State Health Policy (NASHP) is an independent academy of state health policymakers. We are dedicated to helping states achieve excellence in health policy and practice. The organization provides a forum for constructive, nonpartisan work across branches and agencies of state government on critical health issues facing states.

PEW CENTER ON THE STATES Susan K. Urahn, managing director

Writers Editors Publications and Web Katharine Witgert Nicole Barcliff Jennifer Peltak Brittany Giles Jennifer V. Doctors Evan Potler Amanda Richardson Libby Doggett Frederick Schecker Carla Uriona

For additional information, visit www.pewstates.org.

This report is intended for educational and informational purposes. References to specific policy makers or companies have been included solely to advance these purposes and do not constitute an endorsement, sponsorship or recommendation by The Pew Charitable Trusts.

©2012 The Pew Charitable Trusts. All Rights Reserved.

901 E Street NW, 10th Floor 2005 Market Street, Suite 1700 Washington, DC 20004 Philadelphia, PA 19103 Contents

Introduction...... 1 Appendix B: Medicaid and Home Visiting Background ...... 3 State Case Studies ...... 26 Commonly Used Medicaid Illinois...... 27 Financing Mechanisms...... 7 Kentucky...... 30 Other Potential Medicaid Financing Mechanisms...... 13 Michigan ...... 33 Braided Funding: Combining Minnesota ...... 38 Medicaid with Other Funding Vermont...... 42 Sources...... 17 Washington ...... 46 Conclusion...... 21 Appendix C: Appendix A: Medicaid Glossary...... 51 Additional Potential Medicaid Financing Mechanisms for Appendix D: Specific Circumstances...... 23 States Using Medicaid to Finance Home Visiting ...... 54 Appendix E: Letter from Centers for Medicare and Medicaid Services Regarding Coverage Options...... 55 Methodology...... 56 Acknowledgments...... 57 Endnotes ...... 58

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS i ii PEW CENTER ON THE STATES Introduction

Home visits to new parents and young been growing in its potential to finance families help ensure that both mothers and home visiting services for eligible mothers children receive the health services they and children. need to thrive. Home visiting programs vary widely in scope and intensity, but The Pew Home Visiting Campaign studies of certain models have found them engaged the National Academy for State effective at improving outcomes for both Health Policy (NASHP) to investigate new mothers and young children. how states are using — or could use — Medicaid to finance home visiting services. Various funding streams — federal, state, NASHP conducted a literature review and private — support state home visiting and a scan of state policies and practices programs. Recently, however, in light of nationwide to identify mechanisms for Medicaid’s ability to reach so many low- supporting home visiting services through income and at-risk women, interest has Medicaid and facilitated an expert meeting

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 1 INTRODUCTION

at which state and federal government services, Early and Periodic Screening, representatives and national home Diagnosis, and Treatment (EPSDT), and visiting experts discussed the benefits and 1915b Freedom of Choice waivers. The challenges of different Medicaid funding panel also identified four additional mechanisms. mechanisms — Home and Community Based Services (HCBS) waivers, Within the Medicaid program, various benchmark plans, home health services, mechanisms are available to support home and family planning services — that might visiting programs. Five of these were found be applied in specific circumstances. to be currently in use by states: targeted case management, administrative case This report discusses the findings of management, enhanced prenatal benefits, the NASHP scan and the expert panel traditional medical assistance services, and regarding both currently used and managed care. potential additional mechanisms through which Medicaid could pay for home Other Medicaid financing mechanisms visiting and provides state examples where may also lend themselves to funding applicable. Six in-depth case studies home visiting services. The expert panel illustrate states’ experiences with Medicaid discussed several options and felt that financing of home visiting services. three in particular are potentially viable for home visiting: Medicaid preventive

2 PEW CENTER ON THE STATES Background

Many different home visiting program workers, paraprofessionals, or volunteers models are available and often multiple — to participating families. Home visiting home visiting programs operate programs vary widely in both scope and independently of one another within one intensity. Services typically begin during a state. Some home visiting programs follow woman’s pregnancy and may end shortly a federally approved, evidence-based after the birth or continue through the model, others are state-specific adaptations child’s early years. Some programs are of those models, and still others are restricted to first-time mothers while independently developed by states or local others are open to all mothers deemed at agencies (See Table 1).1 risk.2 The services that comprise a home visiting program may include medical care, Each home visiting program consists behavioral health care, health education, of a set of services delivered by trained counseling, and assistance with social providers — registered nurses, social services.3

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 3 BACKGROUND

Table 1 Select Home Visiting Models*

Model Name Description Research-Documented Outcomes

Child FIRST Connects high-risk children, birth to age • Maternal Health six, with a clinician and care coordinator to • Child Development and decrease the incidence of serious emotional School Readiness disturbance • Reductions in Child Maltreatment • Linkages and Referrals

Early Intervention Provides public health nurses who offer • Child Health Program for education to pregnant Latina and African • Family Economic Self-Sufficiency Adolescent American adolescents through the child’s Mothers first year of life

Family Check-Up Helps high-risk parents address challenges • Maternal Health that arise with young children through con- • Child Development and sultation with professionals with advanced School Readiness degrees in psychology • Positive Parenting Practices

Healthy Families Uses trained paraprofessionals to provide • Child Health America support to parents • Child Development and School Readiness • Reductions in Child Maltreatment • Positive Parenting Practices • Family Economic Self-Sufficiency • Linkages and Referrals

Healthy Steps Enhances relationships between health care • Child Health professionals and parents by connecting • Positive Parenting Practices parents with a team of medical practitioners

Nurse-Family Provides one-on-one home visits by a • Maternal Health Partnership trained public health nurse to first-time, • Child Health low-income mothers and their children • Child Development and School Readiness • Reductions in Child Maltreatment • Reductions in Juvenile Delinquency, Family Violence, and Crime • Positive Parenting Practices • Family Economic Self-Sufficiency

*These models represent a subset of those designated by the U .S . Department of Health and Human Services as evidence based at press time . These six models were recognized for evidence of maternal and/or child health outcomes .

Source: U .S . Department of Health and Human Services “Home Visiting Evidence of Effectiveness” found at http://homvee .acf .hhs .gov/programs .aspx .

4 PEW CENTER ON THE STATES BACKGROUND

Several studies have found that certain children in poverty. In addition, 32 states home visiting models are most effective won competitive grants to either develop or at improving maternal and child expand existing home visiting programs.6 outcomes and yielding strong returns on investment for states. Nurse home visiting MIECHV allocates 75 percent of its funding programs, in particular the Nurse-Family to evidence-based home visiting programs Partnership (NFP), have been shown that follow federally approved models.7 to improve children’s health, cognitive (As of December 2011, nine models are functioning, and emotional and behavioral federally approved.) The remaining 25 development.4 Other home visiting percent of grant funds can be spent on models, such as Healthy Families America promising approaches to home visiting, and Child FIRST, have also demonstrated which states must commit to evaluate. This evidence of effectiveness in improving infusion of federal grant funds is driving health and developmental outcomes.5 interest in home visiting and in additional funding options to help states sustain and The Maternal Infant and expand these services. Early Childhood Home Visiting Program Other Funding for Home Visiting Created as part of the Affordable Care Programs and Services Act (ACA), the Maternal Infant Early A variety of public and private funding Childhood Home Visiting (MIECHV) streams support the services that make program provides $1.5 billion over up home visiting programs. Major federal five years for home visiting. MIECHV sources include Temporary Assistance to is a partnership between two federal Needy Families (TANF), the Title V Maternal agencies — the Health Resources and and Child Health Block Grant (Title V), Services Administration (HRSA) and the Individuals with Disabilities Education Act Administration for Children and Families Part C, and Medicaid.8 Each federal, state, (ACF) — which administer the grants, and and private funding stream is characterized the states, which operate the home visiting by its own rules and definitions governing programs. which women and families are eligible for home visiting services, which services To be eligible for grant funds, states are offered, which providers may deliver had to conduct a needs assessment that services, and the length and intensity of included identifying communities that home visits. As a result, public funding for lack home visiting programs. Formula home visiting programs is administered grants were disbursed to all 50 states in by different state agencies through various September 2011 based on the number of categorical funding streams.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 5 BACKGROUND

Proponents of home visiting see the ability of Medicaid to reach many vulnerable In 2003, Medicaid financed women and children as an asset. In 2003, approximately 1.7 million births, Medicaid financed approximately 1.7 million births, or 41 percent of all U.S. or 41 percent of all U.S. births. births.9 The Medicaid eligibility expansions included in the ACA have the potential to — National Governors Association, MCH Update: extend Medicaid-supported home visiting States Increase Eligibility for Children’s Health in 2007 . services to even more new and expectant Washington, D .C .: National Governors Association, 2008 . mothers and young children. Given the high cost of remedial care for poor birth State departments of health and their outcomes, state Medicaid agencies and the maternal and child health programs federal Centers for Medicare and Medicaid often take the lead in administering Services (CMS) have a deeply rooted health-related home visiting programs. interest in assuring healthy pregnancies, State departments of education or child positive birth outcomes, and optimal early welfare typically administer home visiting childhood development. programs with an emphasis on educational development or prevention of child abuse, Home visiting programs not only improve respectively. State Medicaid agencies are the short-term health of children and often involved as payers when particular mothers, they also reduce overall health Medicaid-reimbursable services that care expenditures due to chronic disease are part of a home visiting program are later in life. The purchasing power of delivered to Medicaid enrollees. Less Medicaid can be a significant policy frequently, Medicaid agencies themselves lever for promoting program quality and administer a home visiting program for improving health outcomes. For this their enrollees. (See Washington case study reason, many experts suggest that home in Appendix B, for example.) visiting is a worthwhile investment for Medicaid programs.10

6 PEW CENTER ON THE STATES Commonly Used Medicaid Financing Mechanisms

In 2010, the Pew campaign surveyed state Fifteen states listed Medicaid as a funding agency leaders at offices of maternal and source for at least one home visiting child health, early learning, child abuse program.11 prevention and other state entities with a focus on children’s health and wellbeing An earlier survey, conducted by NASHP in an effort to collect vital funding and for the March of Dimes in 2007, asked other data on home visiting programs in state Medicaid agencies whether they all 50 states and the District of Columbia. offer home visiting through Medicaid as The resulting inventory provides the most an enhanced pregnancy benefit. Thirty- recent information on state home visiting two states reported that they offered this programs and their financing sources. benefit.12 This apparent discrepancy may

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 7 COMMONLY USED MEDICAID FINANCING MECHANISMS

hinge both on which state agencies were surveyed and the specific way the question was asked in the two surveys. Significantly, MEDICAID the Pew inventory asked about offering a FINANCING: home visiting program financed in whole A FEDERAL-STATE or in part through Medicaid, while the PARTNERSHIP NASHP survey identified states offering State funds spent within the home visiting services as a Medicaid Medicaid program are matched by benefit. the federal government based on a formula that takes into account the number of persons living in This distinction is important: home poverty in each state . The federal visiting programs consist of a variable but government’s share, known as comprehensive set of services, including the federal medical assistance medical care, behavioral health care, percentage (FMAP), ranges from 50 i social services, and health education. In percent to nearly 75 percent . When Medicaid expansions take effect in contrast, home visiting services may be 2014, the FMAP for newly eligible discrete medical, social, or educational individuals will be 100 percent ii. activities conducted in the home. State This enhanced FMAP will gradually Medicaid programs may fund components decline to reach 90 percent in iii of comprehensive programs or may choose 2020 . In addition, states receive a federal financing participation to reimburse for discrete, individual (FFP) rate of 50 percent for the home visiting services. There is no federal majority of administrative activities requirement that Medicaid funding be necessary for the proper and applied solely or preferentially to evidence- efficient operation of the Medicaid program iv. based programs.

Within the Medicaid program, various financing mechanisms are available that can be used to fund home visiting i Office of the Assistant Secretary for Planning programs and services. The expert and Evaluation, U .S . Department of Health and Human Services . “Federal Financial panel convened by NASHP discussed Participation in State Assistance Expenditures; the benefits and challenges of various Federal Matching Shares for Medicaid, the Children’s Health Insurance Program, and Aid Medicaid financing mechanisms currently to Needy Aged, Blind, or Disabled Persons for FY 2012 .” http://aspe .hhs .gov/health/fmap12 . in use by states to fund home visiting shtml . services. The major features of each ii Patient Protection and Affordable Care Act [P .L . 111-148 §2001] . mechanism are summarized in Table 2. iii Ibid . iv Email communication from Jean Close of CMS to Kathy Witgert of NASHP .

8 PEW CENTER ON THE STATES COMMONLY USED MEDICAID FINANCING MECHANISMS

Table 2 Commonly Used Medicaid Financing Mechanisms for Home Visiting Services

Targeted Case Administrative Enhanced Managed Traditional Management Case Prenatal Care Medicaid Service Management Benefit

CMS Helps beneficia- Helps beneficia- Allows states to Social Security Medicaid statute Regulations ries gain access ries gain access provide addi- Act §1932 defines mandatory to medical, to Medicaid tional services to and optional social, educa- services; may pregnant women services. [Social tional, and other include eligibility, than it provides Security Act §1905a] services; waives outreach, to other rules that com- and prior Medicaid- parable services authorization eligible individu- be offered to als as long as the all enrollees services are statewide; related to allows states to pregnancy or specify provider conditions that qualifications may complicate [42 CFR 440.169 pregnancy and 42 CFR [42 CFR 440.250] 441.18]

Federal Medical Standard FMAP 50% federal Standard FMAP Standard FMAP Standard FMAP Assistance Per- financial centage (FMAP) participation

State Plan Required Not needed; Required Not needed for Required Amendment reflected in an HV services approved cost allocation plan

Services Assessment and Outreach, Non-clinical and Subject to state Traditional Medicaid Provided reassessment, utilization review, medical services contract with services, location development prior authoriza- related to preg- the Managed of service is client of a care plan, tions, eligibility nancy; includes, Care Organiza- home referrals and determinations but not limited tion (MCO) scheduling, to, prenatal care, monitoring and delivery, post- follow-up partum care, and family planning services

Payment Fee-for-service Subject to the Fee-for-service Subject to state Fee-for-service principles in contract with OMB Circular MCO A-87

Population Specific demo- Activities for Pregnant Subject to state All Medicaid Served graphic popula- the proper and Medicaid contract with recipients statewide tion or eligibility efficient admin- recipients MCO category within istration of the Medicaid state plan

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 9 COMMONLY USED MEDICAID FINANCING MECHANISMS

Targeted Case Management While TCM can be used to reimburse some CMS defines targeted case management portions of home visiting programs, it does (TCM) as those medical assistance services not cover a full package of services. Notably, that help beneficiaries gain access to medical services themselves are not a part medical, social, educational, and other of TCM and must be billed and reimbursed services. TCM includes four components: separately. An additional challenge to assessment services, development of a using TCM cited by the panel is the CMS care plan, referrals and scheduling, and policy that prohibits a case manager from monitoring and follow-up for Medicaid recommending and providing additional enrollees. Services offered as TCM may services at the same visit. To guard against be targeted to a sub-group of beneficiaries conflicts of interest, the state must first (e.g. pregnant or post-partum women) and authorize any recommended additional are not subject to the standard Medicaid services. rules requiring that any Medicaid benefit offered in a state be available to Administrative Case Management all Medicaid enrollees statewide. States Administrative case management (ACM) specify targeted groups to receive TCM in is designed to help Medicaid beneficiaries the state plan amendments filed with CMS gain access to needed medical services. and receive their regular FMAP for TCM ACM activities are available statewide to services. all Medicaid recipients and can include eligibility determinations, outreach, and NASHP’s environmental scan found that securing authorizations needed to access TCM is the Medicaid financing mechanism medical services. The federal government states use most often for home visiting provides 50 percent federal financial services. Benefits of using TCM are the participation for certain ACM activities. ability to target home visiting services to States can offer these activities without filing specific enrollees — women or children a state plan amendment. — and to target services in specific geographic areas. This allows states to ACM is currently used by a few state tailor programs to high-risk women Medicaid agencies (California, Illinois, or to offer services in specific parts of Michigan, North Dakota, Washington, and the state even when services cannot be Wyoming) to reimburse for certain home offered statewide. For example, Kentucky, visiting activities. A major benefit to using which uses TCM to fund a home visiting ACM is that states can limit the entities program, limits participation to high-risk, eligible to deliver Medicaid-funded home first-time parents. visiting. For example, states may require that local health departments conduct home visiting. This allows states to prescribe and monitor the activities provided.

10 PEW CENTER ON THE STATES COMMONLY USED MEDICAID FINANCING MECHANISMS

By definition, ACM cannot be used to The major drawback to offering home reimburse for direct medical services. visiting as an enhanced prenatal benefit Some states, such as Illinois, use ACM to is that women are eligible only during reimburse administrative outreach and pregnancy and for 60 days post partum. coordination activities provided through To provide new mothers and their infants home visiting and then bill Medicaid fee- with Medicaid-funded home visiting for-service (FFS) for any specific medical beyond that time period, states must use services provided. another reimbursement mechanism to pay for those services. Enhanced Prenatal Benefits Recognizing the value of non-medical, Traditional Medical Assistance Services psychosocial support services in The federal Medicaid statute defines the promoting prenatal care, in 1985, mandatory and optional medical assistance Congress gave states the option to services to be provided to Medicaid provide non-clinical benefits to pregnant enrollees.15 (Because these services are women enrolled in Medicaid without defined at Section 1905(a) of the Social also offering the same additional benefits Security Act, they are sometimes known to all Medicaid recipients.13 In 2007, 32 as “1905(a) services.”) States must offer states reported offering home visiting as mandatory benefits and may choose an enhanced prenatal Medicaid benefit for which optional benefits to offer. Each pregnant women. In this context, states state lists the optional benefits offered use home visiting to provide women who to beneficiaries in its state plan. These are pregnant or have recently given birth Medicaid optional services can be offered with pregnancy-related medical and non- by licensed, enrolled Medicaid providers, clinical support services.14 States receive either in a traditional office setting or as the regular FMAP for all services provided part of a home visit. No additional state as enhanced prenatal benefits. plan amendment is needed for offering these services in the home. Offering home visits as an enhanced prenatal benefit has several benefits. First, The main benefit to using 1905(a) home visiting is a recognized service Medicaid services as a way to provide category within enhanced prenatal home visiting services is that no additional benefits. A state can add home visiting administrative actions are required on by filing a state plan amendment with the part of the state. The standard federal CMS and can use the filing to designate FMAP is provided regardless of the place approved providers, define the services of service, though some states reimburse to be provided during home visits, and providers an additional fee for a service ensure consistency of those services.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 11 COMMONLY USED MEDICAID FINANCING MECHANISMS

performed in the home rather than in visiting on a fee-for-service basis as a the office. (Reimbursement forms usually “carve out”16 from managed care. Michigan include a space to note place of service.) requires its contracted Medicaid managed care organizations to, in turn, contract The main drawback to using only with the same providers who deliver the 1905(a) Medicaid services to fund state’s FFS home visiting program. Other home visiting is that it excludes many of states, such as Minnesota, have seen the educational and case management managed care organizations offer home activities that are typically part of a home visiting programs as a way to capitalize on visiting program because they are not their proven cost-effectiveness but do not medical assistance services. Some states, specify home visits as a required service in including Washington, have combined this Medicaid managed care contracts. Where mechanism with TCM to provide a full Medicaid managed care organizations do complement of home visiting services. offer home visiting, however, state agencies often lack direct access to claims or Home Visiting Within Medicaid encounter data, and so cannot adequately Managed Care monitor the service delivery or outcomes. States have several options when home visiting services are offered to Medicaid The extensive and growing use of beneficiaries who are participating in a Medicaid managed care across states — managed care plan. Some states, such as nearly 72 percent of Medicaid enrollees Kentucky and Washington, provide home participated in managed care in 2010 compared with nearly 57 percent of enrollees in 200117 — calls for further investigation of how best to finance home visiting services in the managed care Nearly 72 percent of Medicaid environment. Some considerations for enrollees participated in states wanting to provide home visiting managed care in 2010 compared within managed care include: ensuring providers are included in managed care with nearly 57 percent of organization networks, calculating a per- enrollees in 2001. member, per-month rate for services; and

— Centers for Medicare and Medicaid Services, ensuring contracted services are delivered National Summary of Medicaid Managed Care to eligible enrollees. State contracts with Programs and Enrollment as of June 30, 2009 . managed care organizations can be used to define criteria for home visiting programs.

12 PEW CENTER ON THE STATES Other Potential Medicaid Financing Mechanisms

The previous section examined the potentially feasible and appropriate. States benefits and challenges of the five that wish to pursue any of these options Medicaid financing mechanisms states will need to work with CMS to develop currently use to pay for home visiting the appropriate state plan amendment or services. Additional Medicaid mechanisms waiver. may also lend themselves to funding services provided as part of a home visiting Section 1905a Preventive Services program. NASHP’s environmental scan did As previously discussed, Section 1905a not uncover any home visiting programs of the Social Security Act lists the services currently using these options to finance that state Medicaid programs must and their services. The NASHP-convened may provide. The list of optional services expert panel, however, discussed the includes broadly defined preventive following options and felt that they are services eligible for medical assistance

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 13 OTHER POTENTIAL MEDICAID FINANCING MECHANISMS

payments. Specifically, Medicaid will Preventive services under this section finance “other diagnostic, screening, will be defined by each state as part of its preventive, and rehabilitative services.” Medicaid state plan and must be offered Effective January 1, 2013, the ACA may to all enrollees statewide. A state could afford states a new opportunity to optimize make the case that evidence-based home Medicaid financing for home visiting by visiting programs can prevent negative increasing the FMAP for some of these health outcomes and should therefore be services, including any clinical preventive included as a preventive service. In an services that are assigned a grade of A or August 2011 letter to NFP, CMS suggested B by the U.S. Preventive Services Task this option would be an acceptable Force; certain immunizations for adults; mechanism for financing NFP services, and other medical or remedial services “as long as services are provided by a recommended by a physician or other physician or other licensed practitioner licensed practitioner, including services within the scope of the practice under provided at a home visit.18 States that State law.”(See Appendix E)19 The U.S. include these services in their state plans Preventive Services Task Force is currently and prohibit cost sharing for their delivery reviewing topics including screening and will receive a 1 percent increased FMAP. counseling of alcohol misuse, healthy

14 PEW CENTER ON THE STATES OTHER POTENTIAL MEDICAID FINANCING MECHANISMS lifestyle counseling, and counseling to States can further define a package of prevent unintended pregnancies, in services to be offered under EPSDT. For addition to the many preventive screenings example, Minnesota created a program it already recommends for pregnant of flexible mental health services called women and women of child-bearing age.20 “children’s therapeutic services and supports” through rehabilitative services Participants at the expert panel expressed and included in the state under EPSDT. interest in this option, but it has not These services include individual, group, yet been tested as a mechanism for and family therapy; crisis counseling; and financing home visiting services through the services of a behavioral health aide.22 Medicaid. An interested state would need The state defined the services within to work with CMS to craft a state plan this benefit, required providers to have amendment that either defines a list of certain training, and established a range of services typically delivered at a home payment methods. visit as preventive services or defines a single bundle of home visiting services A similar bundle of services could be for new mothers and young children as a created within EPSDT for home visiting. preventive service. A state would need to work with CMS to define qualifying services and could then Early and Periodic Screening, further define approved providers. States Diagnosis, and Treatment using EPSDT to offer home visiting could The Medicaid statute requires states to include benefits for new mothers younger provide eligible children with periodic than 21 or young children or both. States screening, vision, dental, and hearing would want to assess what proportion of services.21 It also requires states to provide their target population meets the EPSDT children with any medically necessary age criterion. health care services identified through required screenings and diagnosis even if Section 1915b Freedom of the service is not available to adults. These Choice Waiver Early and Periodic Screening, Diagnosis, The §1915b Medicaid waiver, known as and Treatment (EPSDT) services must be a “Freedom of Choice” waiver, is most available to all Medicaid enrollees under commonly used by states instituting age 21 statewide. States receive their Medicaid managed care. A §1915b regular FMAP when providing EPSDT waiver allows states the flexibility to services. forego “statewideness,”23 comparability of services, and the freedom for Medicaid beneficiaries to choose their providers.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 15 OTHER POTENTIAL MEDICAID FINANCING MECHANISMS

That is, states can selectively contract with specific providers for specific services. There are four Freedom of LESS LIKELY Choice waivers, three of which could be MEDICAID useful individually or in combination to FINANCING pay for home visiting services provided to MECHANISMS Medicaid-eligible women and children: The expert panel also discussed other possible Medicaid financing  1915(b)(1) mandates Medicaid mechanisms that might be used enrollment into managed care; to fund home visiting services – the Section 1915c Home and  1915(b)(3) uses cost savings to Community Based Services waiver, provide additional services; Medicaid Benchmark plans, home health services, and family planning  1915(b)(4) limits the number of state plan amendments . These providers for services. financing mechanisms appear to support some of the services By using a §1915b waiver, a state could used in home visiting programs . define a home visiting service package However, the panel concluded that these mechanisms are less well and develop a set monthly payment suited to home visiting services . In for that package. Resulting cost savings specific circumstances, however, could be used to finance the non-medical they may be applicable, so they are services that are sometimes difficult briefly discussed in Appendix A . to reimburse through other Medicaid mechanisms. With this approach, a state also could define the required States interested in pursuing this option qualifications of providers, limit the will have to craft their waivers carefully services to a defined geographic area, or and work with CMS for approval. Section identify a target population to receive the 1915b waivers must be cost effective based home visiting services. Using a §1915b on actuarial rates. Data demonstrating waiver could reduce the administrative the cost-effectiveness of home visiting burden on providers delivering home programs are available and could help visiting services by allowing them to be states with this requirement.24 CMS has paid a fee based on utilization data rather expressed an openness to state flexibility than having to file a reimbursement claim and a willingness to work with states on a for each discrete home visit or service. variety of §1915b waivers.25

16 PEW CENTER ON THE STATES Braided Funding: Combining Medicaid with Other Funding Sources

States can and do use Medicaid in home visiting program participants. While combination with other sources of federal this use of multiple funding streams in (e.g. Title V MCH Services Block Grant), complementary fashion requires careful state (e.g. general revenue funds), and accounting and reporting, such braiding private (e.g. foundation) funding to of funding streams could lead to the most support home visiting programs that efficient use of funds and extend the reach reach both Medicaid-eligible and other and benefits of home visiting programs populations. However, states may only to the largest number of children and spend Medicaid dollars for services and families. activities provided to Medicaid-eligible

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 17 BRAIDED FUNDING: COMBINING MEDICAID WITH OTHER FUNDING SOURCES

Lessons from Early Intervention Medicaid and IDEA regulations permit Financing: Part C and Medicaid Medicaid financing for section 1905(a) As maternal and early childhood services provided under Part C and specify home visiting programs build stronger that Part C is the payer of last resort, partnerships with Medicaid, there is an meaning Medicaid funds are to be used opportunity to leverage the lessons learned before Part C funds to finance Medicaid- from other early intervention programs, covered services for children eligible for which offer a mix of medical and non- both programs. Medicaid billing generally 27 medical services for young children. Early occurs through EPSDT and TCM, and intervention programs were authorized providers must be Medicaid qualified in in 1986 by the Infants and Toddlers order to receive reimbursement. Medicaid- with Disabilities Program (Part C) of the covered services must be medically Individuals with Disabilities Education necessary and may include physical Act (IDEA). Part C is administered at the therapy, speech and language therapy, federal level through the Department psychological and psychiatric services, and of Education, and at the state level by a EPSDT services. Given the history of early range of agencies including education, intervention programs in each state over health, and social services as well as the last 25 years, additional research on some interagency systems.26 Early Medicaid financing of early intervention is intervention programs provide services recommended to identify potential lessons for infants and toddlers (birth to age relevant to the relationship between home three) who have or are at high risk for visiting and Medicaid. developmental delays. Each state defines its own eligibility criteria, services, and A Possible Future for provider requirements; however, services MIECHV and Medicaid typically include physical, occupational, As ACA-funded MIECHV grant programs speech-language-hearing therapies and mature and demonstrate health outcomes, parent-child developmental therapy. Some Medicaid is one possible source of funding states offer more than 90 percent of Part C to help bring home visiting programs services within the home. to scale and ensure their long-term sustainability. State agencies in charge of MIECHV programs may wish to engage their Medicaid agency counterparts to

18 PEW CENTER ON THE STATES BRAIDED FUNDING: COMBINING MEDICAID WITH OTHER FUNDING SOURCES discuss potential financing mechanisms which has raised questions as to whether that can support home visiting services the intent is that the relationship between provided to Medicaid enrollees. Such a Medicaid and MIECHV be the same as partnership could benefit both MIECHV- that between Medicaid and the core Title administering and Medicaid agencies V services. (In the latter instance, Medicaid through the improved health outcomes is the primary and Title V a secondary and cost savings that home visiting payer.) However, the Medicaid regulations programs can achieve. that require interagency agreements with Title V agencies remain unchanged. States The section of the ACA that establishes the that wish to braid MIECHV and Medicaid MIECHV grant program does not explicitly funds should review their interagency cite the portion of Title V that addresses agreements to ensure MIECHV programs interagency agreements with Medicaid, are included.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 19 20 PEW CENTER ON THE STATES Conclusion

Medicaid pays for health care services to Factors to consider include the population enrollees and also makes funds available to be served, the services to be offered, for administrative purposes, including the providers who will deliver services, administrative case management activities and the applicable federal matching that help enrollees obtain medical services. rates. States must also consider the Quality, voluntary home visiting programs administrative burdens involved in provide a combination of medical and preparing a state plan amendment or non-medical services and often struggle waiver, and they will want to work closely to optimize Medicaid’s financing for these with CMS throughout the process. As technically distinct program components. with any complex state plan amendment or waiver process, states may wish to States that wish to support home visiting consult experts who can assist with services through Medicaid must first drafting language, interpreting statutes choose the most appropriate financing and regulations, and making budget mechanism for their circumstances. projections.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 21 CONCLUSION

While it is unlikely that a single Medicaid financing mechanism can fund an entire home visiting program, different mechanisms can fund various services that are part of a comprehensive approach to supporting new and expectant families. Some states are already using a combination of Medicaid funding mechanisms to support home visiting services, and still others are combining Medicaid funding with other sources of public and private funding. In addition, states may have the opportunity to create bundles of services that greatly simplify the administrative burden associated with using Medicaid to pay for home visiting. Ultimately, state home visiting programs will need to embrace a variety of strategies to maximize their resources, most efficiently provide quality services to the greatest number of children and families, and deliver cost savings for Medicaid programs and taxpayers.

22 PEW CENTER ON THE STATES Appendix A Additional Potential Medicaid Financing Mechanisms for Specific Circumstances

The following Medicaid financing traditionally employed by states to serve mechanisms might be used to fund home people with complex needs and avoid visiting services in specific circumstances institutionalization. An HCBS waiver in individual states. A NASHP-facilitated program may provide a combination of expert panel evaluated these Medicaid both traditional medical services as well financing options along with those as non-medical services including case discussed in the body of this report. management. States may administer While the panel concluded that other multiple HCBS waiver programs for mechanisms are likely better suited to different populations and can limit the support home visiting, some states may number of Medicaid enrollees in each. want to consider these options, perhaps in combination with others. Each of States wishing to target home visiting these financing mechanisms appears programs to defined subsets of Medicaid to support some of the services used in enrollees with complex needs could apply home visiting programs. In addition, those a §1915c waiver if the population were states developing a global §1115 Medicaid appropriately defined. However, it may waiver can include home visiting within be difficult to define a population of new that structure. mothers and young children who would be institutionalized but for the availability Section 1915c Home and Community of home visiting services. In addition, Based Services Waiver states are concerned about the increase in Section 1915c Medicaid Home and reporting requirements CMS has instituted Community Based Services (HCBS) for §1915c waivers. States should carefully waivers are available as an option for evaluate whether a §1915c waiver will providing certain services to a defined adequately support the delivery of target population in a state and are maternal and early childhood home visiting services.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 23 APPENDIX A: ADDITIONAL POTENTIAL MEDICAID FINANCING MECHANISMS

Secretary-approved Home Health Services Benchmark Plans Home health services include part-time or The Deficit Reduction Act of 2005 (DRA) intermittent nursing services, home care allows states to develop alternative benefits assistant services, and medical supplies plans for targeted populations of Medicaid and equipment and must be provided enrollees. The DRA defines five types of through Medicaid when medically “benchmark” plans including “Secretary- necessary. At the state’s option, Medicaid approved” plans,28 which states have used also may cover audiology, physical, to target special populations by need, occupational, and speech therapies geography, and risk. To obtain approval delivered in the home. for such a plan, states must submit a state plan amendment using a CMS- Given the common use of the home designed template. Under the DRA, states as the primary service delivery site, can generally require healthy women to home health services may initially be an participate in a benchmark plan. Pregnant appealing Medicaid financing mechanism women with special medical needs can for providing home visiting to pregnant be voluntarily enrolled in a benchmark women, new parents, and young children. plan.29 However, the services included in home health services may not be appropriate to A state could develop a Secretary- include in a maternal and early childhood approved plan targeting pregnant women home visiting program. Two additional or new parents that includes home visiting drawbacks are that a physician must order services. In an August 2011 letter to home health services and that services NFP, CMS suggested that states could must be reauthorized every 60 days. These adopt this approach to providing home requirements are inconsistent with many visiting services to targeted populations home visiting programs that are often or in limited geographic regions. (See designed to use non-physician providers Appendix E.)30 However, enrollment and and to operate for a full year or longer. disenrollment from such a plan would need to be carefully coordinated to avoid gaps in coverage. Similarly, states would need to ensure provider networks in such a plan mirror those in other plans to avoid discontinuity in care. These considerations may make this option impractical for most states.

24 PEW CENTER ON THE STATES APPENDIX A: ADDITIONAL POTENTIAL MEDICAID FINANCING MECHANISMS

Family Planning State Plan a state plan amendment rather than a Amendment waiver.32 The expert panel discussed As of 2008, 27 states had in place whether some home visiting services Medicaid §1115 family planning might fall into the category of family demonstration waivers that allow planning, and concluded that few do. The Medicaid coverage of family planning group did recommend that delivery of services and supplies to women, and family planning services, especially those sometimes men, who are not otherwise provided postpartum, could be good case- eligible for Medicaid coverage. These finding opportunities for home visiting expansions are highly cost effective programs. In addition, there is nothing in for states, since the FMAP for family Medicaid statute or regulation to prohibit planning services is 90 percent.31 family planning services being delivered in The ACA includes an option to offer the home, possibly with other services for family planning services to persons not women, between pregnancies. otherwise eligible for Medicaid through

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 25 Appendix B Medicaid and Home Visiting State Case Studies

Based upon NASHP’s environmental scan Medicaid financing mechanisms and did not of states’ use of Medicaid to fund home limit our case studies to states using U.S. visiting for new and expectant families, and Department of Health and Human Services- in consultation with the Pew Home Visiting recognized evidence-based home visiting Campaign, six states that use different home programs. Indeed, many of these Medicaid visiting models and different Medicaid financing mechanisms were in place long financing methods were selected to before the MIECHV-related review of participate in case studies. Key information program models was conducted. illustrating these six states’ experiences with Medicaid financing of home visiting Among these states, a number of limitations service was gleaned through interviews were noted that impede the optimal with Medicaid and home visiting program delivery and financing of home visiting, officials in these states (See Table B1). including inability to finance both medical and non-medical services through a single The case studies include the history and mechanism; difficulty overseeing home rationale for using Medicaid, describe the visiting services offered through a Medicaid services provided by the home visiting managed care plan; and concern about programs, and outline the provider33 proper adherence to CMS regulations and requirements and Medicaid billing how to appropriately bill Medicaid for home procedures used. We chose states with visiting services. Negotiation of these factors experiences representing a range of is key to successful Medicaid financing.

Table B1

Home Visiting Programs Featured in Case Studies

State Home visiting program name Medicaid financing mechanism

Illinois Family Case Management Administrative case management Kentucky HANDS Targeted case management Michigan Maternal & Infant Health Program Traditional Medicaid service Minnesota Family Home Visiting Managed care Vermont CIS Nursing & Family Support Global §1115 waiver Washington First Steps Targeted case management and traditional Medicaid service

26 PEW CENTER ON THE STATES APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Illinois — Administrative organizations, to serve as contracted Case Management Family Case Management agencies. Integral to this local agency infrastructure Illinois’ Family Case Management are DHS-contracted case managers program is a statewide effort designed working within local agencies that are to connect at-risk families that include responsible for connecting eligible families a pregnant woman, an infant, or a child with various supports. The Illinois with special health care needs to medical Maternal and Child Health Services Code and social services that promote healthy defines and regulates all Family Case pregnancies and infant development. Since Management program activities. The Code 1994, home visiting services have been classifies case management activities as offered as a component of Family Case including, but not limited to: Management. Housed within the Illinois Department of Human Services (DHS)  Assessment of needed health and Bureau of Maternal and Infant Health social services, (the state’s Title V agency), the Family  Development of individual care Case Management program represents the plans, largest home visiting effort in the state, serving approximately 312,389 pregnant  Referral of individuals to appropriate women and children in FY 2010.34 In community providers, addition to Family Case Management,  Ongoing follow-up with program DHS administers three federally participants or service providers to recognized, evidence-based home visiting ensure accessed services, and program models throughout Illinois:  Periodic reassessment of participants’ Healthy Families America, Nurse-Family needs.36 Partnership, and Parents as Teachers.35 However, Family Case Management Within Family Case Management, home has significantly wider geographic and visiting services are considered to be an population reach than these programs and activity of program case management. If is therefore the focus of this case study. case managers refer mothers to receive this service, they may choose to participate Across the state, DHS administers Family in a minimum of one prenatal home visit Case Management funds to 115 local and one home visit during the first year service providers, including health of a child’s life. For infants and children departments, federally qualified health whose mothers are identified as being at centers, and other community-based high risk for poor pregnancy outcomes,

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 27 APPENDIX B: CASE STUDIES — ILLINOIS

families may be referred to receive targeted enrollee’s primary care provider that she is intensive prenatal case management, receiving Family Case Management in an which provides one monthly home visit effort to avoid duplication of services. and one additional face-to-face visit each month with a registered nurse or social Home visiting services rendered by worker. Families can remain in this DHS-qualified agencies are eligible to intensive program for up to six weeks be reimbursed by Medicaid. DHS is during their prenatal period, at which time able to claim a 50 percent federal match they are gradually transitioned back to the rate for outreach and case management regular Family Case Management home activities “for coordination of medical and visiting service activities. medically-related services for the health and well-being of the participant.” Local Case managers must be either a registered Family Case Management providers are professional nurse, a clinical social worker able to submit Medicaid administrative or a licensed social worker, or must posses case management (ACM) claims to a master’s or baccalaureate degree in a finance home visiting activities. When health-related field, if supervised by a a case manager refers mothers or registered nurse. The program also utilizes children for specific medical services, paraprofessionals and lay workers as Medicaid-enrolled providers bill those supervised case manager assistants to help services through fee-for-service (FFS). facilitate participant intake, follow-up, and Programmatic expenses not reimbursable outreach activities.37 by Medicaid are covered using state general funds. Medicaid and Family Case Management Home Visiting In order to bill for ACM, Family Case In order to qualify for Family Case Management case managers are required Management services, pregnant women to report information regarding the time, or new mothers must have incomes at or activity, and participant information below 200 percent of the federal poverty of each home visiting encounter. At a level.38 During intake assessments, case minimum, activity categories must be managers are required to note each identified as case management, outreach, family’s Medicaid eligibility and enrollment administration of outreach and case status.39 If a home visiting recipient is management, or a description of other enrolled in Medicaid managed care, the direct services provided. The Family Case managed care organization must notify the Management program does not distinguish

28 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — ILLINOIS

between place of service for billing Lessons Learned purposes, which allows case managers Illinois’ choice to finance Family Case to use the same billing codes for services Management home visiting services delivered in a participant’s home as they through Medicaid ACM has enabled would in a clinical setting. However, the state to efficiently provide case if a provider agency is a local health management services through local health department, they are permitted to provide departments and other entities that have direct services (such as screenings and historically had the capability to provide vaccines) in a client’s home with a signed these services. However, state budget standing order from a physician. In this shortfalls have affected the workforce case, the agency will be reimbursed on an capacity within local health departments FFS basis, and they are still able to claim and community health centers as well the Medicaid administrative match for as their ability to support Family Case non-direct services provided in the home. Management activities.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 29 APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Kentucky — Targeted Case The program, available to all first-time Management parents, regardless of income or insurance status, offers a basic screening to determine Since 1999, the Health Access Nurturing potential stressors for all participants. Development Services (HANDS) home Clients found to be high-risk receive a visiting program has promoted healthy more in-depth assessment, educational pregnancy and birth outcomes for curriculum, and case management.42 Kentucky residents. The statewide HANDS boasts high retention rates, program served more than 11,000 families with approximately 40 percent of clients 40 in FY 2010. Program goals include receiving services for more than 18 positive pregnancy and birth outcomes; months.43 optimal child growth and development; healthy homes; and family self-sufficiency. Medicaid and HANDS Home Visiting The health prevention curriculum, HANDS was not originally designed with based on Growing Great Kids,41 consists the participation of Medicaid. Originally, of multiple home visits with health the Kentucky Department of Public Health professionals and paraprofessionals to used state funding for implementation in ensure a developmentally appropriate, 15 pilot areas. Initial evaluation of the pilots healthy, and nurturing environment for demonstrated positive birth outcomes for children ages birth to three years. participants, and DPH set a goal to expand the program in order to promote healthier The voluntary home visiting services pregnancies and positive birth outcomes administered by the state include HANDS, throughout the state. Early Head Start, and home visits provided by Child Protective Services. HANDS was In 2000, the Kentucky General Assembly not identified by the U.S. Department of created the early childhood development Health and Human Services as an evidence- act known as Kids Now, which receives based model, but the state is currently 25 percent of Kentucky’s Phase I tobacco conducting an evaluation of the program settlement resources. Several years after that is intended to yield that classification. the inception of HANDS, Kids Now Nurse-Family Partnership and Parents as reviewed client data to find that more than Teachers have several privately run sites in 90 percent of participating mothers were various parts of the state. eligible for Medicaid. DPH, seeking to form a collaborative agreement with the HANDS is administered by the Kentucky agency, approached Kentucky Medicaid Department for Public Health (DPH) and to discuss the benefits of HANDS services implemented by local health departments. and potential for reimbursement. In their

30 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — KENTUCKY collaborations, DPH offered to use Kids Tobacco settlement dollars, in addition Now funds to pay the state share of to funding the state share of Medicaid HANDS services provided to Medicaid reimbursements, are used to cover costs and Children’s Health Insurance Program for individuals without Medicaid coverage. (CHIP) beneficiaries. This arrangement was key to the partnership between Kentucky CHIP is a separate program that Medicaid and DPH and has limited utilizes all Medicaid structures, including the political and financial challenges billing procedures. CHIP beneficiaries are associated with adding HANDS as a also eligible for HANDS reimbursement. reimbursable service.44 Within the fee-for-service system, three Current Procedural Terminology (CPT) Convinced by the positive outcomes billing codes are used for both Medicaid shown in program evaluations, Kentucky and CHIP — one for the assessment, one used a Medicaid state plan amendment for a home visit by a professional nurse to make HANDS available to Medicaid- or social worker, and one for a home visit enrolled first-time parents statewide. As a by a paraprofessional. The reimbursement component of targeted case management rate is contingent on which service is (TCM), HANDS receives the full FMAP, provided and on the type of provider. which in Kentucky is currently 71 percent.45 The billing provider for all claims is the state DPH, and the rendering provider is Licensed nurses and social workers the local health department. Each entity as well as paraprofessionals deliver has its own provider code. DPH submits HANDS services.46 All HANDS services a claim in the Medicaid system using are reimbursable for Medicaid and the CMS 1500 form. Home visiting, as CHIP beneficiaries, and HANDS does a component of prenatal care, is billed not bill other third-party payers. using the parent’s Medicaid identification

Table B2

Kentucky HANDS Medicaid Billing Codes

Service Code Code Definition Payment Professional Home Visit S9444 Parenting classes, $160 non-physician provider

Paraprofessional Home Visit S9445 Patient education, $120 non-physician provider

Assessment T1023 Program intake assessment $170

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 31 APPENDIX B: CASE STUDIES — KENTUCKY

number. Home visiting services delivered  A first-time father or guardian of a after birth are billed with the child’s child identified above. Medicaid identification number, given many mothers are no longer Medicaid-eligible In order to ensure that recipients meet after 60 days postpartum. qualifications for participation in the program, the Department for Medicaid Lessons Learned Services implemented a series of claim edits and audits. The edits and Collaboration with Medicaid has audits consist of checking for previous significantly expanded the capacity of births using the mother’s Medicaid HANDS, helping Kentucky to offer the identification number and comparing program in all 120 counties. Although the claims history for all participants in the state plan amendment was laborious in its program. These procedures ensure that initial development, the highly collaborative only qualified families participate and relationship between DPH and Medicaid has provide data to support paid claims yielded few challenges. Perhaps the most for audit purposes. DPH implemented significant challenge is the determination a rigorous web-based system to track of which Medicaid beneficiaries qualify for which services are provided to each participation in the program. As outlined client and performs site visits and audits in the state plan amendment, HANDS of local health departments annually to is intended only for first time parents. monitor implementation. This information Participation in the program is voluntary supports statewide assessment of HANDS and guidelines for participation as outlined and thorough internal evaluation, in state regulation include: illustrating improvements in health  A pregnant woman who has not outcomes among participants. reached her 20th birthday and who will be a first-time parent; As Kentucky transitions to Medicaid  A pregnant woman who is at least 20 managed care, HANDS will not be years old, will be a first-time parent, required of managed care organizations and a risk is deemed likely for the nor included in their payment rate. The pregnancy or the infant; program will continue to be administered by DPH and its utilization monitored by  An infant or toddler, up to his third Medicaid. As a result, HANDS financing birthday, whose mother meets one of and management is anticipated to remain the eligibility criteria listed in the two relatively consistent despite this shift, previous bullets; which will allow the program to continue  A firstborn up to 12 weeks of age to promote positive birth outcomes for one whose family is determined to be at of Kentucky’s most vulnerable populations. risk; or

32 PEW CENTER ON THE STATES APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Michigan — Traditional appropriate level of care coordination. PHA Medicaid Service ensures that MIHP providers follow program fidelity and is also responsible for training Although various home visiting programs and monitoring program providers. MIHP is are supported by state funds in local currently seeking opportunities to become communities, Michigan’s Maternal and recognized by the U.S. Department of Infant Health Program (MIHP) is the Health and Human Services as an evidence- largest home visiting program developed, based home visiting model within MIECHV. administered, and monitored by the 47 state. The fundamental elements of the MIHP Eligibility and Services MIHP are credited to the state’s previous MIHP operates as a population-management home visiting programs, Maternal Support model, which emphasizes meeting the Services (MSS) and Infant Support Services health needs of an entire target population, (ISS). Developed in 1987 and enhanced as well as the health of individuals within in subsequent years, MSS and ISS sought that population. All Medicaid-enrolled to address the psychosocial and access pregnant women (women living at or barriers to prenatal care for Medicaid below 185 percent of the federal poverty beneficiaries and to promote healthy infant level) and infants are eligible to participate. development, respectively. In this way, MIHP is offered as a benefit of the state Medicaid program. Pregnant In 2004, MSS and ISS were consolidated beneficiaries can receive services until 60 into the MIHP, which was designed to days postpartum or the end of the month correct the inefficiencies of MSS and in which the 60th day postpartum falls, ISS care coordination and improve and infants are eligible following hospital service delivery. Today, MIHP is discharge until their first birthday. administered by two sub-agencies within the Michigan Department of MIHP services supplement routine prenatal Community Health (MDCH) — the and infant health care through care Medical Services Administration (MSA) coordination and intervention services. and the Public Health Administration Care coordination services are provided (PHA).48 MSA is responsible for ensuring by a registered nurse and a licensed social that Medicaid services, provider worker, one of whom acts as the Care policies, and reimbursement are upheld Coordinator. Intervention services are throughout MIHP and for ensuring provided by a team of a registered nurse and that MIHP beneficiaries enrolled in licensed social worker and may also include Medicaid managed care plans receive the

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 33 APPENDIX B: CASE STUDIES — MICHIGAN

a registered dietician (with a physician Medicaid Financing of order) and an infant mental health MIHP Home Visiting Services specialist, depending on the level of care MIHP is part of Michigan’s Medicaid state needed and service intensity. plan and is included in the total state general fund allocation that supports the In general, reimbursable MIHP services state’s Medicaid program. In order to bill can be categorized as an assessment (in Medicaid for providing MIHP services, an home or office), a professional visit (in agency must submit an application to the home or office), childbirth and parenting state Department of Community Health education classes, or transportation. to obtain program certification. There Specifically, the Michigan Medicaid are approximately 115 MIHP provider Provider Manual lists the following agencies operating across Michigan services as being foundational to MIHP: counties, and each provider serves one or more counties. As of January 2010,  Psychosocial and nutritional 39 percent of MIHP providers were local assessment; health departments, and 61 percent  Plan of care development; were federally qualified health centers

 Professional intervention services, or private facilities (i.e. hospitals, home including health education, nutrition health agencies, and individually owned education, social work, nutrition businesses). counseling, and infant mental health services; When a mother or infant is enrolled in MIHP, a provider administers a required  Arranging transportation as needed MIHP Maternal Risk Identifier or the for health care, substance abuse MIHP Infant Risk Identifier assessment. treatment, support services, and/or These tools are used to identify the pregnancy-related appointments; level of service intensity required and  Referral to community services (e.g., to develop a plan of care. For mothers, mental health, substance abuse); the initial assessment and up to nine  Coordination with other medical care professional visits per pregnancy are providers and Medicaid managed billable to Medicaid. The infant assessment care plans; and nine professional visits per infant/ per family are billable, but a medical  Family planning education and provider can approve an additional referral; nine visits if needed.50 Professional  Coordinating or providing childbirth visits can be delivered either in a client’s or parenting education classes.49 home or in an office setting, but visits are required to last at least 30 minutes, must be face-to-face with the beneficiary,

34 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — MICHIGAN and must be conducted by a MIHP Processing System (CHAMPS). This system licensed professional.51 A licensed MIHP reimburses MIHP provider agencies for provider must be a licensed social worker services rendered on a fee-for-service (FFS) or registered nurse with appropriate basis. Table B3 shows the fee schedule, competencies. describes the procedural billing codes, and outlines the reimbursement amounts Upon delivering MIHP services, providers for Medicaid-eligible MIHP services as of bill MDCH through the department’s November 2010. Community Health Automated Medicaid

Table B3 MDCH Maternal Infant Health Program Database*

Use Code for Maternal or Current Proce- Short Description Description Used for Fee Infant Services dural Terminology Billing and Payment of or Healthcare MIHP Services Common Pro- cedure Coding System Codes Maternal and Infant 99402 Prevention Counseling, Professional Visit in $60.72 individual Office Maternal and Infant 99402 Prevention Counseling, Professional Visit in $83.72 individual Home Maternal and Infant A0100 Nonemergency transport Transportation Taxi $21.31 taxi Maternal and Infant A0110 Nonemergency transport Transportation Bus/Van $21.20 bus Maternal and Infant A0170 Transport parking fees/tolls Transportation/Other Determined by review of provider documentation Maternal and Infant H2000 Comprehensive multidisci- Assessment in Home $99.07 plinary evaluation Maternal and Infant S0215 Nonemergency transporta- Transportation Volunteer $0.26 tion mileage Maternal S9442 Birthing class Childbirth Education $29.46 Maternal H1000 Prenatal care at-risk assess- Maternal Assessment in $79.91 ment Office Infant T1023 Program intake assessment Infant Assessment in $79.91 Office Infant 96154 Intervention health/behav- Prof. Visit/Drug Exposed $40.51 ior, family with patient

Infant S9444 Parenting class Parenting Education $39.46

*Michigan Department of Community Health Maternal Infant Health Program Database . Available at http://www .michigan . gov/documents/mdch/MIHP-11-1-2010_337924_7 .pdf .

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 35 APPENDIX B: CASE STUDIES — MICHIGAN

As the fee schedule describes, MIHP services reimburse at higher levels when provided during home visits versus in office settings. Therefore, it is imperative that providers document place of service when seeking Medicaid reimbursement. Generally place-of-services codes describe if the visit was conducted in a homeless shelter, office setting, home, or mobile unit. Providers are also required to report the beginning and end time of each visit, risk factors discussed during the encounter, and any additional actions taken. While providers are encouraged to conduct maternal visits in the beneficiary’s home, only one prenatal home visit is Health contracts with each Medicaid required. For professional infant visits, managed care plan “to provide medical however, it is expected that 80 percent health care, out-patient mental health will be made in the home. Additionally, care for mild or moderate mental health since mothers’ and infants’ eligibility concerns, transportation, and case 53 periods may overlap, some services may management for Medicaid beneficiaries.” be “blended” during professional visits Moreover, these contracts typically (i.e. maternal and infant services may be require that managed care organizations rendered), but providers are allowed to develop agreements with MIHP providers bill only for services delivered to either the to perform outreach and refer pregnant mother or the infant in a single visit. beneficiaries to MIHP services. Having these agreements in place allows the As of December 2010, there were 14 MDCH to monitor and evaluate how managed care entities operating in well MIHP and managed care plans Michigan, and all Medicaid-eligible communicate client data to avoid pregnant women are mandatory Medicaid duplication of effort. managed care plan enrollees.52 The Michigan Department of Community

36 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — MICHIGAN

Evaluation of MIHP Lessons Learned In collaboration with Michigan State The relationships among the public health University Institute for Health Care agency, Medicaid managed care plans, Studies, MIHP has designed a multifaceted and the state Medicaid agency have been approach to program evaluation. The goals integral to MIHP’s success in Michigan. of this approach are to provide data for As previously discussed, the program effective administration, identify areas of was specifically designed to enhance strength and opportunity, ensure fidelity pregnancy and birth outcomes of Medicaid (consistency and appropriate intensity of beneficiaries and has been written into interventions based on client risk status), Michigan’s Medicaid state plan since its and facilitate policy improvements to inception. This historical relationship benefit pregnant women and infants. has allowed the MDCH to reach a The primary intent of the evaluation is critical volume of Medicaid beneficiaries to satisfy MDCH and state legislative in need of MIHP services, even in the requirements; however, because state state’s changing Medicaid managed care and federal MIECHV requirements are environment. Moreover, the experience consistent, Michigan’s additional goal is for MDCH has in negotiating with managed MIHP to satisfy federal standards for home care organizations will allow MIHP to visitation programs. The MIHP evaluation increase its reach within expanding will consist of a quasi-experimental study, Medicaid populations. administrative data analysis, program fidelity review, and analysis of client The state could potentially benefit from satisfaction surveys.54 exploring other Medicaid financing options. The current FFS structure allows MIHP providers to bill for only a limited number of visits that do not always reflect the intensity of the services performed or needed for higher risk beneficiaries. Using ACM as a financing mechanism may cover more of providers’ actual costs for case management services.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 37 APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Minnesota — Managed Care All local health departments must screen FHV participants for income eligibility and Since 1992, Minnesota has funded and provide an initial screening for various risk administered maternal and early childhood factors to ensure they are serving the at- home visiting for low-income families. The risk population. As part of their services, Minnesota Department of Health (MDH) these departments may also screen for shares responsibility for home visiting with infant growth and development, infant- 91 local health departments throughout child social and emotional health, home the state. The goals of the Family Home safety, maternal depression, and domestic Visiting program (FHV) are to foster violence. Following the initial assessment, healthy beginnings, improve pregnancy the home visitor provides relevant referrals outcomes, promote school readiness, and information on infant care, child prevent child abuse and neglect, reduce growth and development, parenting juvenile delinquency, encourage positive approaches, disease prevention, preventing parenting and resiliency in children, and exposure to environmental hazards, improve family health and economic self- and support services available in the sufficiency. community.

Strong stakeholder support and advocacy Most local health departments described at the Minnesota legislature resulted program duration varying from two to in the passage of an FHV statute in seven visits during pregnancy, with visits 2001, amended in 2007,55 which after delivery continuing until the baby is defines the goals of the program and one or two years old. Nurses conduct the the duties of both the state and local screenings, and home visits are conducted health departments. The statute directs by nurses or trained paraprofessional Temporary Assistance for Needy Families home visitors. Local health departments (TANF) funding to all Community Health are also required to collect and submit Boards and Tribal Governments in the annually data on various indicators to the state for FHV to families at or below 200 state, allowing MDH to monitor statewide percent of federal poverty guidelines with measures and to submit a biennial a pregnant woman and/or minor children legislative report. While MDH does not and that meet specific risk criteria.56 currently require local health departments to implement a particular evidence-based home visiting model, the consultation

38 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — MINNESOTA

and training provided by MDH is focused Family Home Visiting on building statewide capacity for such Program Financing models. Detailed plans are submitted by Local health departments in Minnesota the local health departments and are used have a strong history of direct service as planning guides, indicating readiness provision, including well-child and home and progress toward evidence-based visits. As a result, these health departments programs. have the capacity to bill third-party payers for medical services. Local FHV Currently, 25 counties use the Nurse- programs are funded through a variety Family Partnership (NFP) model, 11 use of mechanisms, including TANF, Title V, the Healthy Families America model, and state general funds, local levies, Medicaid 57 three use both in an integrated approach. and other sources such as grants. Local The remaining counties are not currently departments receive varying amounts of affiliated with an evidence-based model, funds from these mechanisms, depending but many more are in various stages upon funding formulas, managed of training or learning about federally care contracts, and other variables. recognized models. The White Earth tribal Furthermore, not every county makes use government and the Fond du Lac tribal of all funding streams nor provides the government, as recipients of MIECHV same set of services. funds, are also implementing NFP. Each of the funding mechanisms is In addition to administrative oversight accompanied by its own eligibility and and statewide evaluation of FHV, MDH implementation requirements. The provides training, technical assistance funds allocated by the FHV statute are and reflective practice mentoring to local distributed via block grant to local health health departments and American Indian departments using a formula based on tribes to support evidence-based FHV the population at risk and require local interventions. MDH also administers departments to perform specific functions a program under MIECHV and directs (i.e., targeting services, initial assessment these funds to build capacity at the state during home visit, client evaluation). and local levels to promote evidence- TANF, Medicaid, and Title V all have based home visiting, specifically NFP and income requirements; clients must be reflective practice. legal residents to receive Medicaid and TANF but not Title V; and Title V clients must meet additional high-risk criteria not required for Medicaid.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 39 APPENDIX B: CASE STUDIES — MINNESOTA

FHV financing from the Medicaid program Home Visiting and Managed Care is distributed via two avenues: fee-for- Medicaid managed care has been the service (FFS) and managed care. Sixty- predominant structure within Minnesota three percent of Medicaid beneficiaries in for several decades. Twelve managed Minnesota are enrolled in managed care care plans are currently contracted by plans, and the remaining beneficiaries are the state to provide services to Medicaid 58 enrolled in FFS. Individuals enrolled in beneficiaries. The state pays each plan a FFS may receive home visiting services, monthly, risk-adjusted rate for each client, which are billed using standard billing and in return, each plan must provide codes and an additional code indicating certain required benefits. Home visiting the home as the place of service. These is not a required benefit, but all 12 plans codes are summarized in Table B4 below. have added home visiting as a service because of the proven cost-effectiveness of DHS continues to evaluate evidence-based high-quality home visiting models. home visiting models to determine which home visiting services can be considered The Medicaid managed care plans do medical services and may qualify for FFS not provide home visiting services reimbursement. By their very nature, directly but, instead, contract with many home visiting activities fall outside local health departments to provide the sphere of medical services. In order FHV. Each plan negotiates contracts to justify reimbursement for non-medical individually with those local health services, cost savings would have to be departments in its service area. The demonstrated to accrue to the Medicaid result is that one Medicaid managed care agency.

Table B4 Minnesota Fee-For-Service Billing Procedure

Service Code Code Definition Home visit: Mother 99501 Home visit for postnatal care and assessment Home visit: Infant 99502 Home visit for newborn care and assessment Health promotion and counseling S9123 Nursing care in the home At-risk care coordination H1002 Prenatal care coordination, at-risk Prenatal nutrition education 97802 Medical nutrition therapy Maternal depression screening 99420 Administration and interpretation of health risk assessment instrument

*Place of service for all services conducted in home is POS 12 . Source: Minnesota Department of Human Services, “Home visiting services for pregnant women or new mothers, 2009-2010, by payment system-Minnesota Health Care Programs,” (March 9, 2011) .

40 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — MINNESOTA plan has arrangements with many local Discussions to promote standardization health departments, and most of those of evidence-based home visiting services departments have contracts with multiple across local health departments are active. Medicaid managed care organizations. MDH continues to provide training and Each of these arrangements is an consultation and to leverage the federal independent proprietary contract between evidence-based home visiting initiatives to each local health department and each further enhance the FHV delivery. Local plan. Medicaid managed care plans have departments may continue to utilize other flexibility as to the provider types that FHV funding sources in ways that best may serve families during home visits. meet their capacities and needs. Some managed care plans offer financial incentives for clients receiving home Among the 12 managed care plans and 91 visiting services (i.e. $20 Visa gift card for local health agencies in the state, potential a prenatal visit within the first trimester of exists for variation in the payment for pregnancy).59 home visiting. Nonprofit organizations that support home visiting programs, such Lessons Learned as Metro Alliance for Healthy Families and There are strengths and limitations to Minnesota Coalition for Targeted Home this complex approach to providing Visiting, are investigating strategies to statewide home visiting services. The promote standardization of managed care development and implementation of payments to local health departments for home visiting programs by local health FHV services. departments allow services to be tailored to the unique qualities and needs of each county’s population. However, the diversity of approaches creates obstacles for uniform evaluation. To support enhanced programmatic evaluation, the legislature added evaluation criteria to the FHV statute when it was amended in 2007. These include the specific indicators of participant satisfaction, rates of children who pass early childhood screening, and utilization of preventive services.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 41 APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Vermont — Global §1115 2004. Early Intervention provides Waiver services to infants and toddlers, who have developmental delays or In 2004, Vermont created Children’s a health condition that may lead to Integrated Services (CIS) to promote delays, and their families. coordination among several existing  Specialized Child Care Services programs serving new and expectant provide assistance to families mothers and children through age six. experiencing significant stress due to The vision of CIS is to connect high-risk concerns about appropriate shelter, families with the appropriate maternal, safety, emotional stability, substance child and family supports and services. abuse, or child behaviors; and those Currently, four services operate under the with children in protective services CIS umbrella. or who have special physical or developmental needs.  Nursing and Family Support services are designed for high-risk Of these four programs, nursing and pregnant women and new mothers family support relies most heavily on and children (birth through five Medicaid funding, and for this reason, will years) to promote healthy maternal be the focus of this case study. and child health outcomes using a prevention and early intervention CIS nursing and family support, formerly case management approach. known as Healthy Babies, Kids and  Early Childhood and Family Families, is a statewide Maternal and Mental Health services utilize Child Health (MCH) program. Nursing community-based mental health and family support was developed by clinicians to enhance the wellbeing the state in 1994 as a case management of children (birth through five years), service that was based on the Nurse- who are experiencing or at risk Family Partnership program. The U.S. of experiencing severe emotional Department of Health and Human disturbance, and their families. Services has not recognized the program  Early Intervention Services is as an evidence-based model. Today, CIS the state’s name for Part C of nursing and family support services reach the Individuals with Disabilities approximately 4,420 individuals per 60 Education Improvement Act (IDEA) year.

42 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — VERMONT

Nurses, social workers, or paraprofessional Medicaid and CIS Nursing and family support workers offer a variety Family Support Home Visiting of services to promote parent and child Vermont’s Medicaid program is financed health and wellbeing. Because the program through two §1115 Waivers with CIS serves such a large range of ages, the covered under the “Global Commitment services are flexible to meet the needs to Health” waiver. The terms of the waiver of the family and include: planning for cap the federal Medicaid funds the state pregnancy, delivery, and becoming a will receive over five years in exchange parent; finding medical and dental care for flexibility in their use. The Vermont during pregnancy and for the child Agency of Human Services contracts through age five; providing information with the Department of Vermont Health about nutrition; or locating community Access (DVHA), which operates, in resources, such as counseling, physical effect, as a state-run managed care entity. therapy, breastfeeding classes, play groups, DVHA receives a per-member-per-month and help with educational goals. capitated fee to provide Medicaid services to the enrolled beneficiaries. If, after To receive services, parents or children providing services to the beneficiaries, must be an eligible or enrolled Medicaid there are unspent funds, DVHA may invest beneficiary and identified as experiencing those funds in any of four broad areas, health, social, or behavioral risks. including increasing access to quality Currently, the majority of referrals come health care services to the uninsured from the Special Supplemental Nutrition or underinsured. This provision allows Program for Women, Infants, and Children CIS to be provided to other high-risk (WIC); the medical home, hospital, families who not eligible for Medicaid, an or other health provider; or another arrangement currently being tested in pilot community agency and are processed areas. through a regional CIS team, which meets weekly. Core team membership includes A state plan amendment for targeted case a CIS coordinator, MCH public health management has supported home visiting nurse, home health nurse, a child care programs in Vermont since 1987. Targeted specialist, representative(s) from a Parent case management (TCM) services are Child Center, and an early childhood voluntary and include a comprehensive mental health agency staff person. This assessment of need, development of a referral team decides which type of specific care plan, referral, and monitoring. provider is most appropriate based on the Nursing and family support services referral information. The CIS provider and are one example of CIS services that are family develop a plan together to address offered as a TCM component. Vermont’s the identified risks.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 43 APPENDIX B: CASE STUDIES — VERMONT

state plan amendment states that CIS In November 2010, Vermont initiated a services be provided on a voluntary basis pilot to improve coordination among early to all Medicaid enrollees who are identified childhood services. Three communities as at risk. received a bundled rate for all CIS services. To allocate funds to each pilot region, the Vermont’s billing code is aligned with the state first calculated the funds previously Healthcare Common Procedure Coding used to administer all CIS services then System (HCPCS) to better facilitate contracted that amount to a designated billing. HCPCS codes, used by Medicare, fiscal agent for each region. Fiscal agents Medicaid, and private health insurers, contract with local providers to deliver support consistency across the state (See services. Table B5). The payment rates for home visiting depend on which services are Providers in the pilot communities receive provided, to which beneficiary (mother or one monthly rate for every client. If infant), the family risk level, and the type providers serve their minimum Medicaid of provider. An excerpt of the billing code beneficiary caseload, they are allowed for CIS services is below: to also provide services to families that do not receive Medicaid. The minimum

Table B5 Vermont Billing Codes

Service Description Client Provider Current Code Definition Reimbursement Procedural Terminology

Home Health, Home Woman RN T1022 Contracted home $125 visit – High risk health agency services Home Health, Home Infant RN T1022 Contracted home $95 visit – Low risk health agency services Home visit, Not Home Age 1-5 MSW S9445 Patient education, $95 Health – High risk non-physician Home visit, Not Home Age 1-5 FSW S9445 Patient education, $55 Health – High risk non-physician Perinatal Group Woman Non- S9436 Childbirth preparation, $1.50 per unit of Education physician non-physician service

Source: Information provided by Vermont program staff.

44 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — VERMONT caseload is determined by historical Vermont is building on current data Medicaid claims data and the population collection efforts to improve tracking of children, birth though age five, living and evaluation of services. CIS currently in poverty. The pilots also allow providers collects data on the number of individuals the flexibility to tailor services to meet that complete plan goals by annual family needs and to meet with other care review or transition to another service; providers to discuss case reviews and care the percent of clients who receive services management. within 45 days from referral; the percent of those that have no further or immediate Lessons Learned support when leaving CIS services; and The CIS pilots were designed to address the percent served through CIS that report gaps in the current system, namely satisfaction. care coordination. Because nursing and family support are billed fee-for-service, With the spirit of innovation and except in the three pilot areas, there dedication to supporting families, Vermont is no appropriate code to bill for care has a strong basis upon which to adapt to coordination provided through CIS. This the needs of the population and advance limits the coordination that can occur. efficient delivery systems.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 45 APPENDIX B: MEDICAID AND HOME VISITING STATE CASE STUDIES

Washington — Targeted  Expedited alcohol and drug Case Management and assessment and treatment services, which are provided to eligible women Traditional Medicaid Service and their infants, and

Established under the 1989 Maternity Care  Ancillary services, which includes Access Act, Washington State’s First Steps expedited eligibility determinations, program is an umbrella program designed “case finding,”62 outreach, and to provide prenatal care and pregnancy transportation services.63 support services to low-income pregnant women and their children. Created to Although First Steps offers these four address access shortages to prenatal care service areas to Medicaid-eligible women and obstetric providers in the most rural and infants, this case study will focus on communities, the program serves about the enhanced services offered through 50 percent of the approximately 47,000 Maternity Support Services (MSS) and annual Medicaid-eligible births in the Infant Case Management (ICM), as they state.61 Previously administered by the are more closely aligned with the goals Washington State Department of Social of maternal and infant home visiting and Health Services (DSHS), First Steps is programs. now administered by the state’s Medicaid agency, the Washington State Health The MSS/ICM programs offered through Care Authority (HCA). The following First Steps provide enhanced support service areas represent the foundational services to mothers throughout pregnancy components of the First Steps program: and for infants through the month of their first birthday.64 Both programs are  Medical services, including prenatal designed to deliver interventions early in care, delivery, and post-pregnancy pregnancy to promote healthy births and follow-up services. Additionally positive parenting skills. Within MSS and newborns receive one year of full ICM programs, services may be offered in medical care, and family planning an office setting, in a beneficiary’s home, or services are offered for up to one year in a non-office setting (See Table B6). for eligible women post-pregnancy.

 Enhanced services, which include The goal of the MSS program is to facilitate Maternity Support Services (MSS), access to preventive health services for Infant Case Management (ICM), and eligible pregnant women. This program is Childbirth Education (CBE). designed to supplement routine prenatal medical visits and to increase access to

46 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — WASHINGTON services such as screening, assessment, When the MSS eligibility period ends for education, intervention, and counseling. a mother, the infant may still be eligible Other Medicaid covered services to receive Infant Case Management. ICM available to women enrolled in MSS and is specifically designed to serve Medicaid- ICM include medical and dental care, eligible high-risk infants and to improve transportation support, interpretation the self-sufficiency of their parent(s).68 services, and specialized substance abuse To qualify, infants must reside with their treatment.65 parent(s), documentation must exist of the parents’ lack of access to needed services, Eligible women (those living at or below and the infant or parent must meet HCA 185 percent of the federal poverty level) high-risk eligibility criteria.69 Infants must be enrolled in a Medicaid benefit enrolled in Medicaid and CHIP are eligible package prior to the end of pregnancy in to receive ICM. order to receive services. Once a client is enrolled, she may elect to participate The eligibility period begins in the first in MSS/ICM as well as the Childbirth day of the month following pregnancy Education program.66 The eligibility period and concludes at the end of the month of for MSS begins as soon as the client is the infant’s first birthday. ICM provides approved for Medicaid and continues referrals and linkages for families in need through the end of the month in which of educational, medical, and mental health the 60th day post-pregnancy occurs. services. Program services are delivered Teenage parents still living with a parent by MSS certified providers (a community are allowed to use their own personal health nurse, registered dietitian, or income when applying to receive MSS. behavioral health specialist), experienced Managed care enrollees can also receive bachelor’s- or master’s-level professionals, MSS services. or an ICM-qualified paraprofessional, who must have a two-year associate At the local level, First Steps agencies are of arts degree and two years of field required to establish an interdisciplinary experience and be supervised monthly by MSS provider team consisting of a a bachelor’s- or master’s-level MSS/ICM community health nurse, registered professional. dietitian, behavioral health specialist, and, depending on the agency, a community health worker. This team is responsible for delivering MSS services, including assessment, education, intervention, and case management, as well as developing individual care plans for each mother. 67

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 47 APPENDIX B: CASE STUDIES — WASHINGTON

Table B6

Washington State Health Care Authority Covered Services*

Maternity Support Services Infant Case Management Services • Screening and assessment of risk factors related • An initial in-person screening which includes to pregnancy and birth outcomes; developing a care plan; • Education that relates to improving pregnancy • Case management services and care and parenting outcomes; coordination; • Brief counseling; • Referring and linking the infant and parent(s) to • Interventions for risk factors identified on the other services or resources; care plan; • Advocating for the infant and parent(s); and • Basic health messages; • Follow-up contact(s) with infants and their • Case management; parent(s) to ensure the care plan continues to • Care coordination; meet their needs. • Family planning screening and referral; • Screening, education and referral(s) for tobacco usage and second hand smoke exposure; and, • Infant case management (ICM) screening.

* Medicaid Purchasing Administration (MPA), Maternity Support Services/ Infant Case Management Billing Instructions [WAC 388-533-0300 and 388-533-0386] . http://hrsa .dshs .wa .gov/Download/Billing_Instructions/MSS-ICM/MSS-ICM_BI .pdf .

Medicaid and First Steps reimbursement claim to Washington’s Home Visiting ProviderOne System, the HCA’s centralized First Steps program services, including Medicaid provider payment system. For MSS and ICM, are available only to MSS, the HCA reimburses services on a Medicaid-enrolled mothers, fathers, or fee-for-service basis, in which one unit infants. In order to bill Medicaid for MSS/ of service is equivalent to 15 minutes. ICM, an agency must be authorized by For ICM, providers claim service the Washington State HCA to provide reimbursement through Medicaid TCM, First Steps services. These public and where one unit of services equals 15 private agencies may be contracted by minutes as well. Table B7 describes the HCA in every county. When MSS or specific payment fee schedule associated 70 ICM services are delivered, the HCA- with MSS/ICM service reimbursement. authorized provider agency submits the

48 PEW CENTER ON THE STATES APPENDIX B: CASE STUDIES — WASHINGTON

Table B7

Washington Medicaid Purchasing Agency (MPA) Fee Schedule, Effective July 1, 2009

Maternity Support Services

Procedure Modifier* Service Maximum Maximum Policy/Comments Code Description Allowable Allowable Office Home Setting Setting

96152 HD Behavioral $25.00 $35.00 1 unit= 15 minutes during a Health MSS Behavioral Health Visit Specialist S9470 HD Nutritional $25.00 $35.00 1 unit= 15 minutes during a Counseling, MSS Dietician Visit dietician visit T1002 HD RN services $25.00 $35.00 1 unit= 15 minutes during a MSS Community Health Nursing Visit T1027 HD Family training $14.00 $18.00 1 unit= 15 minutes during and counseling a MSS Community Health for child Worker Visit development

Infant Case Management T1017 HD Targeted Case $20.00 $20.00 1 unit= 15 minutes Management

*HD= Pregnant/Parenting Program .

As this table demonstrates, MSS program based on intensive need (Basic=7 units, services provided during a home visit Expanded=14 units, or Maximum=30 reimburse higher per unit of service than units) throughout their pregnancies. For those provided in an office setting. HCA mothers that begin MSS post-pregnancy, limits the number of service units that they are eligible to receive different levels can be claimed per mother. For example, of service (Basic= 4 units, Expanded=6 when mothers enter MSS in the prenatal units, or Maximum= 9 units) until the end period, their assessment may flag them of the post-pregnancy eligibility period. to receive different levels of service

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 49 APPENDIX B: CASE STUDIES — WASHINGTON

In the case of ICM, all services provided statute, Thrive by Five will manage and to infants and their families are billed as administer the HVSA, including overseeing Medicaid TCM. All services rendered must competitive grant-making processes, direct be delivered to the family in a face-to-face service implementation and technical meeting with the enrolled infant present. assistance, evaluation, and engaging an Similar to MSS, an ICM Screening Tool is advisory committee. Thrive by Five is used to assess the level of service (Lower also designated to raise the private dollars Level or Higher Level) the family needs. needed for the HVSA. In FY 2012, the Throughout the infant’s eligibility period, a HVSA portfolio includes programs funded family may receive a maximum of 6 units through the federal MIECHV program, of Lower Level services and 20 units of state general funds designated for home Higher Level services. visiting, and private match dollars. The HVSA does not currently support First In 2010, the Washington State Legislature Steps. created the Home Visiting Services Account (HVSA). The primary purpose of Lessons Learned the HVSA is to align and leverage public A significant proportion of pregnant funding with private matching funds to women and children are enrolled in increase the number of families served Medicaid managed care in Washington, through home visiting programs. The and First Steps has always been a carved- legislation authorizes an account under out program available to managed care the purview of the state treasury that as well as FFS enrollees. While managed will consist of state appropriations and care programs do not offer maternal private dollars “to develop, support and and child home visiting services, many evaluate evidence-based, research-based, of them have contracted with provider 71 and promising home visiting programs.” agencies to offer telephonic support to The Department of Early Learning, which high-risk pregnant women. First Steps supports home visiting programs aiming programs and providers do not, however, to reduce child abuse and improve school have access to the utilization data of these readiness, is the designated public agency services or which women are receiving leading the HVSA. these services. HCA is currently working with new managed care entities in the The account expenditures will be used to state to develop contract provisions that provide the state match for home visiting will allow the Authority to access this programs, and the funds are administered patient information. This would allow 72 by Thrive by Five Washington, the both First Steps and managed care entities designated “nongovernmental private- to collaborate in care management for public partnership.” As directed by the overlapping populations.

50 PEW CENTER ON THE STATES Appendix C Medicaid Glossary

“at-risk” or “high-risk” - Maternal and child home Administrative Case Management (ACM) - visiting programs may apply criteria to assess the level Section 1903(a) of the Social Security Act defines of risk for poor health or developmental outcomes case management as Medicaid reimbursable activities posed to mothers and children by developmental, deemed necessary for the “proper and efficient educational, and environmental factors. These criteria administration of a state’s Medicaid plan.” Eligible may follow guidelines set forth by national home activities may include those provided for eligibility visiting program models or may be defined by an determinations, outreach, and securing authorizations individual home visiting program. needed to access Medicaid services. Administrative case management activities may not include those activities 1905(a) Services - Section 1905(a) of the Social directly associated with providing a medical assistance Security Act [42 U.S.C. 1396d] — the federal Medicaid service. statute — defines and provides guidance on “medical assistance” services, or services provided to Medicaid Centers for Medicare and Medicaid Services beneficiaries, that are paid for in part by the federal (CMS) - is a branch of the U.S. Department of Health Medicaid program. and Human Services. CMS is the federal agency that administers Medicare, Medicaid, and the Children’s 1915(b) Freedom of Choice Waivers - Section Health Insurance Program. 1915(b) of the Social Security Act [42 U.S.C. 1396n] permits states to contract with managed care entities to Children’s Health Insurance Program (CHIP) - provide services to Medicaid recipients and thus waive provides health coverage to uninsured children up to the rights recipients otherwise have to choose their age 19 in families with incomes that exceed income providers and plans. States may use the waiver to: eligibility requirements for the Medicaid program. States administer their CHIP programs, which are • [1915(b)(1)] - Implement a managed care delivery jointly funded by federal and state governments. system that restricts the types of providers that States may administer CHIP programs as Medicaid people can use to get Medicaid benefits expansion programs, separate CHIP programs, or as a • [1915(b)(2)] - Allow a county or local government combination of these two approaches. to act as a choice counselor or enrollment broker in Deficit Reduction Act of 2005 (DRA) - affects many order to help people pick a managed care plan aspects of federal entitlement programs, including • [1915(b)(3)] - Use the savings that the state gets Medicaid. The DRA amended Section 1937 of the from a managed care delivery system to provide Social Security Act to give states the flexibility, with additional services CMS approval, to define alternate benefit packages, known as benchmark plans, for targeted populations • [1915(b)(4)] - Restrict the number or type of of Medicaid enrollees. Some protected populations, providers who can provide specific Medicaid services such as pregnant women, have the option to enroll in (such as disease management or transportation). their states’ benchmark plans or remain in the regular Medicaid benefit program.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 51 APPENDIX C: MEDICAID GLOSSARY

Early and Periodic Screening, Diagnostic and Medicaid Managed Care - In this system, states Treatment Program (EPSDT) - is the component contract with organizations that agree to offer all or of Medicaid designed to improve the health of low- most Medicaid services to beneficiaries in exchange for income children. EPSDT services are required to an agreed-upon payment from the state. Managed care be offered by every state, and finance appropriate entities include ‘managed care organizations’ that agree and necessary pediatric services, including medical to provide most Medicaid services to beneficiaries in assistance services that may not be in the state’s plan exchange for a per-member monthly payment; ‘limited and not available to adults. benefit plans’ that provide specific Medicaid benefits like mental health or dental services in exchange for a Federal Medical Assistance Percentage (FMAP) - per-member monthly payment; and ‘primary care case determines the amount of federal matching funds for managers’ who act as a patient’s primary care provider state expenditures for the Medicaid program. FMAPs and also receive a small monthly payment for helping are published annually for each state. Section 1905(c) to coordinate referrals and other medical services. of the Social Security Act specifies the formula used States may require Medicaid beneficiaries to enroll in to calculate the FMAP for each state. In FY 2011, the managed care or enrollment may be voluntary. FMAP ranged from 50% to 74.73%. Medicaid Section 1115 Family Planning Fee-for-Service (FFS) - is a health insurance payment Demonstration Waiver - can be used, upon approval method that reimburses providers per unit of service from CMS, to provide family planning services to provided, rather than on a per-person-per-month or individuals deemed ineligible for state Medicaid or other basis. CHIP programs. Section 2303 of the Affordable Care Individuals with Disabilities Education Act Part Act allows states to also offer family planning services C (IDEA Part C) - authorizes states to “develop and to persons not otherwise eligible for Medicaid by filing implement a statewide, comprehensive, coordinated, a State Plan Amendment. multidisciplinary, interagency system that provides National Academy for State Health Policy early intervention services for infants and toddlers (NASHP) - is a nonpartisan, nonprofit organization with disabilities and their families.” Early Intervention with a mission of promoting excellence in state health services may include state home visiting that addresses policy and practice. NASHP conducts analytic and infants’ or toddlers’ developmental needs (i.e. physical, technical assistance work designed to support states in cognitive, communicative, social or emotional, or their efforts to improve health care and health. adaptive.) Patient Protection and Affordable Care Act Maternal, Infant, and Early Childhood Home (ACA) - is the federal law, passed in 2010, that aims Visiting Program (MIECHV) - Authorized by to ensure quality and affordable care for all Americans. the Affordable Care Act, the Maternal, Infant, and Specific objectives of the law include promoting health Early Childhood Home Visiting (MIECHV) Program insurance market reforms, establishing consumer was designed to improve health and development protections in health insurance markets, increasing outcomes for at-risk children through evidence-based access to health insurance coverage for eligible and home visiting programs. In 2011, federal MIECHV special populations, and providing funds for health funds were awarded to all states through a formula programming to promote the public’s health. grant and additional competitive funds were awarded to 22 states.

52 PEW CENTER ON THE STATES APPENDIX C: MEDICAID GLOSSARY

Section 1915(c) Medicaid Home and Community Based Services Waiver (HCBS) - can be used to provide care and community-based services to targeted state Medicaid populations. Approved programs can offer medical and non-medical services, including case management supports and service coordination. Section 1915(I) of the Deficit Reduction Act of 2005 allows state Medicaid programs to also offer HCBS by filing a State Plan Amendment.

State Plan Amendment (SPA) - States operate their Medicaid programs under agreements with CMS known as state plans. The state plan defines the state’s Medicaid eligibility guidelines and describes benefits offered. Any changes to a state plan, known as a state plan amendment, must be approved by CMS.

Targeted Case Management (TCM) - consists of those medical assistance services that help beneficiaries gain access to medical, social, educational, and other services. TCM includes four components: assessment services, development of a care plan, referrals and scheduling, and monitoring and follow-up for Medicaid enrollees.

Temporary Assistance for Needy Families (TANF) - is a block grant program designed to provide federal funds to needy families in states, tribes, and territories. These funds are used to cover benefits and services to needy families, such as programs that support economic self-sufficiency and family services.

Title V Maternal and Child Health Services Block Grant - Administered by the Maternal and Child Health Bureau at the Health Resources and Services Administration, the Title V Maternal and Child Health Services Block Grant Program aims to ensure the health of the nation’s mothers, women, children and youth, and children with special health care needs. Programs supported by this federal block grant program increase access to quality health care services for low-income women and mothers, and include funds for direct care services, enabling services, population-based services, and infrastructure building services.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 53 Appendix D States Using Medicaid to Finance Home Visiting*

State Lead Agency Model 1 Colorado Department of Public Health and Environment Nurse Family Partnership

2 Kentucky Department for Public Health Health Access Nurturing Development Services (HANDS) 3 Louisiana Department of Health and Hospitals Nurse Family Partnership 4 Massachusetts Department of Public Health Early Intervention Partnership Program 5 Michigan Department of Community Health Maternal Infant Health Program 6 New Department of Health and Home Visiting New Hampshire Hampshire Human Services 7 New York Department of Health Nurse Family Partnership Department of Health Community Health Worker 8 Oklahoma Department of Health Children First (Nurse Family Partnership) 9 Oregon Department of Human Services Maternity Case Management

Oregon Commission for Children and Healthy Start/Healthy Families Families 10 Rhode Island Department of Health The First Connections Program 11 South Dakota Department of Health Bright Start 12 Tennessee Department of Health Help Us Grow Successfully (HUGS) 13 Vermont Agency for Human Services Healthy Babies, Kids, and Families Agency for Human Services/ Early Childhood and Family Mental Health Children’s Integrated Services 14 Virginia Department of Health Resource Mothers 15 West Virginia Department of Health and Human Resources Right from the Start

* This list reflects states that, in a 2010 survey conducted by the Pew Home Visiting Campaign, reported offering home visiting program(s) financed in whole or in part through Medicaid. The campaign’s web inventory defines home visiting as a state-administered program that: • Is managed by a state agency — such as health and human services — that directs funding to local communities to support service delivery, articulate standards and regulations, set performance measures and provide oversight and infrastructure; • Delivers services mainly in families’ homes, though visits may be complemented with other supports such as group classes; and • Receives support through state allocations, using state or federal dollars . • The survey excluded programs that employ home visiting as a strategy but do not fully satisfy the definition above, such as: – Involuntary visits resulting from a child protective services investigation or a court order; – Programs targeting children four or older, unless they are enrolled before the age of two; – Programs that use home visiting as a component of a broader family support strategy but do not identify the home as the primary location for service delivery (such as family resource centers or other primarily center-based initiatives); – Home-based services delivered as required by the federal Individuals with Disabilities Education Act; – Federal funding allocated directly to localities and not state-administered (such as Healthy Start and Early Head Start); and – Funding from private organizations and local communities .

Source: Pew Home Visiting Campaign Web Inventory . 2010 . http://www pewcenteronthestates. org/initiatives_detail. . aspx?initiativeID=61051 .

54 PEW CENTER ON THE STATES Appendix E

In this August 2011 letter to the Nurse-Family Partnership (NFP), the Centers for Medicare and Medicaid Services (CMS) outlined specific coverage options for NFP home visiting services . This letter suggests that states could adopt one or more of these approaches to providing home visiting services . See pages 14 and 24, above, for more information .

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 55 Methodology

The National Academy for State Health Policy (NASHP) conducted a literature review and environmental scan to identify mechanisms for financing home visiting services in Medicaid. Based on this scan, six states that use different home visiting models and different Medicaid financing methods were selected to participate in case studies. NASHP researchers conducted key informant interviews with Medicaid and home visiting program officials in these states. The resulting case studies are presented in Appendix B. In addition, NASHP conducted interviews with three national experts and facilitated an expert meeting that included representatives from some of the case study states; federal representatives from CMS, the Health Resources and Services Administration (HRSA), and the Administration for Children and Families (ACF); and national home visiting experts from academia and practice. This report reflects what was learned through these efforts.

56 PEW CENTER ON THE STATES Acknowledgments

The authors wish to thank the Pew Home Illinois: Andrea Palmer and Glendean Sisk, Visiting Campaign for its support of this Illinois Department of Human Services; project, specifically Jennifer V. Doctors, Deborah Sanders, Illinois Department of Libby Doggett, and Nicole Barcliff who Healthcare and Family Services. contributed to the development and review of this report. This report benefited Kentucky: Brenda English and Sandy greatly from the thoughtful input and Fawbush, Kentucky Cabinet for Health review of Catherine Hess, managing and Family Services; Lisa Lee, Kentucky director at NASHP. Our deepest thanks Department for Medicaid Services. go to the following people, who gave generously of their time and expertise in Michigan: Brenda Fink, Susan Moran, the development of this report: Jackie Prokop and Kathleen Stiffler, Michigan Department of Community Expert Panel: Terry Adirim and Jessie Health. Buerlin, Health Resources and Services Administration; Melissa Brodowski, Minnesota: Susan Castellano, Minnesota Administration for Children and Families; Department of Human Services; Laurel Jean Close, Centers for Medicare and Briske, Sylvia Cook, Maureen Fuchs, Medicaid Services; Lori Conners-Tadros, Candace Kragthorpe and Junie Svenson, The Finance Project; Karen Kalaijain, Minnesota Department of Health. Nurse-Family Partnership; Neva Kaye, National Academy for State Health Policy; Vermont: Russell Frank, Department of Erin Kinavey, Alaska Department of Health Vermont Health Access; Breena Holmes and Human Services; Melanie Lockhart, and Sally Kerschner, Vermont Department March of Dimes; Andrea Maresca, National of Health; Karen Garbarino and Susan Association of Medicaid Directors; Carolyn Shepard, Vermont Department for Mullen, Association of Maternal and Child Children and Families. Health Programs; Cydney Wessel, Healthy Families America. Washington: Christine Bess, Beth Blevins and June Hershey, Washington State National: Kay Johnson, Johnson Group Health Care Authority; Judy King, Consulting, and Sara Rosenbaum, George Washington State Department of Early Washington University. Learning; Barbara Lantz, Washington State Health Care Authority.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 57 Endnotes

1 Johnson, K.A., No Place Like Home: State Home 6 Maternal, Infant, and Early Childhood Home Visiting Policies and Programs. New York, NY: Visiting Program FY 2011 and FY 2012 Grant Awards. The Commonwealth Fund, 2001. http://www. Available at http://www.hrsa.gov/about/news/2011tabl commonwealthfund.org/~/media/Files/Publications/ es/110922homevisiting.html and http://www.hhs.gov/ Fund%20Report/2001/May/No%20Place%20Like%20 news/press/2012pres/04/20120403b.html. Home%20%20State%20Home%20Visiting%20 7 For a list of approved models, see Paulsell, D., Policies%20and%20Programs/johnson_home_452%20 Avellar, S., Sama Martin, E., and Del Grosso, P., pdf.pdf. Home Visiting Evidence of Effectiveness Review: 2 Johnson B. and Witgert K., Enhanced Pregnancy Executive Summary. Office of Planning, Research Benefit Packages: Worth Another Look. Portland, ME: and Evaluation, Administration for Children and National Academy for State Health Policy, January Families, U.S. Department of Health and Human 2010. http://www.nashp.org/sites/default/files/ Services. Washington, D.C., 2010. Washington, D.C., PregBenefits.pdf. November 2010. http://homvee.acf.hhs.gov/homvee_ executive_summary.pdf. 3 Johnson, K.A., No Place Like Home: State Home Visiting Policies and Programs. New York, NY: 8 National Conference of State Legislatures. “Early The Commonwealth Fund, 2001. http://www. Care and Education State Budget Actions FY 2011: commonwealthfund.org/~/media/Files/Publications/ Summary of Findings.” www.ncsl.org/documents/cyf/ Fund%20Report/2001/May/No%20Place%20Like%20 earlycareed2011budgetactions.pdf. Home%20%20State%20Home%20Visiting%20 9 National Governors Association, Policies%20and%20Programs/johnson_home_452%20 MCH Update: . pdf.pdf. States Increase Eligibility for Children’s Health in 2007 Washington, D.C.: National Governors Association, 4 Isaacs, J., Impacts of Early Childhood Programs. 2008. http://www.nga.org/files/live/sites/NGA/files/ Washington, DC: First Focus, September 2008. http:// pdf/0811MCHUPDATE.PDF;jsessionid=7B47A647247 www.firstfocus.net/sites/default/files/r.2008-9.8.isaacs6. DD4E5CB9B709C8F9797AE. pdf; Olds, et. al., “Effects of Nurse Home Visiting on 10 Paulsell, D., Avellar, S., Sama Martin, E., & Del Maternal and Child Functioning: Age-9 Follow-up of a Grosso, P. Home Visiting Evidence of Effectiveness Randomized Trial.” Pediatrics 120 no. 4 (2007): e832 . Office of Planning, -e845. Review: Executive Summary Research and Evaluation, Administration for Children 5 Paulsell, D., Avellar, S., Sama Martin, E., and Del and Families, U.S. Department of Health and Human Grosso, P., Home Visiting Evidence of Effectiveness Services. Washington, D.C., November 2010. http:// Review: Executive Summary. Office of Planning, homvee.acf.hhs.gov/homvee_executive_summary.pdf; Research and Evaluation, Administration for Children Rosenbaum, S., et al. Medicaid and Case Management and Families, U.S. Department of Health and Human to Promote Healthy Child Development. New York, Services. Washington, D.C., November 2010. http:// NY: The Commonwealth Fund, 2009. http://www. homvee.acf.hhs.gov/homvee_ExecutiveSummary_ gwumc.edu/sphhs/departments/healthpolicy/dhp_ Rev10-15-2011.pdf. publications/pub_uploads/dhpPublication_FB044708- 5056-9D20-3D1C4A53DFA85EC7.pdf; Meyer, J. and Markham Smith, B. Chronic Disease Management: Evidence of Predictable Savings. Naples, FL: Health

58 PEW CENTER ON THE STATES ENDNOTES

Management Associates. November 2008. http:// 19 Nurse-Family Partnership, memorandum from www.idph.state.ia.us/hcr_committees/common/pdf/ Cindy Mann, Director, Centers for Medicare and clinicians/savings_report.pdf; Isaacs, J. Cost-Effective Medicaid Services, August 22, 2011. Investments in Children. Washington, D.C.: The 20 U.S. Preventive Services Task Force, Brookings Institution, January 2007. http://www. A and . Available at http://www. brookings.edu/papers/2007/01childrenfamilies_isaacs. B Recommendations uspreventiveservicestaskforce.org/uspstf/uspsabrecs. aspx. htm. 11 Pew Center on the States, State Home Visiting 21 United States Social Security Act [42 U.S.C. Programs and Investments FY ‘10. Available at http:// §1396(d)(r)]. www.pewcenteronthestates.org/uploadedFiles/ wwwpewcenteronthestatesorg/Initiatives/Home_ 22 Minnesota Statutes 2010, section 256B.0943. Visiting/Home_Visiting_Index/home_visiting_ inventory_state_list.pdf?n=5669. 23 The Kaiser Family Foundation defines this as: “The requirement that states electing to participate 12 Hill, I., Hogan, S., Palmer, L., Courtot, B., Gehshan, in Medicaid must operate their programs throughout S., Belnap, D., Snyder, A. Medicaid Outreach and the state and may not exclude individuals residing Enrollment for Pregnant Women: What Is the State of in, or providers operating in, particular counties or the Art? Washington, DC: The Urban Institute, January municipalities.” See: http://www.kff.org/medicaid/ 2009. http://www.urban.org/UploadedPDF/411898_ loader.cfm?url=/commonspot/security/getfile. pregnant_women.pdf. cfm&PageID=14263.

13 Hill, I. “Improving State Medicaid Programs 24 See, for example, Isaacs J.B., Impacts of Early for Pregnant Women and Children”. Health Care Childhood Programs. Washington. D.C.: The Brookings Financing Review. (Dec. 1990 Supp): 75-87. Institution, September 2008. http://www.brookings. edu/~/media/Files/rc/papers/2008/09_early_programs_ 14 Hill, I. The Medicaid Expansions for Pregnant isaacs/09_early_programs_isaacs.pdf; and Olds, et. al., Women and Children: A State Program Characteristics “Effects of Nurse Home Visiting on Maternal and Child Information Base. Prepared for the Health Care Functioning: Age-9 Follow-up of a Randomized Trial.” Financing Administration, DHHS. Washington, DC: 120 no. 4 (2007): e832-e845. Health Systems Research, Inc. Pediatrics 25 Hall, J.M. Presentation at NASHP State Health 15 United States Social Security Act [42 U.S.C. Policy Conference, Kansas City, MO, October 8, 2011. §1905(a)]. Specifics taken from presenter’s remarks and not 16 Medical services that are separated from a contract included in the PowerPoint. with a managed care organization and paid under a 26 Hebbeler, K. et. al. State to State Variations in Early different arrangement. Intervention Systems. National Early Intervention 17 Centers for Medicare and Medicaid Services, Longitudinal Study. September 1999. National Summary of Medicaid Managed Care 27 Families USA. Covering Services for Children Programs and Enrollment as of June 30, 2009. http:// with Special Needs under Medicaid, Individuals with www.scribd.com/doc/45612146/063009-managed- Disabilities Education Act, and Private Insurance. care-medicaid-broken-out-by-type-of-company. November 2003. Accessed 10 October 2011. 28 Definitions of the three benchmark options and 18 Patient Protection and Affordable Care Act [P.L. guidance for developing a Secretary-approved plan are 111-148 §4106]. provided in a State Medicaid Director letter. See SMDL #06-008, March 31, 2006.

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 59 ENDNOTES

29 The Deficit Reduction Act of 2005 [P.L.109-171 40 Interview with Sandy Fawbush, Kentucky Cabinet §6044]. for Health and Family Services.

30 Mann, C. Letter to Nurse-Family Partnership. 12 41 Growing Great Kids is a comprehensive strength- August 2011. based approach to growing nurturing parent-child relationships and supporting healthy childhood 31 Sills, S. and Johnson, B. Medicaid 1115 Family development. The curriculum consists of six modules Planning Demonstration Waiver Programs. Portland, for child development and features innovative activities ME: National Academy for State Health Policy, and interactive discussions that are culturally inclusive November 2008. for families and communities. The home and center- 32 Patient Protection and Affordable Care Act [P.L. based model offers practical strategies for strengthening 111-148 §2303]. protective factors for highly stressed families.

33 Throughout these case studies, the term ‘provider’ 42 Classification of high-risk is defined using a is used to refer to any individual, lay or professional, screening tool developed by the Kentucky Department delivering home visiting services. The case studies of Public Health. Identifiers of high risk include, but describe the training and/or credentials required of are not limited to, teen pregnancy, late prenatal care home visiting providers serving the different programs. (> 20 weeks gestation), preterm delivery, inadequate support system, history of domestic violence, 34 See Family Case Management (FCM) Fact Sheet. postpartum depression, and less than 48 hour Retrieved 11 Oct. 2011. http://www.dhs.state.il.us/ discharge from hospital following delivery. page.aspx?item=32849. 43 Illback, Robert J., et al. Health Access Nurturing 35 Healthy Families Illinois programs with qualified Development Services (HANDS) Kentucky’s Home staff bill Medicaid for the completion of developmental Visiting Program for First Time Parents Program delay screens. Evaluation Findings January 2008. Figure 5. Reach of Louisville, 2008. 36 Illinois Department of Health and Human Services, Maternal and Child Health Services Code, sec 44 Background provided during Interviews with Sandy 630.220. Retrieved 2 Sept. 2011. http://www.ilga.gov/ Fawbush, Kentucky Cabinet for Health and Family commission/jcar/admincode/077/077006300D02200R. Services, and Lisa Lee, Kentucky Department for html. Medicaid Services.

37 Ibid. 45 Ibid.

38 See Illinois Department of Health and Human 46 The paraprofessionals, or family support workers, Services, Community Health and Prevention Program have a high school diploma or GED, are 18 years of Manual, Family Case Management Downstate. age or older, and have received core training prior to Available at: http://www.dhs.state.il.us/page. having family contact. They also receive continuing aspx?item=41549. education and must be supervised by a registered nurse or social worker. 39 Illinois Department of Health and Human Services, Maternal and Child Health Services Code, sec 630.220. Retrieved 2 Sept. 2011. http://www.ilga.gov/ commission/jcar/admincode/077/077006300D02200R. html.

60 PEW CENTER ON THE STATES ENDNOTES

47 Michigan also offers Nurse-Family Partnership delivery; support program administration; identify (NFP), Healthy Families America (HFA), Early Head opportunities of program strength and opportunities Start, and Parents as Teachers (PAT). NFP is funded for improvement; drive policy improvements; and through combinations of state, local, foundation and monitor program costs; Program Fidelity Review: Title XIX match dollars, and is administered at the MDCH works collaboratively with MSU IHCS to state level primarily by public health staff within the assess MIHP program fidelity. IHCS registered Michigan Department of Community Health. HFA nurses with experience in maternal and child health and PAT are available in various communities in collect data from client records to assess adherence Michigan, some with local funding support and others to MDCH policy, intensity of interventions by risk with funding administered through the Department of level, frequency and location of visits, and consistency Human Services or the Children’s Trust Fund. of program delivery across the state; Satisfaction Surveys: MDCH and IHCS developed a uniform 48 MDCH is the Illinois state Title V agency. client satisfaction survey in FY 2011, and a provider 49 Michigan Department of Community Health, satisfaction survey will be developed in FY 2012. Medicaid Provider Manual. Accessed 28 June 2011. Evaluation information provided by Brenda Fink Available at http://www.mdch.state.mi.us/dch- and Jackie Prokop at the Michigan Department of medicaid/manuals/MedicaidProviderManual.pdf. Community Health upon review of a draft case study.

50 Drug-exposed infants are entitled to 18 professional 55 Minnesota Statute §145A.17, Local Public Health visits and an additional 18 visits if permitted by a Act. 2007. physician. 56 Eligible families must meet one of the following 51 A registered dietician may conduct a professional criteria: adolescent parents; a history of alcohol or drug visit if permitted by a physician. abuse; a history of child abuse and neglect, domestic abuse or other types of violence; reduced cognitive 52 Native Americans are a voluntary enrollee functioning; a lack of knowledge of child growth and population, and dual eligibles are excluded from this development stages; low resiliency to adversity and requirement. environmental stressors; insufficient financial resources to meet family needs; a history of homelessness, and 53 See: MIHP Operations Guide, p. 8. Accessed a risk of long-term welfare dependence or family 16 Sept. 2011. Available at http://www.michigan. instability due to employment barriers. gov/documents/mdch/MIHP_Op_Guide_ effective_1.1.11_341618_7.doc. 57 Written communication between the authors and Candace Kragthorpe, Minnesota Department of Health. 54 MIHP’s Evaluation consists of the following elements: Quasi-experimental Study: MDCH and 58 The Kaiser Family Foundation, statehealthfacts.org. MSU will conduct a quasi-experimental study of Data Source: Medicaid Managed Care Penetration MIHP program outcomes beginning in FY 2012. The Rates by State as of June 30, 2009, Centers for hypothesis is that women and infants enrolled in Medicare and Medicaid Services, U.S. Department of MIHP have better pregnancy, birth, and post-birth Health and Human Services, special data request, July outcomes than those not enrolled in the program. 2010. Individuals with disabilities and people living IHCS will test the hypothesis by comparing outcomes in small counties are enrolled in FFS Medicaid. In in five domains between MIHP participants and addition, new Medicaid beneficiaries are temporarily non-participants; Administrative Data Analyses: enrolled in FFS until they choose or are assigned a MDCH conducts ongoing analyses of administrative managed care plan. Medicaid claim, encounter, and electronic screener data to assess patterns of maternal and infant service

MEDICAID FINANCING OF EARLY CHILDHOOD HOME VISITING PROGRAMS 61 ENDNOTES

59 Dakota County, MN. http://www. 67 For more information on MSS/ICM provider co.dakota.mn.us/NR/rdonlyres/00004a8d/ qualifications and job duties, please see the Medicaid gpzgluebvdmnarbjkmylsvtavavvoeml/ Purchasing Administration (MPA), Maternity Support PerinatalSrvsGridincentiveinfoFINALupdated7122011. Services/ Infant Case Management Billing Instructions pdf. [WAC 388-533-0300 and 388-533-0386]. http://hrsa. dshs.wa.gov/Download/Billing_Instructions/MSS-ICM/ 60 Information provided by Vermont program staff. MSS-ICM_BI.pdf.

61 Telephone interview conducted by the authors with 68 For ICM, a parent is a person who resides with June Hershey, Christine Bess, Judy King, and Barbara an infant and provides the infant’s day-to-day care, Lance of Washington State. and is: The infant’s natural or adoptive parent; or a 62 The act of locating Medicaid-eligible individuals person other than a foster parent who has been granted with certain risk criteria in order to provide assistance legal custody of the infant or a person who is legally in accessing resources to meet their needs. obligated to support the infant.

63 Washington State Department of Social and 69 Specific qualifying risk criteria for ICM services can Human Services, Medicaid Purchasing Agency (MPA), be accessed by viewing the Infant Case Management Maternity Support Services/ Infant Case Management Screening, available at http://www.dshs.wa.gov/pdf/ms/ Billing Instructions, [WAC 388-533-0300 and 388- forms/13_658.pdf. 533-0386]. Accessed 22 June 2011. http://hrsa.dshs. 70 Medicaid Purchasing Administration (MPA), wa.gov/Download/Billing_Instructions/MSS-ICM/MSS- Maternity Support Services/ Infant Case Management ICM_BI.pdf. Billing Instructions [WAC 388-533-0300 and 388- 64 For the purposes of First Steps, the maternity cycle 533-0386]. http://hrsa.dshs.wa.gov/Download/Billing_ refers to the eligibility period for maternity support Instructions/MSS-ICM/MSS-ICM_BI.pdf and see services that begins during pregnancy and continues Washington State Health Medicaid Purchasing Agency to the end of the month in which the 60th day post MSS/ICM Fee Schedule. Available at http://hrsa.dshs. pregnancy occurs. wa.gov/RBRVS/2009_Fee_Schedules/HRSA_MSS_ICM_ July_1_2009_Fee_Schedule.xls. 65 Washington State Department of Social and Health Services: Health and Recovery Services Administration, 71 Revised Code of Washington 43.215.130. http:// Washington State Department of Health: Maternal and apps.leg.wa.gov/rcw/default.aspx?cite=43.215.130. Infant Health, First Steps Program Manual. 72 Created in 2006, Thrive by Five Washington is 66 There is no lifetime limit for a woman enrolled in the state’s nonprofit public-private partnership for Medicaid to receive MSS services. Benefit packages early learning. On August 23, 2010, the Department that include MSS are Categorically Needy Medicaid of Early Learning (DEL) contracted with Thrive by and Categorically Needy CHIP, as well as emergency Five Washington to carry out activities of the HVSA. Medicaid. For more information see Washington State Initially, $200,000 in Washington state dollars was Department of Social and Human Services Medical allocated to the HVSA. Due to state budget reductions Assistance Scope of Care, available at: http://www. the state portion of HVSA funding was reduced by dshs.wa.gov/manuals/eaz/sections/MedicalAssistance/ $12,574. Thrive raised $200,000 in match for direct ScopeOfCare.shtml. services, as well as additional private dollars to support infrastructure and evaluation. For more information, see Thrive by Five Washington available at http://www. thrivebyfivewa.org/hvsa_wa.html.

62 PEW CENTER ON THE STATES

STAY CONNECTED  pewstates.org twitter.com/pewstates youtube.com/pew facebook.com/pewtrusts

pewstates.org/newsletter

STAY CONNECTED  nashp.org

twitter.com/NASHPhealth youtube.com/NASHPhealthpolicyTV1