MLTC Policy 25.02: Social Care Network (SCN) Program Policy Paper

Office of Health Insurance Programs
New York Health Equity Reform (NYHER)
1115 Waiver Amendment: Social Care Network (SCN) Program

Effective January 1, 2025

Document last updated 1/23/2025

Table of Contents

I. Overview of SCN Program
II. Network Requirements for SCNs
III. Member Eligibility for Services
IV. Scope of Coverage
V. Billing and Payment
VI. Responsibilities of MCOs

External Resources:

NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS

Social Care Network (SCN) Program

EFFECTIVE JANUARY 1, 2025

I. Overview of SCN Program

On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York Health Equity Reform (NYHER) 1115 Waiver Demonstration Amendment to fund new initiatives and investments to assist New York State in improving health coverage, access, and the consistent provision of high-quality services for Medicaid beneficiaries. As part of this waiver, New York State (NYS) Department of Health's (DOH) Office of Health Insurance Programs (OHIP) is establishing Social Care Networks (SCNs): regional networks that will increase and strengthen the delivery of health-related social needs (HRSN) services to Medicaid members. Each SCN is responsible for maintaining an SCN IT Platform that has the necessary features for ensuring a seamless, consistent, coordinated, end-to-end process in their region for screening, navigation, delivery of HRSN services, payment, and data sharing.

OHIP awarded contracts to organizations serving as SCN Lead Entities for a contract term from August 1, 2024, through March 31, 2027. These organizations will coordinate delivery of HRSN services for Medicaid members through networks of HRSN service providers. SCN Lead Entities and their assigned counties are listed on the SCN website.

The Social Care Networks (SCN) Operations Manual (Section 3, Sub section b: Overview of SCN Program Design) includes additional details on SCN responsibilities.

II. Network Requirements for SCNs

NYSDOH's goal is for SCNs to, in an equitable manner, provide consistent, convenient access to services that meet members where they are. SCNs are responsible for establishing networks of HRSN service providers that are responsive to the needs of the region's population. Strong, accessible networks are critical to ensure that SCNs effectively address members' HRSNs and improve their health outcomes.

To best address the needs of underserved and hard-to-reach populations and ensure choice for members, SCNs will include a wide variety of organizations within each region that serve Medicaid members. Networks will be compromised of mainly Community-Based Organizations (CBOs). To ensure comprehensive HRSN networks in the SCN program, NYSDOH has established criteria for HRSN network capacity and access and will monitor HRSN network capacity and access. Guidance requirements for SCNs can be found in the SCN Operations Manual (Section 4, Sub section a: Network Capacity and Access).

SCNs are required to conduct an HRSN screening annually for every Medicaid member and conduct a re-screening on an as-needed basis due to a major life event (e.g., move to a different SCN region, marriage, serious injury). Members will be screened using the Accountable Health Communities (AHC) Screening Tool to assess member HRSNs related to housing and utilities, food security, transportation, employment, education, and interpersonal safety. Members with identified HRSNs will be connected to services in a timely manner. OHIP's intention is that services are available in members' communities from a diverse and culturally competent network of HRSN service providers.

Members' journeys through the SCN process will be facilitated by Social Care Navigators responsible for screening members, connecting them with service providers, and following up to ensure services have been delivered and members' needs addressed. SCNs are responsible for building capacity for navigation, including through partnerships with providers and Managed Care Organizations (MCOs).

III. Member Eligibility for Services

All Medicaid members can receive screening and navigation. Only eligible Medicaid Managed Care (MMC) members, as determined by the SCN based on CMS-approved criteria and the SCN Operations Manual, may receive enhanced HRSN services.

Eligibility criteria for enhanced HRSN services is detailed in the SCN Operations Manual.

The SCN Operations Manual outlines details on the eligibility assessment process. Please see the following sections for details:

  • Eligibility criteria, including information on eligible Lines of Business and populations eligible for enhanced HRSN services (Section 5, Sub section d: Eligibility Assessment)
  • Eligibility verification process (Section 5, Sub section d: Eligibility Assessment)
  • Consent process (Section 5, Sub section d: Eligibility Assessment)
  • Eligibility changes (Section 5, Sub section f: Changes in Member Eligibility)

IV. Scope of Coverage

Screening, navigation, and enhanced HRSN services will be available in every region throughout NYS.

Effective January 1, 2025, the benefit packages of all eligible MMC members will include:

  • Annual HRSN screening
  • Navigation to existing local, state, and federal services
  • Enhanced HRSN services for eligible MMC members

The SCN Operations Manual (Section 5, Sub section i: HRSN Services) includes a complete list and description of all HRSN services covered in the SCN program.

V. Billing and Payment

Organizations serving as SCN Lead Entities completed a designation process within eMedNY to become professional Medicaid billing Social Care Providers in accordance with NYSDOH's established protocol. The designation process allows SCN Lead Entities to work with Managed Care Organizations (MCOs) to receive per-member-per-month (PMPM) payments to issue payments for services delivered within the SCN program.

Beginning January 2025, MCOs must administer PMPM payments to SCN Lead Entities. MCOs will be paid a non-risk PMPM payment by NYSDOH (based on the billing specifications included in the NYHER Data & Systems Manual). MCOs will pay SCN Lead Entities an amount determined by NYSDOH.

SCN Lead Entities will arrange and pay HRSN service providers in their HRSN Network for services delivered. SCN Lead Entities will submit social care claims to MCOs for services delivered by the SCN Lead Entity's contracted Network. MCOs will coordinate, accept, store, and report these social care claims to NYSDOH as encounter data.

The SCN Operations Manual provides an overview of payments and payment processes:

  • Payments overview for the SCN program (Section 7: Payments)
  • PMPM methodology and process (Section 7, Sub section b: PMPM payments)

The NYHER Data & Systems Manual details MCO responsibilities related to claims processing:

  • Claims submission process and timelines (Section 3, Sub section 12: MCO Acceptance of SCN Claims; Sub section 13: MCO Encounter Submission to State)

VI. Responsibilities of MCOs

MCOs are required to contract with all SCN Lead Entities within their operating regions with initial contract executions that began on October 18, 2024, for an implementation date of January 1, 2025. SCNs and MCOs must establish a contract per the NYSDOH MCO-SCN agreement template that outlines the MCO's responsibilities for the SCN region. NYSDOH provided MCOs advance notice of modifications to the benefit package via Benefit Notice Letters sent on October 23, 2024.

MCO responsibilities also include, but are not limited to:

  • Contracting with SCNs: MCOs are required to establish contracts with SCNs in any counties in which plans are operating. If MCOs expand into additional counties, they are expected to identify and execute MCO/SCN contracts with SCN(s) covering those counties. Information on the SCNs per each county is available on the SCN website
  • Distribute PMPM Payments : Provide PMPM payments to contracted SCN Lead Entities
  • MMCOR Reporting to NYSDOH: MCOs are responsible for submitting the Medicaid Managed Care Operating Report (MMCOR) to NYSDOH based on social care claims submitted to the MCOs by the SCNs. Details are included in:
    • SCN Operations Manual (Section 8, Sub section e: MCO Contract Requirements with OHIP)
    • NYHER data and systems manual (Section 4: Additional Reporting Processes)
  • Ongoing Data Requests: MCOs must submit ongoing data requests from NYSDOH or CMS as requested. Refer to the SCN Operations Manual (Section 8, Sub section e: MCO Contract Requirements with OHIP) for a list of potential data requests
  • Enhanced Services Member File: MCOs are responsible for developing Enhanced Services Member File (ESMF), using the template provided by NYSDOH. Refer to the Data & Systems Implementation Guide (DSIG) and the SCN Operations Manual (Section 5, Sub section e: Enhanced Services Member File) for additional details on the processes by which the ESMF will be created, shared, and updated
  • Reconciliation: NYSDOH will reconcile PMPM payments and payments for HRSN services rendered. Specific MCO responsibilities for reconciliation are determined by NYSDOH. The SCN Operations Manual provides an overview of Reconciliation (Section 7, Sub section b: PMPM payments)
  • Medicaid Member Protections: Refer to the SCN Operations Manual (Section 8, Sub section e: MCO Contract Requirements with OHIP) for a list of Medicaid member protections
  • Medicaid Member Communications: MCOs are responsible for updating and making available their educational materials to inform members about SCN services including but not limited to Member notices and Member handbook updates as approved by NYSDOH.
  • Medicaid Member Grievances and Complaints: Refer to the SCN Operations Manual (Section 6, Sub section c: Member Satisfaction) for guidance on the member grievances and complaints process.
  • Screening and Navigation to HRSN Services (Optional): MCOs may choose to screen members for HRSNs and conduct navigation through the SCN's IT Platform, if mutually agreed upon within the MCO/SCN agreement. Additional guidance on conducting screening and navigation can be found in the SCN Operations Manual (Section 5, Sub section b: Screening; and Sub section c: Social Care Navigation).

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1. If you are from an MCO that needs access to the Data & Systems Implementation Guide (DSIG), please contact DDSANYHER@health.ny.gov ;1