For Participants
Am I eligible?
Health-related social needs (HRSN) are a person’s unmet social and economic needs that affect their ability to maintain their health and well-being – such as food, housing, and transportation. The Social Care Network program aims to support these needs to improve the health and well-being of legal residents of New York City.
Every New Yorker actively enrolled in Medicaid can be screened for (HRSN) services under the Social Care Network program. However, eligibility to receive enhanced services – which offers a higher level of support – is reserved for those enrolled in Medicaid Managed Care plans* who also meet specific requirements under the program. Although everyone with Medicaid can be screened for HSRN services, only a smaller number of people will qualify for enhanced services based on eligibility requirements.**
Am I eligible for enhanced HRSN services?
To be eligible for enhanced HRSN services you must be:
- Enrolled in a Medicaid Managed Care plan,* and
- Have an unmet need based on the program screener, and
- Meet the clinical and/or social risk threshold for the service, and
- Belong to an enhanced care group
Who belongs to an enhanced care group?
- Individuals with a high number of hospital emergency room visits and/or hospitalizations in the last 12 months, or
- Individuals enrolled in the Medicaid Health Home program, or
- Individuals living with a substance use disorder, or
- Individuals living with a serious mental illness, or
- Individuals diagnosed with intellectual disability in need of support, or
- Individuals diagnosed with a developmental disability in need of support, or
- Individuals who are pregnant or recently gave birth within the last 12 months, or
- Individuals with a qualifying health condition who were recently released from jail or prison within the last 90 days, or
- Children under 18 who are at risk for chronic physical, developmental, behavioral, or emotional conditions like asthma, obesity, child abuse or neglect, low birth weight, or autism, amongst other conditions.
What are the clinical and social risk requirements for enhanced HRSN services?
The clinical and social risk requirements for enhanced services are specific to the type of service and the individual’s health and social circumstances. The different types of services and their specific requirements are below:
Social Care Management
Enhanced HRSN Care Management
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – screening indicates an unmet health-related social need
Nutrition Services
Nutrition Counseling and Education
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Medically Tailored Meals
- Clinical Requirement – has a diagnosed chronic condition or is pregnant or recently gave birth in the last 12 months
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Nutritionally Appropriate Home Delivered Meals
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Nutritionally Appropriate Food Prescriptions
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Pantry Stocking – Fresh Produce and Non-Perishable Groceries
- Clinical Requirement – is pregnant or recently gave birth in the last 12 months or is a child belonging to the Children Under 18 enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Cooking Supplies
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for nutrition and meets the definition for low food security
Housing
Home Accessibility and Safety Modifications
- Clinical Requirement – has a physical disability that limits their independence and has a Provider Attestation Form from their healthcare provider indicating medical necessity
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing and a need for home modification services to improve home accessibility and safety
Mold and/or Pest Remediation
- Clinical Requirement – has (or is at risk for) a health condition made worse by their home environment and has a Provider Attestation Form from their healthcare provider indicating medical necessity
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing and a medical need for mold/pest remediation
Ventilation System Repair or Improvement
- Clinical Requirement – has a diagnosed chronic condition, a previous heat-related illness in the last 12 months, a previous cold-related illness in the past 12 months or a documented issue maintaining a stable internal temperature (known as thermoregulation)
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and a medical need for ventilation system repair or improvement where an air conditioner, heater, or air filtration device can support their condition. Please note: a person cannot live in an institutional setting and receive this service.
Refrigerator
- Clinical Requirement –
- is taking a prescribed medication that must be refrigerated for a chronic condition and has a Provider Attestation Form from their healthcare provider indicating medical necessity, or
- is receiving enteral/parenteral nutrition that must be refrigerated and has a Provider Attestation Form from their healthcare provider indicating medical necessity or
- is pregnant or recently gave birth in the last 12 months and requires refrigeration for breast milk
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing and/or nutrition, and a medical need for a refrigeration unit for medications or breast milk. Please note: a person cannot live in an institutional setting and receive this service.
Asthma Remediation
- Clinical Requirement – has an asthma diagnosis and at least one of the following in the last 12 months related to asthma:
- 1 or more hospitalizations
- 2 or more hospital emergency room visits
- 3 or more urgent care visits
- 2 or more instances of prescribing an oral steroid
- 3 or more instances of prescribing a rescue inhaler
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and a medical need for home asthma remediation and a health condition made worse by their home environment.
Medical Respite for Pre- or Post-Procedure Recuperative Care
- Clinical Requirement –
- is a patient who needs pre-procedure and has a Provider Attestation Form from their healthcare provider indicating medical necessity or
- is a post-procedure/post-surgical patient requiring recuperation and care after hospitalization who is also at risk for rehospitalization or hospital emergency room use and has a Provider Attestation Form from their healthcare provider indicating medical necessity
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
Rent/Temporary Housing (Up to 6 Months)
- Clinical Requirement – has a diagnosed chronic condition and meets (or is at risk for meeting) the definition for homelessness*** including individuals/youth transitioning from institutional settings as indicated on the Provider Attestation Form from their healthcare provider
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
Utility Assistance
- Clinical Requirement – has a diagnosed chronic condition and meets (or is at risk for meeting) the definition for homelessness*** including individuals/youth transitioning from institutional settings
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is receiving the Rent/Temporary Housing HRSN service
Pre Tenancy Services (Housing Application Supports)
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
Community Transitional Services (Pre-move In Supports)
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
- Services include things like security deposits, utility activation fees, inspection fees, and pest eradication
Tenancy Sustaining Services (Supports to Stay In Your Home)
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
- Services include things like free/affordable legal services for housing issues, lease renewal help, and housing subsidy renewals
Housing Transition and Navigation Services (Move In Supports)
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for housing, and is (or is at risk for) experiencing homelessness***
- Services include things like help setting up a new housing unit, help with moving, and linkages to rental assistance
Transportation
Public and Private Transportation to Care Management and HRSN Services
- Clinical Requirement – belongs to an enhanced care group
- Social Risk Requirement – assessment indicates an unmet health-related social need for transportation and needs transportation to non-medical, HRSN activities or care management activities