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Children’s experiences before age 5 have dramatic and lasting impacts throughout their lives. During this period, children develop critical foundational capabilities in cognition, language and literacy, emotional growth, and reasoning.¹ When young children deal with poverty and other toxic stressors, it has a detrimental impact on both their short- and long-term development and leads to lifelong health disparities across socio-economic groups.² In the United States, about one in four infants and toddlers grow up in homes experiencing poverty.³ Almost one in four children are exposed to at least one adverse childhood experience—such as income insecurity, the incarceration of a parent, neighborhood violence, or family mental illness—before they start school.⁴ These experiences have profound effects on a child’s development.

For this reason, interventions that help families provide a nurturing, healthy environment are absolutely critical. Evidence-based home visiting programs that engage parents and provide parental coaching and guidance while helping them access other professionals and social services are among the most effective social programs at alleviating the stress of poverty.

The benefits of these programs range from improved school readiness to enhanced maternal and child health. Similarly, some programs have reduced the hospitalization rate among participating mothers and children. Others have effectively decreased the need for safety net programs such as the Supplemental Nutrition Assistance Program, or SNAP, and lowered rates of interaction with the juvenile justice system. In turn, the success of home visiting programs ultimately saves money for states and the federal government by lowering costs for programs such as Medicaid.

In 2010, the federal government established the Maternal, Infant, and Early Childhood Home Visiting, or MIECHV, program, which represents the largest source of federal investment in home visiting. States have used this funding to identify high-risk target populations and expand evidence-based home visiting programs. While the MIECHV program is a critical federal investment, additional funds are needed to reach all the families who would benefit from these services. In 2015, the program reached only 145,500 parents and children, a small portion of the eligible population.⁵

To supplement MIECHV funding, states are leveraging other funding sources to serve more families in need, including philanthropic funds, state funding, and other federal sources such as Temporary Assistance for Needy Families, or TANF, and Medicaid. Of these sources, Medicaid offers a significant opportunity for increased funding. A number of states already finance part of their home visiting programs using Medicaid, but it remains a greatly underused option to support home visiting.

This report highlights strategies that have worked in states where Medicaid supports home visiting, discusses barriers and challenges to leveraging Medicaid funding for these services, and outlines state and federal policy options for streamlining the accessibility of Medicaid funds to support home visiting. Findings presented in this report are based on existing state resources, published information on Medicaid and home visiting, and conversations with national organizations, as well as a series of interviews with 19 practitioners and home visiting administrative staff members in nine states.

State Checklist for Expanding Medicaid to Cover Home Visiting

States can use Medicaid funding to finance evidence-based home visiting programs. This checklist outlines key strategies for states to get started.

This report finds that, while states have been able to support home visiting using Medicaid funding, Medicaid coverage and payment rates fail to cover the full cost of services, and administrative challenges inhibit broader access. To address these challenges, states and the federal government should take a number of actions to streamline efforts around accessing Medicaid for home visiting. Specifically, states should:

• Integrate payment for home visiting services into managed care financing
• Conduct feasibility studies to explore gaps in funding and opportunities to bolster Medicaid support for home visiting
• Obtain buy-in from key stakeholders such as relevant agency administrators, lawmakers, service providers, and the advocacy community
• Develop cross-agency collaborations
• Improve the accuracy of reimbursement rates by rebasing rates more frequently and by providing training and technical assistance to home visitors

It is also critical that the federal government offer more specific support to states working to increase Medicaid support for home visiting services. To this end, the federal government should:

• Issue home visiting-specific waiver templates for states wishing to expand services
• Provide technical assistance to states on billing and bundled payment rates for services
• Clarify the relationship between the MIECHV grant program and Medicaid funding
• Ensure that MIECHV is extended for a longer-term authorization at a higher amount

Investments in evidence-based home vising programs are investments in America’s future economic prosperity. Ensuring that more of the nation’s most vulnerable families can access the resources that they need to thrive can prevent costly negative outcomes and save taxpayer dollars down the road. States and the federal government should prioritize expanding access to these critical services.

Home visiting programs vary in scope and practice but generally connect the parents of young children to nurses, social workers, and other professionals who provide coaching and guidance on how to support healthy development during the early years of a child’s life. Home visitors deliver services designed to promote healthy child development and positive parenting, including screenings for developmental benchmarks, maternal health, and child safety. Common case management activities among home visiting programs include assessing a family’s needs, developing a care plan, providing service referrals, monitoring developmental progress, and conducing follow-up activities as needed. Finally, most home visiting programs offer parent-support activities and coaching, which can include counseling services and referrals along with services that work with parents to develop skills around stress management, nutrition, child discipline, and nurturing interactions.

Through these activities, home visitors develop supportive relationships with the parents that they serve, allowing them to help parents develop the skills and practices to support children’s healthy physical, social, and emotional growth. Home visiting services have existed in the United States since the late 19th century, but in recent decades, research has identified specific models that produce significant positive outcomes for the families and children who participate.⁶ In an effort to expand the most effective of these programs, the federal government created the Maternal, Infant, and Early Childhood Home Visiting program. MIECHV is a federal grant program administered by the Health Resources and Services Administration, or HRSA, of the U.S. Department of Health and Human Services, or HHS. States, tribal communities, and territories receive grant funds to implement one or more of the home visiting models that meet HHS’ evidence-based criteria or evaluate promising practices.

Evidence-based home visiting models provide a specific set of home visiting services that are consistent across every location where the services are offered. Models often include a research-based curriculum, a targeted population, and services for a specific duration and dosage. Home visiting models can vary in their goals and approach, as well as in who they serve and for how long. Across the country, MIECHV grantees conduct needs assessments to identify at-risk communities, then select the eligible evidence-based home visiting models that best support their target populations.

Determining effective home visiting programs

To determine which home visiting programs would qualify for MIECHV funds, HHS conducted a comprehensive review of available academic literature and evaluations of home visiting programs to identify evidence-based home visiting models. HHS considered a program’s impact on eight general outcome areas: child development and school readiness; family economic self-sufficiency; child health; maternal health; positive parenting; reduction in abuse and neglect; reduction in juvenile justice system participation; and referrals and linkages to other social services.¹⁰

HHS deems home visiting models evidence based if they demonstrate favorable and statistically significant impacts in two outcome areas or through multiple rigorous evaluation studies.¹¹ Evaluations or impact studies are considered rigorous if they utilize random control trials or quasi-experimental designs.¹² Today, HHS has identified 17 evidence-based models that support positive outcomes across an array of social indicators.¹³ (see Table 1)

These evidence-based home visiting programs are associated with a variety of positive outcomes for parents and children. Many are linked to improved educational outcomes and academic performance. For example, some models support higher GPAs, reading, and math scores among participating children.¹⁴ Others result in increased participation in school-based gifted programs or reduced need for special education.¹⁵ Parenting practices, too, are improved by participation in home visiting. Parents who participated in some programs were more likely to read to their children daily and have children’s books in the house.¹⁶ Researchers also found improved home safety and decreased rates of harsh parenting practices such as physical and verbal aggression and corporal punishment.¹⁷

Positive health outcomes associated with home visiting are among the strongest benefits of the programs. Specific health outcomes for children include a reduction in instances of low birth weight, preterm births, and hospitalization during infancy.¹⁸ Studies have also linked participation in some home visiting models to an increase in the number of well-child visits, reducing the number of emergency room visits and overnight stays in the hospital.¹⁹ Home visiting also leads to increased rates of breastfeeding, which is a proven boon for infants, and improved child nutrition. Babies whose mothers participate in the programs are less likely to be born preterm or to have low birth weights, and mothers and children participating in the programs have fewer emergency room visits.²⁰

Additionally, home visiting can improve the health of participating mothers by reducing rates of maternal depression, improving nutrition and diet during pregnancy, and lowering reported rates of parental stress.²¹ Participation may also reduce drug and alcohol use among new mothers and pregnant women and increase use of prenatal health care, which reduces complications such as pregnancy-induced hypertension.²² Mothers participating in the program—especially adolescent mothers—are less likely than those who do not participate to become pregnant again soon after the birth of their first child.²³

Home visiting programs produce health care cost savings by improving child and maternal health. Funding home visiting is a critical investment in prevention. By making an upfront investment to identify and head-off risk factors for children and their families—before they cause long-term problems—home visiting programs can produce significant cost savings over a participant’s life.

More specifically, the positive health outcomes associated with participation in home visiting are linked to significant health care savings for states and the federal government by reducing Medicaid expenses and other health care costs. For example, some home visiting services are able to reduce the rate of neonatal intensive care unit, or NICU, care among participants.²⁴ Studies have found that Medicaid pays up to $20,000, on average, for a birth that results in NICU care.²⁵ Comparatively, Medicaid pays up to $13,000, on average, for a routine birth.²⁶ This means home visiting programs that prevent NICU care end up saving the public thousands of dollars. If fully scaled, home visiting services could have a dramatic impact on reducing overall medical costs in the United States.

In addition to the reductions in health care costs, home visiting is associated with federal and state savings in other social service sectors. These savings result from a decreased need for food and income assistance programs, fewer placements in foster care, lower rates of contact with the juvenile justice system, decreased need for special education or grade repetition between kindergarten and 12th grade, and lower rates of child abuse and neglect.²⁷ Broadly, the benefits of home visiting outweigh the costs of providing these services. In fact, for every dollar spent, there is a return of up to $5.70 in savings and benefits.²⁸

Funding sources for home visiting programs

Funding for home visiting is limited and comes from a variety of sources. The Maternal, Infant, and Early Childhood Home Visiting program is the single largest source of federal funding dedicated to home visiting. In some states, MIECHV is the most significant or only source of investment in home visiting. In other states, home visiting has long been a priority, with dedicated state and private funding sources. In these states, a patchwork of funding from various federal, state, local, and private sources comprises the total investment in home visiting efforts.

The MIECHV grant program provides funding to support evidence-based home visiting programs. MIECHV grantees—states, tribes, territories, and nonprofit implementing agencies—receive a formula-based grant every year and can apply for additional competitive grant funds to scale innovative efforts. Seventy-five percent of MIECHV funds must support evidence-based home visiting models that serve either high-risk communities or specific target populations, such as high-poverty communities or underserved rural populations. Up to 25 percent can go toward implementing and evaluating promising practices—or home visiting programs that have not yet completed a rigorous evaluation to prove outcomes.²⁹

Given that MIECHV funds are relatively new and are limited, states also draw from a number of other sources. Before MIECHV funding began in 2010, states relied on alternative funding sources—both public and private—and these continue today. In a number of states, such as California, tobacco tax revenue or tobacco lawsuit settlement funds support home visiting.³⁰ States also rely on philanthropic support to implement and expand home visiting services. For example, Washington’s Department of Early Learning works with Thrive Washington, a state-based nonprofit, to administer the Home Visiting Services Account, which has funded home visiting programs by leveraging private funding to match state dollars.³¹

Some states also allocate resources from other federal programs—including Temporary Assistance for Needy Families, Maternal and Child Health Block Grant funds, and the Early Intervention Partnerships Program—to help support home visiting programs.³² Yet funding from other federal programs is often relatively low and disparate across the country. In 2015, less than 0.1 percent of TANF funds were used to support home visiting programs in only six states.³³

Considering that some home visiting programs have substantial positive health outcomes for low-income families, many states have turned to Medicaid as a funding source. While home visiting is not a specifically covered service under Medicaid, Medicaid-enrolled providers can seek reimbursement from Medicaid for components of home visiting programs in specific situations. For example, programs that incorporate case management services or that refer patients to Medicaid for enrollment may be able to receive Medicaid reimbursement for these activities. Unfortunately, this approach creates added administrative burdens for home visitors and state administrative staff. For example, they must carefully allocate the time spent on different parts of a home visit to make sure that they only bill Medicaid for allowed services.

Despite these barriers, a number of states have used Medicaid funding to support their home visiting programs. These states recognize that home visiting services complement Medicaid, as home visiting programs improve the health and well-being of participating families by addressing many of the health and social risk factors that lead to poor outcomes later in life. Therefore, these states see Medicaid funding as an important supplemental funding source to bolster their home visiting systems.

The sections below detail how nine states have navigated Medicaid’s administrative complexities and piecemeal coverage to support home visiting. These examples not only provide a guide for states that have yet to tap into this funding source but also illustrate the need for policymakers to create a more streamlined approach for states that wish to use Medicaid funding to support home visiting services.

Medicaid is a joint federal-state program that provides health coverage to groups of low-income adults, children, women who are pregnant, and certain individuals with disabilities.* As the primary health care program for low-income pregnant women and children, it makes sense that states would seek Medicaid funding for services provided by their home visiting programs because home visiting programs successfully promote positive health and well-being outcomes among these vulnerable populations.

In some states, Medicaid helps fund national home visiting models—or component services provided by national home visiting models—such as Nurse-Family Partnership and Healthy Families America. In other states, Medicaid funds state-specific home visiting programs, which in some places were developed through state Medicaid programs. Regardless of how these programs were developed, home visiting remains a natural complement to Medicaid. These effective interventions help counteract the ongoing effects of poverty and stress throughout a child’s life and are as critical to improving health and economic opportunity for participants as other Medicaid-covered services.

Medicaid overview

The federal government contributes a percentage of the states’ Medicaid program expenditures for services covered under each state’s unique Medicaid state plan. That percentage is called the Federal Medical Assistance Percentage, or FMAP, and it is based on the state’s relative wealth.³⁴

Federal law sets general requirements for the Medicaid program, but within those parameters, states have a significant amount of flexibility to design their Medicaid programs to meet their specific needs.³⁵ For example, federal law requires states to cover a number of mandatory services, such as inpatient hospital services and physician services, but the Medicaid statute also gives states flexibility to cover other optional services, including case management.³⁶

The Medicaid law also gives a large amount of deference to state professional standards and licensure requirements.³⁷ For many home visiting models, this flexibility is important because some models rely on social workers or other nonmedical professionals to provide services during home visits. Because the Medicaid program only pays for services furnished by qualified Medicaid providers, states must designate nonmedical professionals as qualified providers of home visiting services. Guidance from the U.S. Department of Health and Human Services describes this flexibility:

In many areas of health care, it is clear what type of provider can perform certain services (e.g., surgery, prescribing medications). However, where a licensing category does not exist or does not fit for the purp