New York Social Care Networks: Who Qualifies for Meals, Housing Help, Home Modifications, and Transportation?

A person can have Medicaid coverage and a treatment plan but still struggle to stay healthy because there is not enough food at home, the apartment is unsafe, or transportation is difficult.

New York’s Social Care Networks (SCNs) screen Medicaid members for needs like these and connect them with community resources. Some members also qualify for temporary services through New York’s Medicaid waiver. The state’s SCN overview, revised in September 2026.

Who can ask for help?

A New York Medicaid member can ask for a health-related social needs screening. This includes members with Medicaid fee-for-service coverage and those enrolled in Medicaid managed care. If the screening finds an unmet need, a social care navigator can help the member find existing local, state, or federal resources.

Enhanced SCN services have additional eligibility rules. Generally, the member must:

1. Have an unmet need identified through the state’s screening process.

2. Be enrolled in an eligible Medicaid managed care plan.

3. Belong to one of the state’s designated enhanced populations.

4. Meet any additional requirements for the specific service requested.

The enhanced populations include pregnant people and those up to 12 months postpartum; certain high-risk children; members enrolled in a New York State Health Home; people with a serious mental illness, substance use disorder, or intellectual or developmental disability; certain people recently released from incarceration; and members with substantial recent hospital or emergency department use.

For the high-utilization category, the current SCN Operations Manual generally identifies five emergency department visits, four emergency department visits plus a hospital stay, or two hospital stays within the preceding 12 months. An acute hospital stay can separately be relevant when assessing someone for medical respite.

A diagnosis or membership in one of these groups does not automatically approve every benefit. The member must also meet the rules for the particular food, housing, or transportation service.

The state’s service eligibility summary. For detailed and more recent instructions, use the August 2026 SCN Operations Manual

Food and nutrition: what can a member receive?

A member who screens positive for food insecurity can ask a social care navigator to determine which nutrition service fits their circumstances.

Service What it may provide Important rule

Nutrition counseling and education Help with meal preparation, nutrition, and grocery budgeting from a qualified dietitian or nutritionist. The SCN manual allows up to two hours per six-month authorization period, with possible reauthorization if the member remains eligible. Medically tailored meals Prepared meals tailored to an applicable medical condition or pregnancy or postpartum need. Requires the applicable food insecurity and clinical criteria. Clinically appropriate home-delivered meals Prepared, nutritionally appropriate meals that need not be tailored to a particular disease. The service must match the member’s assessed needs. Food prescriptions Appropriate foods supplied through boxes, vouchers, or coupons. An alternative to prepared meals; food boxes may be delivered weekly. Fresh produce and nonperishable groceries, called pantry stocking Groceries to supplement meals. Limited to qualifying pregnant or postpartum members and high-risk children under 18. Cooking supplies Necessary items for preparing meals when otherwise unavailable. Subject to assessment and rules against duplicating another benefit.

These services are alternatives in important respects. A member generally cannot receive SCN delivered meals, an SCN food prescription, and SCN pantry stocking simultaneously. Receiving SNAP or WIC does not, by itself, disqualify an otherwise eligible member from SCN nutrition services.

The detailed nutrition rules are in the August 2026 manual:

How many meals per day, and for how long?

The August 2026 SCN manual permits up to three prepared meals per day, seven days a week for an approved member. That is a maximum of 21 meals per week, not an automatic award of 21 meals. The assessment determines the appropriate type and amount of support.

For members who qualify during pregnancy or postpartum, meal services can run throughout pregnancy and up to 12 months postpartum. Other qualifying members may receive meals for up to six months at a time, with one reauthorization of up to six additional months if the need and eligibility continue. The manual sets comparable duration rules for food prescriptions and pantry stocking.

A household member does not automatically receive prepared meals because someone else in the home qualifies. Ask for each Medicaid-covered person with a food need to be screened.

The meal quantity, duration, and household rules

What to ask: “Please screen me for food insecurity. Do I qualify for medically tailored meals, clinically appropriate meals, food prescriptions, or pantry stocking? How many meals or deliveries are authorized, for which person, and through what date?”

Special rules for partial MLTC, MAP, and PACE

The August 2026 SCN manual states that members of partial-capitation managed long-term care (MLTC) and Medicaid Advantage Plus (MAP) are not eligible for SCN nutrition services other than cooking supplies. When these members need meal assistance, the SCN navigator should contact their MLTC or MAP plan. Members should ask the plan care manager to assess and authorize any available meal benefit.

New York’s partial MLTC model member handbook Its MAP model member handbook, which lists home-delivered meals among plan benefits, is at. A member should also check their own plan’s handbook for the applicable benefit and authorization process.

PACE participants should bring meal and nutrition needs to their PACE interdisciplinary team. The SCN manual identifies PACE as outside its enhanced-service payment population. New York’s PACE overview

What to ask your plan: “Please assess my need for delivered meals or other nutrition support. Is this available through my MLTC, MAP, or PACE plan? Who makes the authorization decision, how much can be approved, and how will I receive the decision?”

Home modifications: ask both the SCN and your long-term care plan

Home modifications can be available through partial MLTC, MAP, and PACE plan benefits as well as through the SCN program. New York’s current partial MLTC and MAP model member handbooks list social and environmental supports, including home modifications, among plan benefits:

Partial MLTC model member handbook:

MAP model member handbook:

PACE program overview

A partial MLTC or MAP member should ask their plan care manager to assess a safety or accessibility problem. A PACE participant should ask their interdisciplinary team. Partial MLTC and MAP members may also be assessed for certain SCN housing services; the SCN navigator should check what the plan has already provided so the same work is not duplicated. The coordination rules are in the August 2026 SCN manual

What modifications might qualify through an SCN?

Examples in the SCN program include ramps, handrails, grab bars, electric door openers, widened doorways, accessible pathways, changes to bathroom facilities or certain kitchen fixtures, and nonskid surfaces.

The member must have an applicable limitation, a provider’s documentation of medical necessity, and a navigator’s assessment of the need. The work must provide a direct medical or remedial benefit. Approval may require proof of residence, a dwelling assessment, a written scope of work, and technical review. Invasive work in a rental requires the property owner’s written permission.

The state’s service summary. The detailed assessment and approval process

Do not hire a contractor expecting the SCN or plan to reimburse work that was never authorized.

What is the home modification spending limit?

SCN home accessibility modifications and certain home remediation services share a per-member spending cap. The publicly posted August 2026 SCN Operations Manual refers to that cap but does not state its current dollar amount in the manual text. An older fee schedule is not a reliable basis for telling a member how much can be approved today.

Before planning work, ask the regional SCN for its current fee schedule, the member’s remaining cap, and the approved scope of work in writing. If the member has partial MLTC, MAP, or PACE, ask the plan to assess its separate home modification benefit. Do not assume the SCN cap is the plan’s limit.

The current SCN manual

What to ask: “Because of my condition, I cannot safely [enter my home/use my bathroom/move through my home]. Please assess a medically necessary modification. Should my MLTC, MAP, or PACE plan authorize it, or can the SCN? What documentation, property-owner permission, spending limit, and written approvals apply?”

Mold, pests, ventilation, and medically necessary equipment

SCN home remediation may address mold or pests, certain ventilation problems, or limited equipment needed for medical treatment or prevention. Depending on the member’s circumstances, examples may include a clinically appropriate air conditioner, heater, air filtration device, or small refrigerator needed for prescribed medication or breast milk.

Each service has specific housing and clinical criteria. These are assessments for health-related needs, not general apartment upgrades. The state summarizes the categories at and provides detailed requirements

What to ask: “My home has [specific condition], and it affects [my health condition or treatment]. Can you assess me for home remediation or medically necessary equipment? What does my clinician need to document?”

Asthma remediation

An eligible member whose asthma is worsened by conditions at home may qualify for asthma self-management education, an assessment of home triggers, certain remediation work, or supportive products. The state applies additional criteria involving recent asthma-related hospital, emergency, or urgent care use, or medication history.

The asthma criteria are summarized. The August 2026 manual describes the assessment and service process

What to ask: “My asthma gets worse at home. Can you check my recent visits and prescriptions against the asthma remediation criteria and assess triggers in my home?”

Medical respite after a hospital stay

Medical respite, also called recuperative care, may provide a place to recover after hospitalization or prepare for a procedure for a qualifying person who is homeless or at risk of homelessness and cannot safely recover in their current setting. The member needs the applicable clinical assessment. This is not general hotel coverage.

Ask the hospital discharge team and SCN to review eligibility before discharge. The current service rules are in the August 2026 SCN manual

What to ask: “I do not have a safe place to recover after discharge. Can you assess me for medical respite and tell me whether a placement can be arranged before I leave?”

Rent, utilities, and help finding or keeping housing

For qualifying members who are homeless or at risk of homelessness, possible SCN services include:

Rent or temporary housing assistance, including certain back-rent arrangements, for up to six months during the waiver period.

Utility setup or assistance, which may include qualifying activation costs, back payments, or up to six months of utility assistance.

Pre-tenancy services, such as help with applications, interviews, and leases.

Community transitional services for certain costs of establishing a home.

Tenancy-sustaining services, including help with lease or subsidy renewals.

Housing transition and navigation when moving from an institution or finding a more stable setting.

Each service has its own eligibility rules, documentation requirements, and limits. Having Medicaid does not automatically entitle someone to rent payments. The service categories are at, with detailed rules

What to ask: “I may lose my housing on [date]. Please assess me for rent, utility, pre-tenancy, and housing navigation services. Which requirements do I meet, what documents do you need, and what help can be arranged before my deadline?”

Transportation: which trips count?

SCN transportation may help a qualifying member reach an enhanced social care service or related care-management activity. It is separate from regular Medicaid transportation to medical appointments. An assessed need may involve having no usable vehicle, being unable to travel or wait alone, or having a physical, cognitive, mental health, or developmental limitation.

The service criteria and in the August 2026 manual

What to ask: “I cannot get to the social care service you referred me to. Can SCN transportation cover this trip? If I am going to a medical appointment, who arranges my regular Medicaid transportation?”

What does a social care navigator do?

A navigator can review screening results with the member, assess eligibility, develop a social care plan, make referrals, and follow up. Even if a member does not qualify for a funded enhanced SCN service, the navigator may help connect them with existing programs such as SNAP, WIC, or housing resources. Some qualifying members may also receive enhanced social care management.

New York explains how members can connect with SCNs and provides member information

What to ask: “Which needs did my screening identify? Which services am I eligible for? What referrals were made, who accepted them, and when will someone follow up?”

How do I get started?

1. Complete New York’s social needs screening

2. You can also ask your doctor or care manager, contact your Medicaid plan, or find your regional SCN

3. Describe each unmet need separately: food, home safety, housing instability, or transportation.

4. Ask for an eligibility assessment and the exact name of each service being considered.

5. If you have partial MLTC, MAP, or PACE, also ask your plan to assess its meal and home modification benefits.

6. Ask what was actually authorized: the service, amount, provider, start date, end date, and renewal process. For home work, request the written scope before construction begins.

7. Follow up if the service does not start. Ask whether the provider accepted the referral and whom to contact next.

New York lists Public Health Solutions as the regional SCN lead for Brooklyn, Manhattan, and Queens. Use the state’s current regional directory to find the appropriate contact and service area

SCN screening and navigation are free to eligible Medicaid members, and qualifying enhanced services are provided at no cost. Participation does not change a member’s ordinary Medicaid medical benefits. More information for members is at