Social Care Network

A core piece of the New York State Health Equity Reform (NYSHER) 1115 Waiver program is the development of Social Care Networks (SCNs). Care Compass Collaborative was selected to be the Social Care Network lead entity for Broome, Chenango, Delaware, Otsego, Tioga, and Tompkins County.

What are Social Care Networks?

SCNs are tasked with delivering Health-Related Social Needs (HRSN) services to the Medicaid population. Networks will bring together health care systems, community-based organizations, behavioral health providers, and other social service providers to expand access to critical unmet needs.

Who is Eligible for Services

Medicaid Members that reside in New York State and meet the following criteria are eligible to receive Enhanced Health-Related Social Needs (HRSN) services. Click here for additional information the enhanced population criteria, clinical criteria, and social risk factors for enhanced Health-Related Social Needs Services.

Criteria to Receive Enhanced Services:

Enrolled in Medicaid Managed Care
Demonstrate One or More Unmet Social Needs
Meet Criteria for One or More Enhanced Service Populations

Enhanced Service Populations:

Individuals with a Substance Use Disorder (SUD)
Individuals with a Serious Mental Illness (SMI)
Individuals with an Intellectual and Developmental Disability (I/DD)
Pregnant or Postpartum Persons
Individuals who are up to 90 days post-release from incarceration with a chronic condition
High-risk children under the age of 18 (e.g., justice-involved youth, foster care youth, kinship care)
Medicaid High Utilizer (e.g., emergency department or inpatient utilizers)
Individuals enrolled in a NYS-designated Health Home

Services Offered

New York State Medicaid is expanding access to services to address health-related social needs (HRSNs), to improve the health and well-being of its members. These services are an additional benefit and will not affect your current Medicaid benefits. To see if you are eligible for these services, use the Public Resource Directory to find a provider near you.

Enhanced Health-Related Social Needs Services

Nutrition

Nutritional Counseling and Classes (e.g., meal prep education, food/ diet planning related to conditions such as diabetes, obesity, etc.)
Medically Tailored or Clinically appropriate Home-Delivered Meals
Food Prescriptions (e.g., medically tailored or clinically appropriate food boxes or nutrition vouchers)
Pantry Stocking (e.g., fresh produce and non-perishable groceries – can include delivery)
Cooking Supplies (e.g., pots, pans, plates, bowls, cups, silverware, etc.)

Housing

Medically Necessary Home Modifications and Remediation Including Asthma Remediation
Medical Respite
Rent/ Temporary Housing
Utility Set-up/ Assistance
Housing Navigation
Pre-Tenancy Services
Community Transitional Services
Tenancy Sustaining Services

Social Care Management

Navigation to Social Care Services (including other enhanced HRSN services and existing services such as education, childcare, interpersonal violence resources, etc.)

Transportation

Reimbursement for Public and Private Transportation to Connect to HRSN Services and HRSN Care Management Activities (e.g., transportation to housing appointments, nutrition classes, or to pick up food prescription box)