Medical Care Coordination

Dedicated coordinators to help address your individual medical needs

The continuous enrollment condition of Medicaid has ended. States can now terminate Medicaid enrollment for individuals no longer eligible. These changes will affect NYS Medicaid, Child Health Plus, and the Essential Plan. If you are enrolled in our Medicaid Health Home Program and looking for assistance with your Medicaid recertification, please get in touch with your assigned Care Coordinator or the regional offices where you receive your services.

If you are living with HIV/AIDS, have Medicaid, and need assistance obtaining additional health insurance or assistance with medication costs please contact our Health Insurance Navigation Program or call 518-912-2231.

TO OBTAIN WHAT THEY NEED TO KEEP THEM HEALTHIER AND SAFER WITHIN THEIR COMMUNITIES

We work with a group of Health and Community agencies that help individuals just like yourself, facing serious and chronic health issues, get what they need to keep themselves healthier and safer within their communities. Each individual is paired with one of our Care Coordinators.

We can help with

- Attend appointments with you, as needed
- Link you to needed services
- Advocate and coach you on how to speak with your providers
- Provide health education
- Assist with scheduling transportation to your medical appointments
- Educate and assist with accessing services from the Department of Social Services & other community providers
- Access to HIV medication

Apply for Care Coordination Services

How does it work?

Step 1: Meet

In the first meeting with your Care Coordinator, you'll discuss your challenges and goals.

Step 2: Create a plan

Your Care Coordinator will work with you to create a plan to address your immediate needs including housing, food, transportation, and medication access.

Step 3: Follow the plan

Review your goals on a timely basis to make sure you are on track with a focus on prevention methods to help avoid emergency rooms or hospital visits.

What Clients Say

Changing lives by meeting people where they are.

Tell us your experience

I went here for the first time to get free testing and got a test that was administered by Brooks. This place not only has the most calmest ambiance, but the nicest staff ever, especially Brooks. I couldn't have had a more comfortable, validating, non-judge-mental, and overall positive experience.

Anonymous

Do I qualify?

To qualify, you must have

HIV/AIDS* and be Medicaid eligible OR
Two or more chronic conditions like Substance Use Disorder*, Asthma, Diabetes, Heart Disease, High Blood Pressure, and Morbid Obesity OR
One single qualifying chronic condition
- Serious Mental Illness* (Adults) OR
- Sickle Cell Disease (Adults and Children) OR
- Serious Emotional Disturbance or Complex Trauma (Children)

*If an individual has HIV or Serious Mental Illness, they do not have to be at risk for another condition to be eligible for Medical Care Coordination services. Substance Use Disorders are considered chronic conditions and do not by themselves qualify an individual. Individuals with Substance Use Disorders must have another chronic condition to qualify.

Frequently asked questions about Medical Care Coordination

Where can I access Medical Care Coordination?

In each of our five locations throughout Northeastern New York.

How will this affect my current health services?

Your current health services should not be interrupted. You will not have to change medical providers or managed care programs. Your connection with Medicaid will NOT change.

How do I qualify?

To qualify, individuals must

Medicaid eligible and have HIV/AIDS or,
Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes, Heart Disease, High Blood Pressure, morbid obesity) or,
One single qualifying chronic condition:
- Serious Mental Illness* (Adults) or,
- Sickle Cell Disease (both Adults and Children) or,
- Serious Emotional Disturbance or Complex Trauma (Children)

*If an individual has HIV or SMI, they do not have to be determined to be at risk of another condition to be eligible for Health Home services. Substance use disorders (SUDS) are considered chronic conditions and do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify.

For additional details and specific guidance, please review this document.

Ready to take action?

Apply

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