Social Care Networks (SCN)

Increasing and strengthening the delivery of social care services to Medicaid members across New York State.

The mission of New York State is to protect and promote health for all, building on a foundation of health equity. In New York and nationally, there is growing recognition that fully achieving health for all requires a focus not only on physical and behavioral health but also on health-related social needs (HRSNs).

It is now widely acknowledged that addressing social needs such as food insecurity, housing instability, and lack of transportation improves health and lowers health care costs. To ensure that these needs are consistently addressed for New York's Medicaid Members, New York needs a coordinated infrastructure and set of processes through which member's unmet social needs can be identified, Members can be connected to services to address those needs, and the organizations who provide those services can be paid.

On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York Health Equity Reform (NYHER) 1115 Waiver Demonstration Amendment, including new funding to establish Social Care Networks (SCNs) and deliver HRSN services.

Pie of Ecosystem partners/social care network/Medicaid members

The establishment of Social Care Networks (SCNs) is a core part of the NYHER Amendment. New York State has established 9 regional Social Care Network Lead Entities who are responsible for building a robust Network of Community-Based Organizations (CBOs) and other organizations providing health-related social needs services and coordinating with health care providers (inclusive of behavioral health and primary care providers). Together, each Social Care Network is responsible for ensuring that there is a seamless, consistent, coordinated, end-to-end process in their region for Screening, Navigation, and delivery of health-related social needs services. This requires close collaboration within each Network, as well as shared data and technology provided by the State. Social Care Network Lead Entities also engage a broader ecosystem of partners to achieve their goals, including health insurance plans, local government, and child & family supports.

Social Care Networks (SCN) Program Overview (PDF)

Social Care Networks will Achieve Four Goals for Medicaid Members:

  1. Expand access to high-quality HRSN services
  2. Enable consistent, timely screening using the Accountable Health Communities (AHC) HRSN Screening Tool and Navigation to HRSN services
  3. Create shared end-to-end visibility of the Member journey from HRSN Screening and Navigation through delivery of HRSN services
  4. Strengthen collaboration between HRSN service providers and other partners in their regional health ecosystem, including, providers, care managers, and health plans

The Role of Social Care Network Lead Entities

The Social Care Network Lead Entities are organizations chosen for their expertise in supporting New York Medicaid Members, deep understanding of their region, and ability to coordinate an ecosystem of partners. They are responsible for creating and managing networks to provide screening and navigation to Medicaid Members, and ultimately to ensure services are delivered to address health-related social needs.

The role of Lead Entities includes:

  • Building a Network within the region to provide screening, navigation, and nutrition, housing, and transportation services to Medicaid Members
  • Paying providers in their Network for heath-related social needs services delivered
  • Facilitating secure data exchange to support navigation and service delivery
  • Reporting on Network performance to support health equity goals and measure impact of the Social Care Network program
  • Establishing a governing board that reflects the unique needs of the region
Map of New York
Lead Entities Map Color Counties
Care Compass Collaborative Broome, Chenango, Delaware, Otsego, Tioga, Tompkins
Forward Leading IPA Allegany, Cayuga, Chemung, Genesee, Livingston,Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, Yates
Health and Welfare Council of Long Island Nassau, Suffolk
Healthy Alliance Foundation Inc.
1
 Albany, Columbia, Greene, Rensselaer, Montgomery, Saratoga, Schenectady, Schoharie
2
 Cortland, Herkimer, Madison, Oneida, Onondaga, Oswego
3
 Clinton, Essex, Franklin, Fulton, Hamilton, Jefferson, Lewis, St. Lawrence, Warren, Washington
Hudson Valley Care Coalition, Inc. Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester
Public Health Solutions Manhattan (4), Queens (5), Brooklyn (6)
Staten Island Performing Provider System Richmond
Somos Healthcare Providers, Inc. Bronx
Western New York Integrated Care Collaborative Inc. Cattaraugus, Chautauqua, Erie, Niagara

The Social Care Network program brings new or expanded opportunities for providers of nutrition, housing, transportation, and social care management services. Organizations that provide at least one health-related social needs service can join a Social Care Network. Joining a Social Care Network means contracting with one or more Lead Entities and participating in required trainings. Organizations spanning multiple regions may contract with multiple Social Care Network Lead Entities. Reach out to the Lead Entity in your region(s) to learn more.

Overview of Reimbursement Processes

Health-related social needs service providers who join a Social Care Network will be paid by the regional Lead Entity for screening and/or services they deliver.

To receive reimbursement, health-related social needs service providers must:

  • Be in contract with a Lead Entity (note, HRSN providers can join more than one SCN)
  • Provide screening and/ or services in a manner consistent with the Social Care Network program
  • Complete training (provided by Lead Entities) and use the Social Care Network IT platform

More information on payment amounts and processes can be shared by your regional Lead Entity.

Health care providers are a key partner in the Social Care Network program, which aims to increase integration of physical health, behavioral health, and services that address health-related social needs. Coordinating these aspects of a Member's care is foundational to New York State's health equity goals. Please review the SCN: Introduction for Health Care Providers Guide (PDF) here.

Health care providers, including physical and behavioral health, can participate in the Social Care Network program in many ways:

  • Talk to Medicaid patients about Social Care Networks and the services that may be available to them across nutrition, housing, transportation, and navigation supports; Lead Entities may share factsheets and other informational material that can be distributed via your offices
  • Share contact information for a regional Lead Entity
  • Conduct screening for health-related social needs in Medicaid patients using the Accountable Health Communities Health-Related Social Needs Assessment in the domains of housing, utilities, nutrition, transportation, employment, education, and interpersonal safety.

Providers who join a Social Care Network may receive reimbursement for screening and navigation of Medicaid Members if using twelve questions from the Accountable Health Communities Health-Related Social Needs Assessment. To receive reimbursement, health care providers must:

  • Be in contract with a Lead Entity (providers working across multiple regions may contract with multiple Lead Entities)
  • Be able to submit the HRSN screening through the regional Qualified Entity to the Statewide Health Information Network OR use the Social Care Network IT platform.
  • Remain in good standing with New York Medicaid

Reach out to the Lead Entity in your region(s) to learn more.

For Social Care Networks (SCNs) to truly serve as an interconnected Network that identifies and addresses health-related social needs (HRSNs), information needs to be shared seamlessly across organizations and electronic systems, using standardized assessment instruments, terminology, data elements, and metrics. Further, data security and privacy (reorder) are crucial for the SCN Lead Entity to promote data interoperability and protect sensitive Member information from being misused or accessed by unauthorized people. The below resources provide more information:

  • The NYS Medicaid program uses the Accountable Health Communities (AHC) Health Related Social Needs Screening (HRSN) Tool Core Questions and two supplemental questions on education and employment.
  • New York eHealth Collaborative (NYeC)
    • 1115 Waiver - New York eHealth Collaborative (nyehealth.org)
    • Home - v1.0.0
      • This New York State 1115 SHIN-NY FHIR Implementation Guide (IG) was created for the exchange of health-related social needs (HRSN) data for New York State'as Health Equity Reform (NYHER) 1115 Waiver Amendment. Specifically, this guide defines fast healthcare interoperability resource (FHIR) exchange between an organization supporting the Waiver and a Qualified Entity (QE) here in New York State (NYS).
    • SCN Lead Entities and their IT Platform partners can access this information will have access to the terminology below and a minimum viable data set through the SHIN-NY and 1115 Waiver specific implementation guides for coded terminology uses found on NYeC'as NYHER 1115 Extranet. Please make sure SCN technical teams have access. If you do not, please reach out to rwagers@nyehealth.org
  • Gravity Project - Confluence page
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