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Medicaid Service Coordination

Providing options to individuals with disabilities to make informed life choices is a major part of Opportunities Unlimited of Niagara’s philosophy. Coordinated Services is an innovative way of giving these individuals the freedom to choose services and supports to meet their needs and enrich their lives. At the same time, the service coordinator assures fair and equitable access to these services and supports.

Goal of Coordinated Services

To create service environments for people and help them to:

  • Have meaningful relationships with family, friends & others
  • Experience optimal health & personal growth
  • Live in the home of their choice
  • Fully participate in their community

Guiding principles of Coordinated Services

  • A person with a developmental disability shall be as independent as possible and have the opportunity to determine the direction of his or her life
  • A person with a developmental disability shall receive support and assistance to define and achieve personal aspirations and life goals
  • A person with a developmental disability shall have the opportunity to make informed choices that do not compromise health and safety, and such choices shall be respected and supported by the people involved in their lives
  • A person with a developmental disability should have the opportunity to communicate his or her fears and have them addressed, and not to be subjected to fear, harm or reprisal in connection with the provision of supports and services
  • A person with a developmental disability shall be encouraged to engage in productive activities and to fully participate in their chosen community, consistent with their interests
  • The person’s overall satisfaction will be considered a priority

Basic skills of service coordinator

  • Ability to put the person’s needs and desires first; promote choice making and self-advocacy
  • Ability to understand and utilize “person-centered” planning principles
  • Ability to develop a thorough working knowledge of available services and supports, including those funded by OPWDD, as well as, those available within the community at large
  • Ability to recognize and address health and safety issues
  • Good listening and effective communication and organizational skills
  • Innovative in facilitating and developing natural supports for people
  • Ability to negotiate and resolve conflicts
  • Ability to initiate and take appropriate actions in crisis situations
  • Knowledgeable of and able to access entitlements and benefits on behalf of the person
  • Ability to take steps to ensure the quality of the person’s living environment
  • Effective in advocating for the person
  • Maintenance of an up-to-date ISP for the person, and required MSC documentation.
  • Understanding of service coordination ethics and conflict of interest
  • The purpose of a Service Coordinator is to provide effective management of care in accordance with the person’s Individual Service Plan (ISP)

Role of Medicaid Service Coordinator

The Service Coordinator works for the individual and in partnership with the person’s advocate to develop an Individualized Service Environment (ISE) consistent with their personal goals, preferences and desired activities.

This process results in the development of an Individual Service Plan (ISP), which serves as an outline of the services and supports that are either necessary or desired by the person to assist them in achieving their personal aspirations. The aim of the ISP is to ensure that a person receives appropriate services and/or supports, consistent with their valued outcomes as identified in the plan and their needs.

Specific services and supports provided by the Service Coordinator range from assistance with financial matters, arranging respite, securing leisure and recreational activities, identifying environmental modifications and adaptive equipment needs, if any, housing issues and in-home and out-of-home service needs, etc.

Enabling individuals to make their own choices promotes change, growth and the ability to meet new challenges every day.


The Medicaid Service Coordinator engages in activities that focus on needs identification, including but not limited to: assessment of the individual to determine the need for any medical, social, educational or other services; compiling the person’s history, identification of the person’s needs and completing related documentation. It may also include compiling information from other sources such as medical providers, family members, other providers, as necessary to form a complete assessment of the person and his or her needs/goals.

Development, implementation & maintenance of Individual Service Plan (ISP)

Develops the ISP based upon information collected through the assessment process and ensures the active participation of the person, their advocate and others working with the individual to develop goals and needed courses of action to meet the person’s needs and valued outcomes.


The Medicaid Service Coordinator serves as an advocate who assists the individual to make informed decisions which impact on the quality of their life. The Medicaid Service Coordinator provides an “arms-length” relationship with all providers who deliver services in order to avoid any conflict of interest. Their primary role is to promote self-advocacy whenever possible, and advocate in the event that the individual is unable to do so themselves.

Linkage & referral

The process of assisting the individual/advocate to identify and access specific services appropriate to the person’s needs and interests, as well as, completing/providing any necessary paperwork to complete the referral process and ensure services are obtained.

Follow-up & monitoring

The Service Coordinator ensures that services are delivered as requested by the individual, in accordance with their ISP. Part of this process involves on-going assessment of the person’s satisfaction with the services and supports being received.


  • Documentation of developmental disability
  • Medicaid eligibility
  • Live independently or with family
  • Live in Individual Residential Alternative (IRA) or other residence certified by OPWDD (e.g., Individual Residential Alternatives, Community Residences or Family Care Homes)
  • Have a demonstrated need for on-going & comprehensive service coordination in accordance with OPWDD guidelines

Cannot be enrolled in any other comprehensive, long-term care service, including case management/service coordination.


Same criteria as listed in eligibility section with the addition of ICF/MR level of care eligibility determination.

Medicaid Service Coordinators responsibilities include

  • Develop, implement and maintain the person’s Individualized Service Plan (ISP)
  • Review the ISP at least twice annually
  • Maintain required service coordinator documentation in the person’s service coordination record
  • Attend 10 – 15 hours of professional development training annually
  • Meet with the person face-to-face in accordance with their assessed need for service coordination services. At least one of these meetings must occur in the person’s home during the calendar year
  • For service coordinators who do not serve members of the Willowbrook class, maintain a weighted caseload not to exceed 40
  • Facilitate the person’s entry into MSC; change of MSC vendor; and withdrawal from MSC
  • Complete the Service Coordination Agreement upon enrollment and review periodically/update as necessary
  • Complete and maintain service coordination notes
  • Document ISP reviews in the service coordinator’s notes

Responsibilities specific to waiver services

  • Complete HCBS waiver enrollment forms
  • Ensure the completion of an annual level of care for ICF/MR enrollment
  • Secure or continue searching for an advocate for each enrolled person who requires one
  • Assist individuals in maintaining Medicaid eligibility.
  • Notify DDSO of HCBS terminations, and inform the terminated individual about connecting with follow-along services

Ensure that the person’s fire safety needs are addressed as stated in the ISP. If a person lives in an IRA, the Service Coordinator ensures the assessment of that person’s fire safety needs at least annually. The fire safety needs of people living in their own homes should be reviewed and discussed, but an assessment is not required.