DRAFT: Guidelines for Independent Service Coordination (ISC) Agencies

Helping Families. Supporting Communities. Empowering Individuals.


The purpose of this Information Bulletin is to provide guidance to Independent Service Coordination (ISC) Agencies regarding monitoring and other contacts for Medicaid Waiver Participants.


Effective July 1, 2017, Independent Service Coordination (ISC) Agencies are required to conduct at least two face-to-face annually visits with Developmental Disabilities Medicaid Waiver Participants: one visit to complete the Person Centered Planning Process (including both the discovery and planning components), and one visit to monitor the implementation of the Plan. It is important to remember that these two visits are a minimum requirement. On average within an ISC agency, Waiver Participants should receive at least four face-to-face visits annually, with those in the greatest need receiving more than four annually. Additionally, other types of contacts, e.g., phone calls, electronic mail, or video conferencing, may be conducted as well.

Process and Procedures

Many factors contribute to the determination of whether an individual has sufficient supports, protections, or personal abilities to be in a safe and healthy environment. ISC agencies must direct their resources based on the needs of the Participants at any given point in time. The following are a list of circumstances which may require at least one additional face to face visit. ISC agencies should complete an additional face to face visit to address the specific circumstance or adequately document the individual's record to justify the reason for not completing a visit. Documentation should include confirmation that the events related to the circumstance no longer present a risk to the individual.

  • Police involvement [with or without court action]
  • Investigative findings of egregious Neglect, Abuse, and/or Exploitation
  • Status Post Hospitalization
  • Significant life changes/transitions
  • Significant behavioral issues/concerns that pose changes to the individual's Personal Plan or Implementation Strategy.
  • Significant medical issues/concerns
  • Death of family or close supports that have a potential to adversely affect the individual's services and/or supports.
  • Changes in level of care needs within the Waiver
  • Guardian's interests are in conflict with the person's desires/needs/outcomes.
  • Unresolved Individual/Guardian issues/concerns
  • Other situations which create concerns related to health, well-being, and service provision.
  • Danger of losing current placement
  • Involvement of Service and Support Teams (SST), Short-term Stabilization Homes (SSH), and CART

Effective Date

This Information Bulletin is effective immediately once it is posted as final.