As public healthcare evolves in New York State, two major programs are making it easier for value-based care providers and community-based organizations to help Medicaid members get the help they need:
While they work hand-in-hand, these programs serve different purposes — and they’ve sparked a lot of questions from both care providers and Medicaid recipients.
At Hudson Valley Care Coalition (HVCC), we serve as a lead entity for both programs in Westchester, Orange, Rockland, Dutchess, Putnam, Ulster, and Sullivan counties. Through our network of 100+ community-based organizations (CBO), we connect people to care management, medical care, behavioral health, and social services — all with a coordinated, person-first approach.
Why do these programs matter?
More than 80% of a person’s health outcomes are determined by social and environmental factors — not just clinical care. Medicaid members are disproportionately impacted by issues like housing instability, food insecurity, and lack of transportation:
- 1 in 4 Medicaid enrollees live in food-insecure households
- 1 in 5 low-income households face housing instability or risk of eviction
- 3.6 million people each year miss or delay care due to transportation barriers, others cannot get to government services, job interviews, or other non-clinical daily living commitments.
(Sources: https://nam.edu/perspectives/social-determinants-of-health-101-for-health-care-five-plus-five/; https://www.kff.org/medicaid/issue-brief/the-implications-of-federal-snap-spending-cuts-on-individuals-with-medicaid-and-other-health-coverage/; https://home.treasury.gov/news/featured-stories/emergency-rental-assistance-supporting-renting-families-driving-lasting-reform; https://www.aha.org/ahahret-guides/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals)
These unmet needs often lead to more ER visits, missed appointments, and worsening chronic conditions. Care management models like Health Homes — and newer, more flexible programs like SCN are designed to prevent that.
“The key difference between our Health Home and Social Care Network programs lies in their eligibility and reimbursement,” says Meghan Weygant, Chief Operating Officer of HVCC. “All Medicaid members can be screened for free SCN services, and they do not have to meet the criteria for Health Home eligibility to receive services.”
Adds Weygant: “Enhanced services, such as additional food vouchers, mold remediation or utility support that are not reimbursable under the Health Home model, may be covered under the SCN, based on the program’s lower eligibility threshold and unmet health-related social needs, like nutrition assistance, housing support, and transportation.”
To help clarify how these programs work together, we’ve answered common questions from community partners and healthcare providers. Have more questions? Reach out to us — we’re here to help.
For Health & Social Service Providers: Your Questions Answered
What is the difference between a Health Home and the Social Care Network (SCN)?
A Health Home offers comprehensive care management for Medicaid members with chronic conditions or serious mental illness. Powered by community-based organizations (CBOs) under HVCC, the Social Care Network (SCN) identifies and addresses health-related social needs (HRSNs) — like food, housing, or transportation — for a broader group of Medicaid members, including those who don’t qualify for a Health Home.
CBOs are the critical underpinning of the social care network. They know the communities in which they serve, and they provide direct contact with vulnerable populations, providing vital services that address social determinants of health and improve individuals’ overall well-being.
Can someone receive services from both programs?
Yes. A Medicaid member can be screened and supported by both programs — and both screenings are reimbursable to partner organizations. Services are designed to complement, not duplicate.
Do both programs use the same screening form?
Yes, New York State uses a standard 12-question HRSN screening tool. A Health Home screening is separate from a Social Care Network screening for billing and tracking purposes. Medicaid members can be screened once annually, or twice if a life-changing event occurs.
What types of services does the SCN cover that Health Homes may not?
The SCN enables providers to fulfill needs that were previously identified but couldn’t be reimbursed through Health Home models. Examples include:
- Mold or pest remediation
- Utility bill support
- Cooking supplies or medically tailored meals
- Home modifications for safety and accessibility
- Non-medical transportation
Even if a Health Home identifies these needs, the SCN may be the mechanism to fund and fulfill them.
How quickly are services delivered after screening?
- Navigation and eligibility assessments: 3–5 days
- Referral acceptance by provider: within 48 hours
- Services typically begin shortly after, depending on availability
How do we get started?
Whether you’re interested in joining HVCC’s Health Home network or becoming part of the Social Care Network (SCN), there are multiple ways to get involved:
For Community-Based Organizations and Providers:
- Join the Social Care Network (SCN):
If your organization has a TIN and NPI and can bill Medicaid, you can apply to become a contracted SCN partner. This allows you to screen, navigate, and provide reimbursable services related to food, housing, transportation, and more. - Join the Health Home Network:
Organizations that provide care management services to individuals with chronic conditions or serious mental illness may qualify to join HVCC’s Health Home network as a downstream provider. You’ll help coordinate medical, behavioral, and social care for eligible Medicaid members. - Start Screening:
Use the 12-question HRSN tool to identify unmet needs. Both Health Home and SCN screenings are reimbursable and can be conducted annually — or more frequently if there’s a life-changing event. - Refer Clients to the Right Program:
If you’re not ready to become a contracted partner, you can still refer Medicaid members to HVCC’s network for help with housing, nutrition, transportation, or care management. - Use the Self-Screen SCN Tool:
Medicaid clients with health-related social needs can complete their own screening online to be evaluated for free services, like food, housing support or non-medical transportation. It’s fast, confidential, and mobile-friendly. - Tap into Capacity-Building Funds (SCN only):
Eligible SCN providers may apply for funding to support IT upgrades, workforce onboarding, and service expansion.
Need help deciding where to start?
Email info@hudsonvalleycare.org and we’ll help you figure out which program(s) make the most sense for your organization and how to move forward.
