6-Public Health Solutions SCN HRSN Fee Schedule.pdf

HRSN Fee Schedule

SCN Lead Entity: Public Health Solutions Region: NYC Release date: 8/1/2025 Effective date: 10/1/2025

Service Type Service Name Unit of Service

Max Units / Duration SCN Lead Entity Rate / Range / Cap

0. Screening Screening Per 15-minutes Max of 4 units per year to account for annual screen (max 2 units) and re-screen with major life event (max 2 units)

$17.50

Up to $35.00 per screening

1. Care Management

1.1 Navigation Services -

Eligibility Assessment and Navigation to existing resources (Level 1)

Per 15-minutes Navigation services following each HRSN screen have max of 4 units.

Max of 8 units per year.

$17.50

Up to $70.00 per event

1.2a Enhanced HRSN Care Management - Eligibility Assessment Only (Level 2)

Per 15-minutes Max of 20 units per month for Waiver period

$17.50

Up to $350.00 per month

1.2b Enhanced HRSN Care Management – Care Management, Inclusive of Navigation (Level 2)

2. Housing

2.1 Home Accessibility and

Safety Modifications

Cost-based, up to cap

Up to capped amount for Waiver period

$10,000

2.2a Home Remediation Service: Mold and Pest Remediation 2.2b Home Remediation Service: Ventilation Improving Systems 2.2c Home Remediation Service: Equipment Provision 2.3a Asthma Remediation:

Self-Management Education

Per 15-minutes Max of 24 units for Waiver period

$17.50

Up to $420.00 for Waiver period

2.3b Asthma Remediation and Provision of Supportive Products

Cost-based, up to cap Up to capped amount for Waiver period

$8,000

2.4 Recuperative Care

(Medical Respite)

Per diem Post hospitalization stay:

up to 90 days per 12 months (assessed on a rolling basis)

Pre-procedural care:

based on the provider’s directions and limited to a clinically appropriate amount of time as determined by a medical professional, but cannot exceed 30 days per year

$245 - $388 per day

Studio/Efficiency: $2,233

2.5 Rent / Temporary

Housing (Rental Subsidy and Back Rent)

Per unit per month; cost-based, up to cap

Up to 6 months for the Waiver period (inclusive of back rent and prospective rent payments)

1-Bedroom: $2,330

2-Bedroom: $2,580

3-Bedroom: $3,215

4-Bedroom: $3,469

2.6a Utility Setup – Activation Expenses

Cost-based, up to cap

One time, up to capped amount for Waiver period

$350

2.6b Utility Setup – Back Payment

Cost-based, up to cap

One time, up to capped amount for Waiver period

$4,566

2.6c Utility Assistance Cost-based, up to cap per month

Up to 6 months for Waiver period, with capped amount per month

$761

2.7 Pre-Tenancy Services Per 15-minutes Max of 24 units over 6 months for Waiver period

$17.50

Up to $420.00 for Waiver period

2.8a Community Transitional Supports (CTS)

Cost-based, up to cap

Up to capped amount for Waiver period

Studio/Efficiency: $5,347

1-Bedroom: $5,565

2-Bedroom: $6,827

3-Bedroom: $8,475

4-Bedroom: $9,741

2.8b CTS Broker's Fee Cost-based, SCN-level cap (Jan 1, 2025 – Mar 31, 2026)

One time, up to capped amount for Waiver period

Manhattan: $40,116 Brooklyn: $122,673 Queens: $88,343

• SCN Lead Entity Year 1 cap

• SCNs determine Member rate

2.9 Tenancy Sustaining

Services

Per 15-minutes Max of 24 units over 6 months for Waiver period

$17.50

Up to $420.00 for Waiver period

2.10 Housing Transition and

Navigation Services

Per 15-minutes Max of 16 units per month up to 6 months, may be reauthorized up to 6 months per re-authorization, up to the duration of the Waiver as long as the member has an unmet need and is eligible to receive services

$17.50

Up to $280 per month

3. Nutrition

3.1 Nutrition Counseling and

Education

Per 15-minutes Up to 8 15-minute units;

or 4 30-minute units; or a combination of 15- and 30-minute units totaling 2 hours, up to 6 months, may be reauthorized up to 6 months per re-authorization, up to the duration of the Waiver as long as the member has an unmet need and is eligible to receive services

Individual Initial Assessment: $24.05

Individual Re-Assessment:

$21.74

Per 30-minutes Group (2 or more individuals): $11.50

3.2a Medically Tailored Meals

Per meal; cost-based, within range

Pregnant / postpartum individuals: eligible for services with each pregnancy (throughout

$10 - $16 the pregnancy and up to 12 months postpartum)

Other eligible individuals:

can receive services up to 6 months, which can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

3.2b Clinically Appropriate Home Delivered Meals

Per meal; cost-based, within range

Pregnant / postpartum individuals: eligible for services with each pregnancy (throughout the pregnancy and up to 12 months postpartum)

Other eligible individuals:

can receive services up to 6 months, which can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

$10 - $16

3.3 Medically Tailored or

Nutritionally Appropriate Food Prescriptions

Per week; cost-based, within range

Pregnant / postpartum individuals: eligible for services with each pregnancy (throughout the pregnancy and up to 12 months postpartum)

Other eligible individuals:

can receive services up to 6 months, which can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

$97 - $146

3.4 Fresh Produce and Non-

perishable Groceries (Pantry Stocking)

Per week; cost-based, within range

Pregnant / postpartum individuals: eligible for services with each pregnancy (throughout the pregnancy and up to 12 months postpartum)

Other eligible individuals:

can receive services up to 6 months, which can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

$30 - $78

3.5 Cooking Supplies Cost-based, up

to member and SCN-level cap (Jan 1, 2025 – Mar 31, 2026)

Up to capped amount for Waiver period

Manhattan: $1,055,260 Brooklyn: $3,226,974 Queens: $2,323,901

• SCN Lead Entity Year 1 cap

• SCNs determine Member rate

4.

Transportation

4.1 Transportation Cost-based, SCN-level cap (Jan 1, 2025 – Mar 31, 2026)

Up to 6 months, with capped amount for Waiver period. Possibility of re-authorization, up to 6 months per re-authorization, up to the duration of the Waiver as long as the member has an unmet need and is eligible to receive services

Manhattan: $1,864,583 Brooklyn: $5,701,871 Queens: $4,106,196

• SCN Lead Entity Year 1 cap

• SCNs determine Member rate

Note on ranges for cost-based services: OHIP has set ranges for cost-based services to account for variation in regional costs and individual member needs. OHIP expects SCNs to work with HRSN service providers to align on service costs either for each individual member, or for different types of services within the category (e.g., different types of MTMs). This is essential to SCNs’ ability to deliver services within the PMPM and for the success and sustainability of the SCN program. OHIP will be monitoring the distribution of cost-based claims across the range and will engage SCNs in performance dialogues if the top of the range is being used frequently/by default. It is OHIP's expectation that the top of the range will be used only for the highest/complex needs members. For nutrition services, OHIP expects service expenditures to fall at the top of the range only in circumstances where specialty meals/ingredients are required due to dietary needs and/or delivery is to more rural or remote locations.

Note on services subject to SCN Lead Entity cap: For services subject to SCN-level caps: 2.8b CTS Broker’s Fee,

3.5 Cooking Supplies, and 4.1 Transportation, SCNs are responsible for managing their spend against these caps.

SCN Lead Entities will be financially accountable for any expenditure that exceeds SCN-level caps. OHIP will ask

Lead Entities to report spend against each SCN-level cap and will monitor spending via social care claims. SCNs are required to set a per-member cap for 3.5 Cooking Supplies.

Note on services that may be re-authorized: As a guiding principle, services are not intended to be permanent solutions, and Social Care Navigators should work to connect members to more permanent resources (existing federal, state, and local services) where possible.

Note on services for children living in multiple households: For children in multiple households who may receive the same service on the same day (or date range) from the same provider at multiple households, the ‘concurrent claim’ modifier -76 should be added when submitting the claim. The modifier only needs to be added to claims beyond the first to avoid claims auto-rejection from MCO systems.

Screening

0. Screening

Service Description

Screening conducted to assess member for health-related social needs. Each Medicaid member will receive a Screening annually or on an as-needed basis due to a major life event. See the SCN Operations Manual for a detailed list of major life events.

To be reimbursed, Screening must include a 1:1 interaction between the Screener and member (interaction may be in-person, telephone, or other synchronous format). Reimbursement for Screening is time-based. Screening time includes time spent explaining the SCN program to a member, obtaining consent, walking the member through the screening, inputting the member’s information and answers to screening questions, and responding to member’s questions about next steps.Entities will not receive payment if a member self-screens without a subsequent 1:1 interaction with a Screener or Social Care Navigator, including Screenings in which the member only uses an online self-screening tool or other digital Screening with no 1:1 interaction (e.g., online form, AI chatbot). All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes

Unit Max 2 units per year (additional 2 units possible if major life event); max of 4 units per year

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Screening – All Medicaid Member Screening

G0136 U8, U2

Re-screening – All Medicaid Member Screening

G0136 UB, UA

https://www.health.ny.gov/health_care/medicaid/redesign/sdh/scn/docs/operations_manual.pdf

Care Management

1.1 Navigation Services (Eligibility Assessment and Navigation)

Service Description

Eligibility Assessment and Navigation of FFS and non-eligible Medicaid Managed Care members to existing federal, state, and local benefits and programs.

To be reimbursed, Navigation must include a 1:1 interaction between the Social Care Navigator and member (interaction may be in-person, telephonic, or other synchronous format). All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes

Unit Max 4 units per year (additional 4 units possible if major life event); max of 8 units per year

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Procedure codes: T1016 Modifiers: UB, U1

1.2a Enhanced HRSN Care Management – Eligibility Assessment Level 2 Only 1.2b Enhanced HRSN Care Management – Care Management Level 2 Only

Service Description

Engagement by Social Care Navigator with Medicaid Managed Care (MMC) members that are part of an Enhanced Population eligible for Enhanced HRSN Services, including time spent on Eligibility Assessment, referral management, care coordination, coordination of select Enhanced HRSN Services, education, and follow-up to ensure member needs were met by services. Social Care Navigators may bill care management for coordination of the following services: 2.1 Home Accessibility and Safety Modifications, 2.2 Home Remediation Service, 2.3 Asthma Remediation, 2.4 Recuperative Care (Medical Respite), 2.5 Rent / Temporary Housing (Rental Subsidy and Back Rent), 2.6 Utility Setup / Assistance, 2.8 CTS,

3.5 Cooking Supplies, 4.1 Transportation

To be reimbursed, Navigation must include a 1:1 interaction between the Social Care Navigator and member (interaction may be in-person, telephonic, or other synchronous format). All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Application fees: Covers application fees relevant to Enhanced HRSN Services (including Enhanced Care Management) to help support members to secure housing, transportation, employment, etc. Some examples include applying for a driver's license at DMV, background check fees, and housing application fees.

For detailed service descriptions by service name/modifier, please refer to Appendix C of this document.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes Application Fees: Cost-based, up to capped amount per member

Unit Max 20 units per month Application Fees: $100 for entire Waiver period (through March 2027)

Duration Entire Waiver period (through March 2027)

Service Name Procedure Code Modifiers

Codes & Modifiers

Enhanced Care Management – Eligibility Assessment Level 2 Only

T1016 U5, U3

Enhanced Care Management – Care Management Level 2 Only

T2023 U9, U8

Enhanced Care Management - Follow Up Level 2 Only

T2023 U9, U5

Enhanced Care Management - Application Fees Level 2 Only

T2023 U9, U2

Housing

2.1 Home Accessibility and Safety Modifications

Service Description

Home Accessibility and Safety Modification services will consist of limited internal or external physical adaptations made to eligible member’s home or community dwelling when necessary to ensure maximum health, welfare, and safety, or to allow the member to live independently in a community-based setting. The Home Accessibility and Safety Modifications service consists of the following elements:

• Dwelling Assessment & Statement of Work (SOW) Development

• SOW Technical Review

• Home Accessibility and Safety Modifications

• Quality Assurance (QA) Inspection (if applicable)

Both the HRSN service provider and contractors’ coordination and administrative costs should be included in the SOW and should not exceed 10% of the total costs of the project.

Adaptations are limited to: accessibility ramps, handrails, grab bars, electric door openers, widening of doorways, pathways, door and cabinet handles, bathroom facilities, kitchen cabinet or sinks, non-skid surfaces. All installation services include general education on how to use and properly care for equipment, provided during installation.

These services are available for a home that is owned, rented, leased, or occupied by the Medicaid member. OHIP will be monitoring distribution of spending across these services to ensure efficient and sustainable funding usage.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap

Unit Max Up to capped amount for Waiver period (inclusive of all services in 2.1 and 2.2:

Home Accessibility and Safety Modifications, Mold and Pest Remediation, Ventilation Improving Systems, Equipment Provision)

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Dwelling Assessment - Modifications_Remediations Service

S5165 UA, U8

SOW Technical Review – Modifications and Remediation Service

T2025 U2, UA

Quality Assurance Inspection – Modifications and Remediation Service

T2025 U3, UA

Home Accessibility and Safety Modifications – Accessibility Ramps

S5165 U3, UC

Home Accessibility and Safety Modifications – Bathroom Facilities

S5165 U1, U4

Home Accessibility and Safety Modifications – Doors and Cabinet Handles

S5165 U4, UB

Home Accessibility and Safety Modifications – Electric Door Opener

S5165 U4, U9

Home Accessibility and Safety Modifications – Grab Bars

S5165 U5, UC

Home Accessibility and Safety Modifications – Handrails

S5165 U4, UC

Home Accessibility and Safety Modifications – Kitchen Cabinet or Sinks

S5165 U2, U4

Home Accessibility and Safety Modifications – Non-skid Surfaces

S5165 U3, U4

Home Accessibility and Safety Modifications – Pathways

S5165 U2, U8

Home Accessibility and Safety Modifications – Widening Of Doorway

S5165 U8, U7

2.2a Home Remediation Service: Mold and Pest Remediation

Description

Home Remediation services to promote member’s health and wellbeing may include mold remediation (including fixing water leaks and removing damp or wet items to prevent mold growth) and pest remediation (including sealing / patching holes and cracks through which pests can enter the home). The Home Remediation: Mold and Pest Remediation service consists of the following elements:

• Dwelling Assessment & Statement of Work (SOW) Development

• SOW Technical Review

• Home Remediation: Mold and Pest

• Quality Assurance (QA) Inspection (if applicable)

Both the HRSN service provider and contractors’ coordination and administrative costs should be included in the SOW and should not exceed 10% of the total costs of the project.

These services are available for a home that is owned, rented, leased or occupied by the Medicaid member. OHIP will be monitoring distribution of spending across these services to ensure efficient and sustainable funding usage.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Pricing Unit Cost-based, up to cap

Unit Max Up to capped amount per member (inclusive of all services in 2.1 and 2.2: Home Accessibility and Safety Modifications, Mold and Pest Remediation, Ventilation Improving Systems, Equipment Provision)

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Dwelling Assessment - Modifications_Remediations Service

S5165 UA, U8

SOW Technical Review – Modifications and Remediation Service

T2025 U2, UA

Quality Assurance Inspection – Modifications and Remediation Service

T2025 U3, UA

Home Remediation: Mold and Pest S5165 U7, UC

2.2b Home Remediation Service: Ventilation Improving Systems

Description

Medically necessary improvement of ventilation systems. May include provisions of devices and appliances that are eligible by clinical criteria (limited to air conditioner, air filtration devices, de-humidifier, humidifier and heater). The Home Remediation:

Ventilation Improving Systems service consists of the following elements:

• Dwelling Assessment & Statement of Work (SOW) Development

• SOW Technical Review

• Home Remediation: Ventilation Improving Systems

• Quality Assurance (QA) Inspection (if applicable)

Both the HRSN service provider and contractors’ coordination and administrative costs should be included in the SOW and should not exceed 10% of the total costs of the project.

These services are available for a home that is owned, rented, leased or occupied by the Medicaid member. OHIP will be monitoring distribution of spending across these services to ensure efficient and sustainable funding usage.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Pricing Unit Cost-based, up to cap

Unit Max Up to capped amount per member (inclusive of all services in 2.1 and 2.2: Home Accessibility and Safety Modifications, Mold and Pest Remediation, Ventilation Improving Systems, Equipment Provision)

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Dwelling Assessment - Modifications_Remediations Service

S5165 UA, U8

SOW Technical Review – Modifications and Remediation Service

T2025 U2, UA

Quality Assurance Inspection – Modifications Remediation Service

T2025 U3, UA

Home Remediation – Air Conditioner S5165 U8, UC

Home Remediation – Air Filtration Devices S5165 UA, UC

Home Remediation – De-humidifier S5165 U4, U7

Home Remediation – Humidifier S5165 U5, U4

Home Remediation – Heater S5165 U9, UC

2.2c Home Remediation Service: Equipment Provision

Description

Provision of medically necessary mini refrigeration units as needed for medical treatment and prevention (e.g., insulin).

These services are available for a home that is owned, rented, leased or occupied by the Medicaid member. OHIP will be monitoring distribution of spending across these services to ensure efficient and sustainable funding usage.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap

Unit Max Up to capped amount per member (inclusive of all services in 2.1 and 2.2: Home Accessibility and Safety Modifications, Mold and Pest Remediation, Ventilation Improving Systems, Equipment Provision)

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Dwelling Assessment - Modifications_Remediations Service

S5165 UA, U8

SOW Technical Review – Modifications and Remediation Service

T2025 U2, UA

Quality Assurance Inspection – Modifications Remediation Service

T2025 U3, UA

Home Remediation: Equipment provision - Refrigeration Units

S5165 U6, U1

2.3a Asthma Remediation: Asthma Self-Management Education (ASME)

Description

Health education tailored to the needs of the member and family / caregivers to expand asthma knowledge. Content may include early warning signs and management of worsening symptoms, asthma control and medication adherence, and identification and reduction of asthma triggers. Initial visit must be conducted in-person in member's dwelling. Final visit may be conducted in-person in member’s dwelling or face-to-face virtually (e.g., video call). In the rare circumstance where the member does not allow a face-to-face visit in-person or virtually, the final visit may be conducted telephonically.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes

Unit Max 24 units for Waiver period

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code Modifiers

Asthma Remediation - Self Management Education - (In-person Visit)

S9441 U6, U5

Asthma Remediation - Self Management Education - (Telehealth/Teleconference)

S9441 U2, U3

2.3b Asthma Remediation & Provision of Supportive Products

Description

Provision of remedial services and supportive products to address ventilation and air quality, removal of asthma triggers, and Integrated Pest Management (IPM) in the member’s home. Remediation services will be tailored to the individual needs of the member and the primary residence (owner-occupied or rental dwelling) of the member. The Asthma Remediation & Provision of Supportive Products service consists of the following elements:

• Dwelling Assessment & Statement of Work (SOW) Development

• SOW Technical Review

• Asthma Remediation & Provision of Supportive Products

• Quality Assurance (QA) Inspection (if applicable)

Both the HRSN service provider and contractors’ coordination and administrative costs should be included in the SOW and should not exceed 10% of the total costs of the project.

These services are available for a home that is owned, rented, leased or occupied by the Medicaid member. OHIP will be monitoring distribution of spending across these services to ensure efficient and sustainable funding usage.

A detailed list of covered Asthma Remediation services and Supportive Products is provided in the Social Care Networks Operations Manual.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap

Unit Max Up to capped amount for Waiver period

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code

Modifiers

Dwelling Assessment – Asthma_Remediations Service

S5165 U1,U2,U5

SOW Technical Review – Asthma_ Remediation Service

T2025 U1,U2,U3

Quality Assurance Inspection – Asthma_Remediation Service

T2025 U1,U2,U4

Asthma Remediation – Air conditioner S5165 U6, U9

Asthma Remediation – Air duct maintenance S5165 UA, U4

Asthma Remediation – Basement water proofing S5165 U9, UA

Asthma Remediation – Cleaning and installation of gutter screens and downspouts

S5165 UB, U2

Asthma Remediation – Dirt floor vapor barrier S5165 UB, U3

Asthma Remediation – Dryer vent cleaning S5165 U9, U7

Asthma Remediation – Exhaust fans S5165 U8, U4

Asthma Remediation – Forced air furnace and additional filters

S5165 U7, U3

Asthma Remediation – Integrated Pest Management (IPM)

S5165 U8, U6

Asthma Remediation – Repairing water damage S5165 UB, U9

Asthma Remediation – Carpet removal S5165 UB, U8

Asthma Remediation – Carpet steam cleaning S5165 UB, U7

Asthma Remediation – Whole house fan S5165 UA, U2

Asthma Remediation – Mold Remediation (≤10

sq. feet)

T2025 U5, UA

Asthma Remediation – Mold Remediation (>10 sq feet)

T2025 U7, U5

Asthma Remediation – Insulation and Air Sealing T2025 U2, UB

Asthma Remediation – Replacement of air filters in HVAC system

T2025 U5, UB

Asthma Remediation – Heating unit clean and tune, repairs, or replacement

T2025 U3, U8

Asthma Remediation – Sump pump repair or replacement

T2025 U3, U5

Asthma Supportive Products – Asthma-friendly cleaning supplies

T2025 U6, U8

Asthma Supportive Products – Indoor Allergen Reduction

T2025 U9, U6

2.4 Recuperative Care (Medical Respite)

Description

Temporary residential care and supportive services provided to homeless or unstably housed members who do not have an acute need to be hospitalized but require health care services and supports to continue to recover from an illness or prepare for a medical procedure. Services include short-term residential care that allows homeless individuals the opportunity to rest in a safe environment while accessing medical care and other supportive services. Service must be provided by NYS-certified Medical Respite Programs and in accordance with New York State’s established Medical Respite regulations (10 NYCRR 1007) and program guidance.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per diem; SCNs can set individual provider rates within range provided. The range reflects different models of care and staffing intensity. OHIP expects that members will receive an appropriate level of care.

Unit Max Post hospitalization stays up to 90 days once every 12 months (assessed on a rolling basis). Pre procedural care is limited to a clinically appropriate amount of time as determined by a medical professional but cannot exceed 30 days per year.

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Procedure codes: S9125 Rate code: 7980

2.5 Rent and Temporary Housing (Rental Subsidy and Back Rent)

Description

Rent / Temporary Housing (Rental Subsidy and Back Rent) includes payment for rent for up to six months. Rental subsidy and back rent may be used for a) Permanent / Long Term Housing or b) Temporary / Transitional Housing.

All additional requirements defined in the Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Modifiers are used to identify the unit size of the rental property / temporary housing. Social Care Navigators determine the appropriate unit size during the Eligibility Assessment based on the number of members in the household (See Operations Manual for additional guidance). OHIP will monitor service expenditure to ensure that the unit size is appropriate for the household size.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per unit per month based on assigned unit size; cost-based, up to cap

Unit Max Limited to 6 months for the Waiver period (inclusive of back rent and prospective payments)

Duration Up to 6 months

Service Name Procedure Code Modifiers

Rent and Temporary Housing – Studio H0044 U4, U1

Rent and Temporary Housing – 1 Bedroom H0044 U4, U3

Rent and Temporary Housing – 2 Bedroom H0044 U4, U5

Rent and Temporary Housing – 3 Bedroom H0044 U2, U9

Rent and Temporary Housing – 4 Bedroom H0044 U3, U9

2.6a Utility Setup - Activation Expenses

Description

Provides payment for non-refundable, non-recurring utility set-up costs or restart costs if the service has been discontinued This service will cover expenses for the following types of utility payments: gas/oil, electric, water, sewage, garbage, recycling, internet and phone (inclusive of landline and cell phone).

Available only to members receiving 2.5 Rent and Temporary Housing (Rental Subsidy and Back Rent) services.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap

Unit Max One time, up to capped amount for Waiver period

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Procedure codes: T2025 Modifiers: UC, U3

2.6b Utility Setup - Back Payments

Description

Covers costs of back payments to secure and maintain utility service. This service will cover expenses for the following types of utility payments: gas/oil, electric, water, sewage, garbage, recycling, internet and phone (inclusive of landline and cell phone). Available only to members receiving 2.5 Rent and Temporary Housing (Rental Subsidy and Back Rent) services.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap

Unit Max One time, up to capped amount for Waiver period

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Modifiers: UC, U4

2.6c Utility Assistance

Description

Covers recurring monthly utility costs. This service will cover expenses for the following types of utility payments: gas/oil, electric, water, sewage, garbage, recycling, internet and phone (inclusive of landline and cell phone). Available only to members receiving 2.5 Rent and Temporary Housing (Rental Subsidy and Back Rent) services.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap per month Unit Max Up to 6 months, with capped amount per month

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Procedure codes: H0044 Modifiers: UB, UC

2.7 Pre-Tenancy Services

Description

Services to assist with navigating the complexities of the housing search and application process when undergoing tenant screening, completing rental applications, negotiating lease agreements, and preparing for and attending tenant interviews. This also includes assistance with search for rentals and contacting apartments.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes

Unit Max 24 units over 6 months

Duration Up to 6 months for Waiver period

Codes & Modifiers

Service Name Procedure Code Modifiers

Pre-Tenancy services - Navigating and Completing Housing Application

T2025 UC, UA

Pre-Tenancy services - Negotiating Lease Agreements

T2040 UC, U8

Pre-Tenancy services -Tenant Screening Assistance and Tenant Interviews

T2025 UC, U7

2.8a Community Transitional Supports

Description

Assistance to members who have secured a new housing unit to have a smooth and seamless transition to community living. Includes assistance with the set-up of the new housing unit and review of the living environment to ensure that it meets the member’s clinical, furnishings, adaptive aids, environmental modifications, and food and clothing needs at transition.

The following one-time transition and moving costs are included:

• Security deposit;

• Utility activation fees, movers, and relocation expenses;

• Pest eradication and inspection fees;

• Pantry stocking food (limited to a maximum of 30 days of food); and

• The purchase of household goods and furniture. Covered furnishings are limited to:

Living Room: Couch/ loveseat/ recliner; Table Lamp

Kitchen: Table and chairs; Countertop microwave; Garbage pail; Kitchen kit: pots, pans, utensils, dishes, dish soap, dishtowels; Coffee pot; Toaster

(not oven)

Bathroom: Bathroom kit: bath towels, wash cloths, hand towels, mats for floor and bathtub, basic toiletries including toothbrush, hairbrush or comb, and initial purchase of soap, shampoo, conditioner, toothpaste, and toilet paper; toilet plunger; tension rod; shower curtain, liner, and rings; grab bar; handheld shower head

Other: Secure medicine storage container; vacuum under $100; essential cleaning supplies; clock; blinds/ curtains; foldable shopping cart

Bedroom (per participant): Sheets and pillows; waterproof/vinyl mattress and pillow protector; bed (mattress, box spring, and frame; twin or full size); comforter; chest of drawers; nightstand; lamp

It is the responsibility of the HRSN service provider to obtain receipts for all items purchased. Copies of receipts must be submitted to the SCN Lead Entity.

Modifiers are used to identify the unit size of the property associated with CTS services. Social Care Navigators determine the appropriate unit size during the Eligibility Assessment based on the number of members in the household (See Operations Manual for additional guidance). OHIP will monitor service expenditure to ensure that the unit size is appropriate for the household size.

Note: Coverage of broker’s fees is limited to Manhattan, Bronx, Brooklyn, Queens, Staten Island, and Long Island regions.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Cost-based, up to cap based on assigned unit size

Unit Max Up to capped amount based on assigned unit size, may be used in increments without exceeding cap if member is eligible. Service does not continue after the individual is stably housed.

Duration Entire Waiver period (through March 2027)

Codes & Modifiers

Service Name Procedure Code

Modifiers

Community Transitional Supports - Studio T2025 U4, U1

Community Transitional Supports – 1- Bedroom

T2025 U4, U3

Community Transitional Supports – 2- Bedroom

T2025 U4, U5

Community Transitional Supports – 3- Bedroom

T2025 U2, U9

Community Transitional Supports – 4- Bedroom

T2025 U3, U9

2.8b Community Transitional Services - Broker’s Fee

Description

One-time transition cost to cover broker's fees for housing as part of CTS services.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Service Delivery

Allowed one time during Waiver period for qualified members in Manhattan, Bronx, Brooklyn, Queens, Staten Island, and Long Island.

SCNs are accountable to manage their spend against their SCN-level caps for CTS Broker’s Fee. SCNs will be financially accountable for services delivered over and above SCN-level caps. OHIP will ask Lead Entities to report spend against each SCN-level cap for CTS Broker’s Fee; OHIP will also monitor spending via social care claims.

Pricing Unit Cost-based, SCN-level cap (Jan 1, 2025 – Mar 31, 2026)

Unit Max N/A

Setting N/A

Duration Once during Waiver period (through March 2027)

Codes & Modifiers

Modifiers: U4, U2

2.9 Tenancy Sustaining Services

Description

Services to assist in maintaining and sustaining member tenancy in affordable or supportive housing by providing tenant rights education and eviction prevention.

Tenancy sustaining services are intended to assist members in securing housing and have a smooth and seamless transition to community living. These services can include:

• Assistance in linking to free or affordable legal services for members facing housing-related issues;

• Connection to available resources to assist in establishing a bank account and paying bills;

• Assistance in connecting the member with social services to assist with filling out applications and appropriate documentation to obtain sources of income necessary for community living, establishing credit, and in understanding and meeting the obligations of tenancy;

• Assistance in addressing circumstances and/or behaviors that may jeopardize housing. This should include direct interventions to address risks and connecting the member to relevant community resources that may offer assistance;

• Assistance in resolving disputes with landlords and/or neighbors to reduce risk of eviction or other adverse actions

• Assistance with housing recertification processes, including lease renewals and housing subsidy renewals

• Assistance with housing and utilities coordination services (e.g., coordination of back payments)

Pricing Unit Per 15-minutes

Unit Max 24 units over 6 months

Duration Up to 6 months

Service Name Procedure Code Modifiers

Tenancy Sustaining Services - Rights, Education, Eviction Prevention, Dispute Resolution, Risk Intervention, and Legal Services

T2040 UC, UB

Tenancy Sustaining Services - Financial Education, Literacy and Resources

T2040 U1, UC

Tenancy Sustaining Services - Housing Recertification and Renewals

T2040 U2, UC

2.10 Housing Transition and Navigation

Description

Services to assist with an eligible member's transition into a new home, including:

• Assisting with the set-up of the new housing unit, including coordinating clinically appropriate residential modifications and arranging the move

• Connecting member to resources aiding with housing costs and other expenses; including linkages to rental assistance vouchers, security deposits, application fees, moving costs, etc.

• Reviewing the living environment to ensure that it meets the clinical needs of the individual and is ready for move-in, including collaborating with the relevant provider staff where the individual is institutionalized (e.g., hospital or facility social worker) to ensure a seamless transition to the community

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes

Unit Max 16 units per month for up to 6 months, may be reauthorized up to 6 months per re-authorization, up to the duration of the waiver demonstration period as long as the member has an unmet need and is eligible to receive services

Duration Entire waiver demonstration period (through March 2027)

Codes & Modifiers

Procedure code: H0043 Modifiers: UA, U5

Nutrition

3.1 Nutrition Counseling & Education

Service Description

Nutrition counseling and education services, covering topics on healthy meal preparation and connecting members with grocery budget resources. Service should be delivered by a Certified Dietitian / Nutritionist (CDN) or Registered Dietician Nutritionist (RDN) and can be conducted in individual or group settings.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Pricing Unit Per 15-minutes (Individual); Per 30-minutes (Group)

Unit Max Up to 8 15-minute units; or 4 30-minute units; or a combination of 15- and 30-minute units totaling 2 hours, up to 6 months total.

Duration Up to 6 months with possibility of re-authorization, up to 6 months per re-authorization, up to the duration of the Waiver as long as the member has an unmet need and is eligible to receive services

Codes & Modifiers

Service Name Procedure Code Modifiers

Nutritional Counseling and Education-Counseling and Education: Individual (Initial assessment)

97802 U6, U2

Nutritional Counseling and Education-Counseling and Education: Individual (Re-assessment)

97803 U6, U3

Nutritional Counseling and Education-Counseling and Education: Group (2 or more individuals)

97804

U7, UA

3.2a Medically Tailored Meals and 3.2b Clinically Appropriate Home Delivered Meals

Description

Medically tailored meals are designed to be tailored by a Registered Dietitian Nutritionist (RDN) or Certified Dietitian Nutritionist (CDN) to an individual member with a chronic condition and/or pregnant or post-partum persons and must adhere to standards informed by established nutrition guidelines, such as the Food is Medicine (FIMC) MTM nutrition standards, for specific health conditions.

Clinically appropriate meals must provide well-balanced, nutritionally appropriate meals that adhere to evidence-based nutritional guidelines. Clinically appropriate meals promote health and wellness for Enhanced Populations who have an unmet HRSN under the food domain and meet the USDA definition of low food security but do not have chronic conditions and are not pregnant/postpartum persons. All meals provided must be approved by a Registered Dietitian Nutritionist (RDN) or Certified Dietitian Nutritionist (CDN) and must adhere to standards informed by appropriate nutrition guidelines.

Members who receive home delivered medically tailored or clinically appropriate meals cannot also receive 3.3 Medically Tailored or Nutritionally Appropriate Food Prescriptions or 3.4 Fresh Produce and Non-perishable Groceries (Pantry Stocking).

HRSN service providers may charge for food, delivery, and administrative costs associated with each member’s services. Costs associated with the initial intake / assessment and meal plan design may be billed under the reimbursement range.

SCN Lead Entities should monitor HRSN service providers’ costs within the reimbursement range to ensure program efficiency.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Members can participate in federally funded programs and still be eligible for HRSN nutrition services if they meet HRSN nutrition service eligibility criteria.

Pricing Unit Per meal; cost-based, within range

Unit Max This service is limited up to three (3) prepared meals a day, seven days a week.

Meal services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Duration Meal services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Codes & Modifiers

Service Name Procedure Code Modifiers

Clinically Appropriate Meals S5170 U6, U4

Medically Tailored Meals (MTM) S5170 U6, U7

3.3 Medically Tailored or Nutritionally Appropriate Food Prescriptions

Description

Food prescriptions (dairy, produce, meat, grains and spices) in the form of nutrition vouchers, coupons, or food boxes. Vouchers and coupons may only be redeemed at food pharmacies, food pantries, grocery stores, farmer's markets, mobile markets, and Community Supported Agriculture (CSA) subscriptions. Members who opt for food boxes will receive a weekly delivery of food appropriate for preparing weekly meals. Meals can only be delivered to the enrolled member’s home or private residence.

Members who receive food prescriptions cannot also receive 3.2 Medically Tailored Meals or Clinically Appropriate Home Delivered Meals, or 3.4 Fresh Produce and Non-perishable Groceries (Pantry Stocking).

HRSN service providers may charge for food, delivery, and administrative costs associated with each member’s services. Costs associated with the initial intake / assessment and meal plan design may be billed under the reimbursement range.

SCN Lead Entities should monitor HRSN service providers’ costs within the reimbursement range to ensure program efficiency.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Members can participate in federally funded programs (SNAP or WIC) and still be eligible for HRSN nutrition services if they meet HRSN nutrition service eligibility criteria

Pricing Unit Per week; cost-based, within range

Unit Max This service is limited to up to three (3) prepared meals a day, seven days a week.

Food prescription services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Duration Food prescription services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Codes & Modifiers

Service Name Procedure Code Modifiers

Medically Tailored or Nutritionally Appropriate Food Prescriptions – Boxes

T2025 U3, U2

Medically Tailored or Nutritionally Appropriate Food Prescriptions – Voucher

T2025 U5, U1

3.4 Fresh Produce and Non-Perishable Groceries (Pantry Stocking)

Description

Pantry stocking of fresh produce and nonperishable groceries (excludes perishable meat and dairy products) furnished via pick-up or delivery. Fresh Produce and non-perishable groceries will serve to nutritionally supplement up to 3 meals/day, 7 days/week.

Members who receive this service cannot also receive 3.2 Medically Tailored Meals or Clinically Appropriate Home Delivered Meals or 3.3 Medically Tailored or Nutritionally Appropriate Food Prescriptions.

HRSN service providers may charge for food, delivery, and administrative costs associated with each member’s services. Costs associated with the initial intake / assessment and meal plan design may be billed under the reimbursement range.

SCN Lead Entities should monitor HRSN service providers’ costs within the reimbursement range to ensure program efficiency.

All additional requirements in Social Care Networks Operations Manual must be met in order to qualify for reimbursement.

Eligibility Refer to Social Care Networks Operations Manual for the latest eligibility criteria (including guidance on duplicative services in Section 5.l).

Members can participate in federally funded programs (SNAP or WIC) and still be eligible for HRSN nutrition services if they meet HRSN nutrition service eligibility criteria.

Pricing Unit Per week; cost-based, within range

Unit Max Pantry stocking services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Duration Pantry stocking services are provided for:

• Pregnant/postpartum individuals: throughout their pregnancy and up to 12 months postpartum

• Other eligible individuals: up to 6 months at a time, can be re-authorized one-time for up to 6 additional months as long as the member has an unmet need and is eligible to receive services

Codes & Modifiers

Procedure code: T2025 Modifiers: U2, U6

3.5 Cooking Supplies

Description

Cooking supplies that are necessary for meal preparation and nutritional welfare for a member when not available through other programs, including kitchenware, microwave, and full-size refrigerator (independent of medical mini refrigerator available under Home Remediation Service 2.2c). Social Care Navigators are strongly encouraged to spend no more than $600 per refrigerator.

Kitchenware may include (but are not limited to) the following items: plates, bowls, cooking utensils, mixing bowls, pots and pans, chef’s knife, cutting board, eating utensils, silverware, glassware, can opener, colander. Note: Small appliances to support meal preparation and nutritional welfare (e.g., food blender) are allowed.

Appliances beyond microwave and full-size refrigerator are not covered.

For HRSN service providers that are not Social Care Navigators, time spent coordinating the purchase of a member’s cooking supplies may be billed under the Cooking Supplies service. HRSN service providers’ coordination costs are capped at 5% of the cost of each Member’s cooking supplies.

All additional…