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Care Management

Whether you need help navigating the healthcare system, managing a chronic condition, or connecting with local resources, our dedicated care managers are here to guide you every step of the way.

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What is Care Management?

Our Care Management services provide you with a personal Care Manager who acts as your advocate and navigator. We help you bridge the gap between your physical health, mental health, and the social support you need to thrive.

Whether it’s finding a specialist, securing transportation to your next appointment, or connecting you with local housing and food resources, we are here to ensure you get the right care at the right time.

Who Qualifies

New York Medicaid members with two chronic condition diagnoses

Note: you do not need to be an existing Athena patient to qualify.

Care Management Services

Mental Health Support

Medical Coordination

Community & Lifestyle

Social & Basic Needs

Logistics & Administration

Substance Use Support

What we do

A Dedicated Partner: You get a single point of contact who knows your story and helps you navigate the system.

No Cost to You: This service is fully covered by New York Medicaid.

Keep Your Doctors: You do not need to be an Athena patient to join. You can keep all your current providers while we help coordinate your care.

Support for All Ages: We provide care management for both children and adults.

Simple & Voluntary: Enrollment is 100% voluntary. We’re here for as long as you need us.

Care Management Services Include

 

Medical & Clinical Coordination

  • Specialist Referrals: Finding doctors who accept Medicaid and specialize in specific conditions (e.g., cardiology, endocrinology).
  • Appointment Scheduling: Booking visits and setting up automated reminders so appointments aren’t missed.
  • Medication Management: Coordinating with pharmacies for refills, home delivery, or “blister packing” to help keep track of daily doses.
  • Post-Hospital Transitions: Arranging “step-down” care, home health aides, or follow-up visits after a person is discharged from the hospital.
  • Medical Equipment: Ordering wheelchairs, oxygen tanks, hospital beds, or diabetic supplies.

Mental Health Support

  • Therapy & Counseling: Connecting members to licensed mental health professionals.
  • Crisis Intervention: Creating a safety plan and providing immediate contact info for mental health emergencies.

Substance Use Support

  • Rehabilitation Services: Arranging placement in detox centers, inpatient rehab, or outpatient support groups.
  • Harm Reduction: Connecting members to needle exchange programs, naloxone distribution, and other community-based resources.

Social & Basic Needs

  • Housing Assistance: Helping with applications for supportive housing, Section 8, or emergency shelter placement.
  • Food Security: Connecting members to local food pantries, soup kitchens, or enrolling them in SNAP (Food Stamps) and WIC.
  • Utility Assistance: Applying for programs like HEAP (Heating Energy Assistance Program) to ensure heat and electricity aren’t shut off.
  • Legal Aid: Referring members to pro-bono legal services for issues like eviction prevention or immigration status.

Logistics & Administration

  • Transportation: Arranging “MAS” (Medical Answering Services) for Medicaid-funded rides to and from medical appointments.
  • Benefit Enrollment: Assistance with Medicaid recertification paperwork to ensure coverage doesn’t lapse.
  • Document Retrieval: Helping members obtain birth certificates, ID cards, or Social Security cards needed for services.

Community & Lifestyle

  • Vocational Training: Referrals to job placement programs or GED classes.
  • Peer Support: Connecting members with “Peer Advocates”—people with lived experience who offer mentorship.
  • Social Engagement: Finding local senior centers, youth programs, or community support groups to reduce isolation.

Care Management Referrals

CIN has 8 characters total: 2 letters, 5 numbers, 1 letter e.g. AB12345C
I certify that the member is eligible for care management services based on the New York State Department of Health (DOH) criteria: possessing either one single qualifying condition (e.g. SMI or HIV/AIDS) or two or more chronic conditions.(Required)

Demographics

Name(Required)
Date of Birth(Required)

Address

Address(Required)

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