Helping People with Disabilities Coordinate Services

Service Coordination assists people and their families in gaining access to services and supports appropriate to their needs and desires. AIM Services, Inc. Service Coordinators utilize a person-centered planning process in developing, implementing, and maintaining an Individualized Service Plan (ISP) that expresses how you or your loved one wants to be represented and what they wish for themselves.

What is the Role of the Service Coordinator?

You and your Service Coordinator work together to determine the services and natural supports needed to achieve your desired outcomes. Your Service Coordinator provides ongoing linkage and referrals to access and maintain what you need and want in your life. Your Service Coordinator will provide ongoing monitoring and follow-up to ensure that your Individualized Service Plan changes with you.

Important Update to MSC, effective July 1, 2018

Exciting changes are coming to how Medicaid Service Coordination (MSC) will be provided and received in New York State. Effective July 1, 2018, the MSC department at AIM Services is expected to transition to a newly formed model of service provision, known as a Care Coordination Organization (CCO). MSCs will become known as Care Managers, and supports will be added to achieve a holistic and integrated approach to meeting each unique person’s full range of needs.

The new service model has been created to address a Federal requirement that mandates MSC to be provided as “Conflict Free Case Management.” In order to comply with federal regulations/guidance, OPWDD has agreed to restructure the delivery of Medicaid Service Coordination and PCSS to meet these standards. This means that the organization providing MSC (soon to be Care Management) must be separate from any agency providing OPWDD Home and Community Based Waiver Services. This will affect all MSC providers across New York State and will feature additional health care and wellness related supports.

AIM is partnering with local MSC agencies to form a limited liability corporation known as Capital North Cares, LLC. Capital North Cares, LLC will be joining Care Design NY (one of the developing CCO’s) in the transition to Care Coordination. AIM is committed to advocacy and efforts to ensure that high quality service delivery carries forward into the new model. Our MSCs are expected to transition to employment with Care Design NY on or about July 1, 2018. We are choosing to partner with Care Design NY because they value our input to bring forth the same person-centered framework that we all believe in. We are working hard to make this transition from MSC to Care Coordination go as smoothly as possible for you, your family members and your MSCs. Our goal is for you to continue to work with your current MSC as we move forward to the new structure. We also want to reassure you that there will not be any disruption to your other Medicaid-funded services (i.e. day habilitation, residential, community habilitation, supported employment, etc.) as a result of the shift to Care Coordination.

For questions or concerns, please contact Carrie Wood, Program Director of Service Coordination directly at (518) 450-2879 or

Please take the time to watch the video below to better understand Care Design NY:

Types of Service Coordination

Medicaid Service Coordination

Your Medicaid Services Coordinator (MSC) will provide advocacy, monitoring and related activities on a monthly basis. Related activities vary depending on what kind of advocacy is needed. For an example, imagine a service is dropped at school. The MSC will then advocate and potentially schedule a Committee on Special Education (CSE) meeting, visit the school to observe, work with the social worker, and any other required steps to ensure the service can either be replaced or received somewhere else.

Your MSC will meet with you at least four times a year to review and revise your ISP. However you can meet more often if you desire. Three of the visits take place at a location of your choice, and one needs to take place in your home. Your MSC will work with you and your natural supports to schedule these meetings based on your needs and convenience. Depending on what is happening in your life, you may need to meet with your MSC more frequently.

Department of Health Service Coordination

Your DOH Service Coordinator will meet with you on a monthly basis. At these meetings, your Service Coordinator will discuss your satisfaction with service provisions. You will work together to ensure that you are able to live comfortably and safely in your home and pursue your interests and goals. Where and when you meet up is up to you, however once per quarter the meeting must be held in your home.

Plan of Care Support Services (PCSS)

PCSS is a waiver service that can be chosen as an alternative to Medicaid Service Coordination. PCSS is designed to support you or your loved one to access resources needed and assist in reaching goals at least quarterly, or as needed, rather than monthly as in traditional Service Coordination.

AIM Services, Inc.