Screening & care coordination

A navigator in your corner, from the first call

It starts with a free, confidential conversation about what you need. If you qualify, a dedicated Social Care Navigator builds your plan, makes referrals, and follows up over time.

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What’s included

  • Health-Related Social Needs Screening

    A 30-minute conversation — in person or over the phone — to understand the challenges you face. We ask about housing, food, transportation, utilities, employment, and personal safety. There's no obligation, and we keep what you share private.

  • Eligibility Assessment

    If your screening shows unmet needs, we work with you to determine which Enhanced HRSN services you qualify for under New York Medicaid. This is also a conversation, not a test.

  • Social Care Navigation

    For members who qualify for Enhanced services, you'll be paired with a dedicated Social Care Navigator who builds a plan with you, makes referrals, follows up, and stays in your corner over time.

Who can get this support

  1. 1

    Do you have New York Medicaid?

    You must be enrolled in Medicaid Managed Care. If you have Medicaid Fee-for-Service or no insurance, we can still help connect you to community resources.

  2. 2

    Do you have unmet social needs?

    Housing instability, food insecurity, transportation barriers, utility challenges, employment or education needs, or personal safety concerns.

  3. 3

    Not sure if you qualify?

    Don't worry — call us or fill out a short form. Our team will walk you through the process in under 30 minutes. No paperwork required to start.

Even if you don't qualify for Enhanced services, We can still connect you to SNAP, WIC, NYCHA, Section 8, food pantries, and other community programs. No one leaves without options.

How to get started

  1. 1

    Talk to Us

    A free 30-minute conversation to understand what you need — in person, over the phone, or by video. In your language. No paperwork required.

  2. 2

    Get a Plan

    Your Social Care Navigator creates a personalized plan connecting you to the right services for your situation, health needs, and family.

  3. 3

    Receive Services

    Medically tailored meals, home safety changes, rides to your social care services, rental assistance — services come to you.

  4. 4

    Stay Supported

    Your Navigator stays with you, checks in regularly, and adjusts your plan as your needs change. You're never on your own.

Most members can complete a screening within 1–2 business days. Services typically begin within 2–4 weeks of completing your Eligibility Assessment.

Areas we serveBrooklynQueensManhattan

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Find out what you qualify for

Free, confidential, and no paperwork to start. Most members can complete a screening within 1–2 business days.

Prefer a call? We’ll call you back.

Leave your name and number. Our team will call you within 1 business day — free and confidential.

We only use your number to call you back.