For Providers
The Social Care Network program addresses health disparities in low-income communities by leveraging federal funding to facilitate Medicaid members’ access to nutritional meals, housing supports, transportation and other social services that can have a significant impact on an individual’s health. By integrating social care and health care, this program advances a key initiative under the New York Health Equity Reform (NYHER) waiver amendment.
The Hudson Valley Care Coalition (HVCC) is the Lead SCN for the Hudson Valley. We convene healthcare providers, community-based organizations, County government departments, hospitals, Federally Qualified Health Centers, and Medicaid managed care organizations, and other partners that work together to meet Health-Related Social Needs (HRSNs), including food, housing support, and transportation for non-medical services or appointments, for Medicaid members in the region.
Social factors, such as food insecurity, unstable housing, or lack of transportation, drive up to 80% of health outcomes
As the lead Social Care Network Entity for NYS Region 3, the HVCC serves Medicaid members, community partners, health systems, and managed care organizations across Westchester, Rockland, Orange, Dutchess, Putnam, Ulster, and Sullivan counties. We provide the infrastructure, governance, and reimbursement coordination necessary for successful collaboration among more than 100 community-based organizations focused on health-related social needs.
By bringing together care management, provider support, and social care, we create efficiencies and a seamless safety net for Medicaid members that reduces ER visits and rehospitalizations.
The SCN ensures that every partner is connected, resourced, and aligned toward a whole-person model of care. We play a critical role in supporting Medicaid members’ long-term well-being and our leadership ensures this work is strategic, sustainable, and deeply community informed.
All Medicaid members should be screened annually using the state’s 12-question HRSN screening tool—either by a community-based organization or via self-screening online. Screenings and follow-up eligibility assessments are reimbursable for SCN-contracted providers.
Once a positive screen is received, eligibility assessments typically happen within 3–5 days. If a need is verified, referrals are made to contracted CBOs. Providers have 48 hours to accept referrals. Most needs are addressed quickly due to our growing network of 100+ CBOs.
While both Health Home and SCN use similar screenings, the SCN screening does not duplicate existing health-related social needs (HRSN) services referred by a Health Home. If a Health Home care coordinator has already identified certain HRSNs, those services may not have been reimbursable under the Health Home model. The SCN can step in to fill those gaps. For example, if mold remediation or utility support was previously identified but not funded, SCN can now cover and reimburse those services.
To be eligible for enhanced services through the Social Care Network (SCN), individuals must meet the following criteria:
Screenings can be conducted annually—or twice in a year if there’s a life-changing event—and are always consent-based. Individuals may also self-screen via the SCN website, and screening, navigation, and services are all reimbursable under the 1115 Waiver program.
Learn more about the SCN
This is a common question. While Health Home and SCN overlap in some areas, the SCN is designed to uncover additional unmet needs. The same screening tool is used, but it’s reimbursed separately under SCN. If Health Home is covering a need, SCN will only provide services for new or additional unmet needs, not duplicating what is already covered.
Both the Health Home and Social Care Network use the same screening questionnaire. However, the screenings are conducted separately under each program and are both reimbursable. Under the SCN, members can be screened once per year—or twice if a life-changing event occurs, making a second screening eligible for reimbursement. SCN screening is open to all Medicaid members; they do not have to be enrolled in or eligible for Health Home services.
Importantly, the SCN screening does not duplicate existing services. Even if a Health Home care coordinator has already identified certain health-related social needs (HRSNs), those services may not have been reimbursable under the Health Home model. The SCN can step in to fill those gaps. For example, if mold remediation or utility support was previously identified but not funded, SCN can now cover and reimburse those services.
There are similarities in that both Health Home and SCN health related social needs coordination overlap. The key difference is in eligibility and reimbursement. All Medicaid members can be screened, and they do not have to meet the criteria for Health Home eligibility to receive reimbursable services. 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. The member receives services through a participating CBO and the Health Home conducting the screening and care navigation will be reimbursed for their work. This is a time-sensitive opportunity to service a wider range of at-risk Medicaid members.
Yes, SCN uses a large, pre-approved network of over 115 organizations. Referrals happen within this system, making it easier than Health Home’s referral model.
Yes. Every Medicaid member should be screened. Even if not eligible for Health Home, they may still have unmet needs that SCN can address, like food or housing support.
Yes. Ideally, eligibility assessments occur within 3–5 days of screening. Once assessed, referrals are made and must be accepted within 48 hours. Most cases are resolved faster than these benchmarks.
Under the SCN, members can be screened once per year—or twice if a life-changing event occurs, making a second screening eligible for reimbursement. Health Home and SCN are separate; both can conduct and be reimbursed for screenings—even for the same member—because they’re funded separately.
Absolutely. If SCN identifies a member that could benefit from Health Home, they will refer them. SCN is not a replacement but an extension of services.
Yes, that’s a fair way to describe it. It helps connect families to multiple services based on their specific needs and each family member should be screened individually if they have their own Medicaid number.
Community-based organizations need to have a TIN and NPI number to participate in the SCN and receive reimbursement.
Yes. Self-screening is available via the HVCC website. It’s the same 12-question screener that community partners use, and results go into Unite Us for navigation. Consent is confirmed at every step before moving forward.
We’re proud to work alongside a diverse network of organizations and agencies throughout the Hudson Valley.
A&A Support Services
Able Pathways Inc.
Access: Supports for Living
Action Toward Independence
Activate Care
Ahivim
Alley Valley
Alpha Wellcare
American Health and Survival Resources
Amnutal
Amudipes Behavioral Health
Astor Services for Children & Families
Behavioral Solutions NY
Bento
Bikur Cholim (Achieve Behavioral Health)
Braverhood
Bridges (Rockland Independent Living Center
Brooklyn Kitchen
Candlelit Care/Therapy
Cardinal McCloskey Community Services
Catholic Charities Community Services of Archdiocese NY
Catholic Charities Community Services of Rockland County
Catholic Charities of Orange, Sullivan & Ulster
CBHS Inc
CCO Services
CDAANY
Center for Human Development and Family Services
Centro De Amigos
Chemlu Developmental Disabilities Center,Inc
Children’s Home of Wyoming Conference
CHOICE of NY, Inc.
Collaborative for Children & Families, Inc.
Community Based Services, Inc. (HVSP)
Community Home Health Care
Community Housing Innovations
Community Outreach Center
Comprehensive Care Solutions
Cong Chasdei Slotifna
Cong Lonefesh
Consumer Directed Choices
Cornerstone Family Healthcare
CoveCare Center
CP Unlimited (HVSP)
Darko Resources
Devoted Care Services
Diced Energy Solutions
Dominican American Coalition For Action (DACFA)
Dutchess Outreach, Inc
Dynamic Youth Community Inc.
EatWell
eHomecare
Epicured
Evergreen Kosher
Family First Support Services
Family of Woodstock, Inc.
Family Service Society of Yonkers
Family Service, Inc.
Family Services of Westchester
Feeding Westchester
Fireside Kosher Steakhouse
Food is Medicine Marketplace- (Performance Kitchen)
GA Foods
GoCab
God’s Love We Deliver, Inc.
Golden Little Stars
Golden Meals
Gratus Community Care Inc.
Greater Mental Health of NY
GUIDED STEPS NY
Hamaspik of Orange County
Hamaspik of Rockland
Headwater Food Hub
Hearth Meals
Heavenly Hands
Homestyle Direct
HONORehg, Inc
Horizon Home Care Services Inc.
Hudson River Housing
Human Care Services for Families and Children
Human Development Services of Westchester
Hungry Harvest
Independent Living
Institute for Family Health
Jawonio Inc
Jewish Family Service of Orange County Inc
Journey Support Services
Jump Start Therapy
Kehilas Belz Rockland Inc
Kiryas Joel Social Service Org
Lehaskil
Lehoel Inc.
Lower Hudson Valley Perinatal Network
Lower West Side Household Services
Mae Health, Inc
Marba Lasova
Meals on Wheels Rockland
Mental Health America of Dutchess County
Mental Health Association of Orange County
Mercato
Metropolitan Development Center, Inc.
ModifyHealth
Moms Meals
My Child My Friend
New York Family Community Council, Inc. (NYFCC INC)
Newburgh Ministry
Nutrition Education for All
Nutrition4Good
NYS Easy Air ( NYSEA)
Ohros of Rockland
Open Door Family Medical Center
Partner Links Care
People USA
Project FoodBox
Regional Economic Community Action Program
Regional Food Bank of Northeastern NY
Rehabilitation Support Services
Resources to Thrive Inc
Restorative Management Corp.
Ride Health
Rising Stars
Rockland Psychological Services
Roots to Grow
Saint Dominic’s
Search for Change, Inc.
Sentinel Construction Inc,
Serenity Community Care
Shine 24/7
Simcha Talent Inc
Sparks Electronics & Housewares Inc
Sparx Support Services
St. John’s Riverside Hospital
St. Joseph’s Medical Center/St. Vincent’s
Stand Out Care
Sun River
Sunray HomeCare
Supportive Future Foundation
Supreme Green Energy
Taconic Innovations Inc.
Tangelo
Teton Health Solutions
The Dennelisse Corporation
The Derech Shalom Center
The Guidance Center of Westchester
Titanium Care Management of New York, Inc.
TOUCH
TRC Engineers
Triangle Square Services
Umoja Health
United Community Center of Westchester Inc
United Way of Dutchess & Orange
United Way of Westchester and Putnam
United Way Rockland
Upside (Upsidehom, Inc.)
VCS Inc.
Warwick Area Farmworker Organization
Westchester Community Health Center
Westchester Disabled On The Move
Westchester Jewish Community Services
Westchester Latinos Unidos
WILC – Westchester Independent Living Center
Yad Lachmu Anyu
YMCA of Kingston and Ulster County
Youth Shelter Program of Westchester
