What are Social Care Networks (SCN)? HRSN screening for Medicaid members

The Department of Health describes Social Care Networks as "groups of local, primarily non-profit organizations that support the health and well-being of communities across New York State." They exist to address what DOH calls health-related social needs, or HRSN, among Medicaid members. DOH's program page says the State established nine regional networks covering every county, funded through the New York Health Equity Reform 1115 waiver amendment that the federal government approved on January 9, 2024.

For a member, the networks do three things, in DOH's words:

• Screening. Helping "identify social needs impacting their health, such as living situation, access to healthy food, access to transportation, employment, education, and personal safety."
• Navigation. Helping "find services in the community to meet their social needs," working with a Social Care Navigator in person or by phone.
• Social care services. For some members, "additional one-time or temporary services (up to 6 months)" beyond existing Medicaid benefits.

DOH's member page is direct about this: "Medicaid Members in New York may connect with a Social Care Network to identify social needs impacting their health." Screening is for any Medicaid member. Navigation, help finding services, "may be available to Medicaid Members who have a social need impacting their health."

The third tier is narrower. One-time or temporary social care services are for members in a Medicaid managed care plan who, in DOH's words, "qualify by having a specific health condition." DOH lists the categories of need that may open that door:

• living with a mental health condition or substance use challenge;
• living with an intellectual or developmental disability;
• pregnant or recently had a baby;
• recently released from jail or prison with a chronic health condition;
• children and young people with health needs such as asthma or diabetes;
• frequent visits to the emergency room or hospital;
• enrollment in a New York State Health Home.

DOH adds that some services carry extra requirements, and that availability of temporary services "may vary by region." None of this is something a family can determine at home. The network and the plan determine it.

DOH gives examples so members know what to ask about. Food and nutrition help such as home-delivered meals, food prescription boxes, or cooking supplies. Housing support such as navigation for someone who is unhoused, home safety modifications for a person with a physical disability, or mold and pest removal for someone with uncontrolled asthma. Transportation to appointments. Social care management after a temporary service ends. Services may run for a short period of one to two weeks or up to six months depending on clinical need.

For a household also working through a home care request, the overlap is obvious: a grab bar, a ramp, or pest remediation can change what an assessment finds about safety at home. The two processes are separate, but they can run at the same time.

DOH's member page says a member "may be asked about health and daily needs, like living situation, access to healthy food, access to transportation, education, employment, and personal safety," and directs members to "reach out to your Social Care Network to find out more about programs and services available by region." In practice, there are several doors, and DOH's program page names the first of them:

1. The self-screener. DOH's program page links a statewide self-screening tool at screening.shinny.org and says to complete the questions "to get connected to help."
2. Your doctor's office or clinic. Health care providers participate in screening and can refer you to the regional network.
3. Your Medicaid managed care plan. Plans coordinate with the networks. Call the member services number on your card and ask about Social Care Network screening.
4. A participating community organization. Food pantries, housing groups, and senior programs in the network can start a screening.
5. Your care manager, if you have one through a Health Home or a plan.

DOH's program page lists the lead organization for each regional network by county. For New York City, the counties of Kings, New York, and Queens are served by one network, Richmond by another (which also covers a handful of ZIPs in Brooklyn and Queens in partnership with the first), and the Bronx by a third. This site does not name those organizations; the official list is on the DOH page linked below and is the only list you should trust. For the step-by-step version, including what the state screening site asks for and what happens after you submit, read how to connect with your Social Care Network, by county.

Nothing. DOH states it three ways: "There is no cost for Medicaid Members to receive assistance determining any social needs impacting their overall health." For members with a need, "there is no cost for navigation." And managed care members with qualifying conditions "can receive temporary services at no cost through the Social Care Network program." If anyone asks you for money to be screened or navigated, they are not the network.

DOH's FAQ answers the question families worry about most: "Medical benefits for Medicaid Members are not affected by the Social Care Network program." Screening does not touch the Medicaid case, the home care assessment, or plan enrollment. It adds; it does not substitute.

If you are helping someone through the New York Independent Assessor process, keep the two tracks distinct in your notes. NYIA (1-855-222-8350) assesses the need for hands-on help with daily activities. The Social Care Network screens for food, housing, transportation, and related needs. A member can pursue both. If you are not sure where a particular problem belongs, NY Connects at 1-800-342-9871 can sort it, and the plan's member services line can say whether the plan has already screened the member.