Health Home Care Management for Medicaid Beneficiaries

Health Home Care Management is a free program for Medicaid recipients that is an optional addition to existing support.

Circare Care Managers work with individuals to develop and maintain a person-centered comprehensive plan for accessing and using community services and supports necessary to promote well-being. These services and supports are provided through a network of organizations, with the care manager overseeing the process. The network includes not only healthcare providers but other social and community supports that are essential to a person’s overall health, such as housing and vocational services. The goal is to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits, promote the use of Health Information Technology (HIT), and avoid unnecessary care.

Please click here for more information about what a Health Home is.

Services Include

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
  • Individual and family support, which includes authorized representatives
  • Referral(s) to community and social support services, if relevant
  • The use of Health Information Technology (HIT) to link services, as feasible and appropriate

Eligibility Criteria

  1. Individual currently has active Medicaid; AND
  2. Individual meets the New York State Department of Health eligibility criteria of: two chronic conditions, or HIV/AIDS, or one or more serious mental illnesses; AND
  3. Individual has significant behavioral, medical, or social risk factors which can be addressed through care management.

Non-Medicaid recipients who have a Serious Mental Illness may qualify for services through our Non-Medicaid Care Management Program. Further information and referral instructions to the Non-Medicaid Care Management Program can be located here.

In addition, our Forensic Care Management program provides services to inmates, with a psychiatric disorder, who are transitioning into the community following incarceration. Further information and referrals to the Forensic Care Management Program can be located here.

Referral Process

Circare accepts referrals from the community including health care providers, community organizations, individuals and/or family members. Learn More.

Assistance with completing a referral can be provided by a Circare enrollment specialist at our office during business hours (Monday through Friday 8:30 AM – 5:00 PM) or by telephone at 315-472-7363.

Hours of Operation

Services are provided both in the Circare office and in the community Monday through Friday from 8:30 AM to 5:00 PM.

On-Call services are available 24 / 7.


Molly Stuttler-James
Adult Care Management Services Coordinator
315-472-7363 x 165