For Providers
Our care management network is built on trusted relationships and local knowledge. We know how to reach people where they are and keep them connected to the services that support their health and well-being. We actively manage referrals, monitor progress and access resources that matter.
There is no cost to refer providers or members. Health Home Services are reimbursed through Medicaid and managed care plans.
Each Medicaid-eligible member is assigned a dedicated care manager who works closely with them to:
This is a Medicaid benefit to improve care coordination for individuals with chronic conditions like diabetes, asthma, or mental health issues.
Conditions including, but not limited to asthma, diabetes, mental health, substance use disorder, or single conditions such as HIV/AIDS, Serious Mental Illness (SMI), Sickle Cell Disease.
No primary care provider, difficulty managing medications, recent incarceration, unstable housing or limited family support, and other challenges with daily living activities.
Once we receive a referral and determine the member is appropriate for Health Home care management, they are matched with a partner agency. Health Home services operate separately from the Social Care Network (SCN), though members may qualify for both. The same individual can be screened under both programs—and both screenings are reimbursable—but services provided must address distinct or unmet needs to avoid duplication.
A care manager is a healthcare a professional who coordinates and manages care for individuals with chronic conditions or complex health needs, ensuring they receive all necessary medical, behavioral, and social services.
It is your choice to join the program or not, even though the doctor is recommending the program. We suggest that you try it, and if it does not suit you, you can leave the program at any time. All we ask is that you inform your Care Manager
No, there is no fee for this service as long as you are an active Medicaid member.
No, you can continue to see your current doctor. You can get services from any provider that is a part of the Medicaid program.
No, there is no fee for this service.
No, but it is strongly recommended. Your Health Home program will help you with all your health-related needs.
We’re proud to work alongside a diverse network of organizations and agencies throughout the Hudson Valley.
