STEPS (Support and Training for Employing People Successfully)
Individualized Service Plan

Member name: First and Last	DOB: Enter date	Primary phone #: Include area code	Medicaid ID: Enter #
Member address: Street Address	City, State: City, State	Zip: Zip code
Alternate contact #: Include area code	Email: Enter email	PPL ID: Enter ID
☐Mailing address same as member street address
Mailing address: Mailing Address	City, State: City, State	Zip: Zip code
☐ Guardian or ☐ Representative: First and last name	Phone #: Include area code	Email: Enter email
☐ Guardian/Representative address same as member address
Guardian address: Mailing Address	City, State: City, State	Zip: Zip code
MCO: Choose	Care Coordinator: First and last name	Phone or email: Enter contact info
Community Services Coordinator: First and last name	CSC Agency: Enter Agency
CSC Phone #: Include area code	CSC Email: Enter email
CSC Address: Street Address	City, State: City, State	Zip: Zip code

Date of STEPS Initial/Annual Assessment: Choose date	Date of Revised Assessment: Choose date
Service Plan Start Date	Service Plan End Date
Type Example: Annual or Revised	Always the 1st of the month	Always the last of the month
INITIAL SERVICE PLANS START ON THIS LINE (always keep this row)	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
Choose type	If not annual, provide explanation	Start date	End date
♦MCOs: You must reauthorize Community Service Coordination for 12 months with each Annual Service Plan.♦

All Service Plans (along with any additional documentation) must be submitted by the CSC to the MCO CC/CM and CC’d to the STEPS Program Manager no later than the 18th of the month to ensure adequate time for plan approval and entry of authorizations into the FMS system.

Pre-Vocational Services
Pre-Voc Service Provider: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
# of service hours: @ $40/hour	Estimated monthly cost: $ 0.00
☐ Initial	☐ Reauthorization	☐ Provider Change	*CSC must enter the # of service hours according to plan type
Pre-Voc services are capped at 34 hours over a given 6-month service plan period. The member will need a revised service plan completed if they change providers before the hours have been used or if a reauthorization of these hours is needed (with required justification documentation).

Independent Living Skills Training
IL Skills Training Provider: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
# of service hours: @ $32/hour	Estimated monthly cost: $ 0.00
☐ Initial	☐ Reauthorization	☐ Provider Change	*CSC must enter the # of service hours according to plan type
IL Skills Training is capped at 34 hours over a given 6-month service plan period. The member will need a revised service plan completed if they change providers before the hours have been used or if a reauthorization of these hours (with required justification documentation).

Service Plan Type	# of Service Hours to enter
Initial – First authorization of hours, Initial Service Plan	34
Reauthorization – Authorization of an additional hours.	# requested by provider
Provider Change – If member changes providers before all authorized hours have been used	Remaining hours for new provider
CSCs must contact the current service provider when discussing provider changes to request the number of hours used (including those not yet billed) by the current provider to determine how many hours remain for the new provider. All revised Service Plans must be completed before the current plan expires. Failure to complete the Service Plan in a timely manner will result in providers not being paid. Any changes can only start on the first day of a month and end on the last day of a month.

Transportation – Vendor/Agency invoice, Member reimbursement, or PAS payment based on EVV
Enter total # of assessed hours for transportation:	Total dollar amount available for transportation costs: $ 0.00
Vendor/Agency or Member – Who is to be paid (If member is to be reimbursed for transportation, enter their first and last name)	Invoice or reimbursement?	Description/details of transportation – Monthly cost, capped amount, bus pass, etc. (Receipt required for reimbursement and/or an invoice needs # of provided trips.)	Monthly Cost
Vendor/Agency and contact info	Choose method	Description
Vendor/Agency and contact info	Choose method	Description
Vendor/Agency and contact info	Choose method	Description
PAS Transportation – Use Provider Pay Rates for Service Plan chart for hourly wage	Relationship to the member	# of hours per month	Hourly wage	Cost to employer/hr.	0.00
First and last name, phone #	Choose one.	$15.00	$ 0.00
First and last name, phone #	Choose one.	$15.00	$ 0.00
First and last name, phone #	Choose one.	$15.00	$ 0.00
Total hours:	0	Total cost:	$ 0.00

Supported Employment (SE) Services
SE Provider: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
Enter total # of assessed SE hours per month:	Monthly SE support cost: $ 0.00
Supported Employment is assessed by the employment supports provider and may be authorized concurrently with Pre-Vocational Services. New services can only start on the first day of a month and end on the last day of a month.

Personal Assistance Services – Agency-Directed
PAS Agency: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
Enter total # of assessed monthly PAS hours: @ $16.50/hour	Monthly PA Services cost: $ 0.00
♦Providers of agency-directed services are responsible for conducting background checks on all PAs for the STEPS program.♦ ♦They must also receive a copy of the STEPS assessment in order to direct their staff which services need to be provided to the STEPS member.♦

Enhanced Services (ES) – Agency-Directed
PAS Agency: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
Enter total # of assessed nights per month: @ $92/night	Monthly cost of Enhanced Services: $ 0.00
♦Providers of agency-directed services are responsible for conducting background checks on all PAs for the STEPS program.♦ ♦They must also receive a copy of the STEPS assessment in order to direct their staff which services need to be provided to the STEPS member.♦

Personal Assistance Services (PAS) – Self-Directed
Enter total # of assessed monthly PA hours:
Name of PA and relationship to the member (Use Provider Pay Rates for Service Plan chart for hourly wage)	Total hours per month	Hourly wage	Cost to employer/hr.	Total cost per month
First and last name, phone #	Choose one.	$16.50	$ 0.00
First and last name, phone #	Choose one.	$16.50	$ 0.00
First and last name, phone #	Choose one.	$16.50	$ 0.00
First and last name, phone #	Choose one.	$16.50	$ 0.00
First and last name, phone #	Choose one.	$16.50	$ 0.00
First and last name, phone #	Choose one.	$16.50	$ 0.00
Total hours:	0	Total cost:	$ 0.00

Enhanced Services – Self-Directed
Enter total # of assessed nights per month:
Name of PA and relationship to the member (Use Provider Pay Rates for Service Plan chart for nightly rate)	Total nights per month	Nightly rate	Cost to employer/night	Total cost per month
First and last name, phone #	Choose one.	$92.00	$ 0.00
First and last name, phone #	Choose one.	$92.00	$ 0.00
First and last name, phone #	Choose one.	$92.00	$ 0.00
First and last name, phone #	Choose one.	$92.00	$ 0.00
First and last name, phone #	Choose one.	$92.00	$ 0.00
First and last name, phone #	Choose one.	$92.00	$ 0.00
Total nights:	0	Total cost:	$ 0.00

Supplemental Services – Services in place of PAS hours
♦ Check the appropriate box for any supplemental services that the member will receive. If no supplemental services were authorized on the assessment, leave this section blank. CSCs must enter the 1-time costs and total cost per month manually (unless otherwise indicated). ♦
Category of service	Vendor/Agency	Details of service(s) to be provided	Total cost per month
☐	Home-Delivered Meals Service Code: S5170 U3	Vendor/Agency and contact info	# of meals per month:	$ 0.00
(Enter # of meal per month)	(This will calculate)
☐	PERS Service Code: S5161 U3	Vendor/Agency and contact info	1-time cost? Service Code: S5160 U3
☐	Medication Minder Service Code: T1505 U5	Vendor/Agency and contact info	1-time cost? Service Code: T1505 U3
Total cost:	$ 0.00

♦In order to complete this form, you MUST use the Run Calculations button. Anytime you change a value above, you must use this button again.♦

Monthly Cost	Number of Hours or Units	Service Code
Pre-Vocational Services	$ 0.00	0.00	T2047 U3
Independent Living Skills Training	$ 0.00	0.00	H2014 U3
Supported Employment	$ 0.00	0.00	H2023 U3
Transportation	$ 0.00	0.00	T2003 U3
PAS - Agency-directed	$ 0.00	0	S5125 U3
PAS - Self-directed	$ 0.00	0	S5125 U5
Supplemental Services (only available with PAS)	Enhanced Services	$ 0.00	0	T2025 U3
Home-Delivered Meals	$ 0.00	0	S5170 U3
PERS	$ 0.00	0	S5161 U3
Med Minder/Dispenser	$ 0.00	0	T1505 U3
Total Monthly Cost	$ 0.00
1-Time Costs
PERS Install	$ 0.00	S5160 U3
Medication Reminder/Dispenser Install	$ 0.00	T1505 U5

STEPS Service Plan Agreement

I agree:

To follow the STEPS Program Policy Manual.

That I was provided with information regarding my provider options for all of my STEPS services.

To make sure all time sheets are correct and approved in a timely manner. I will be at fault for any mistakes. It could be Medicaid Fraud to approve time sheets that are known to be incorrect.

To use only the amount of self-directed services authorized on this Service Plan. Any units of self-directed service used over the authorized amount will be my responsibility to pay.

That Pre-Vocational Services and/or Independent Living Skills Training are limited to 34 hours within 90 days. These services are not on-going and are expected to end.

That Supported Employment is limited to 13.25 hours per month for the first 15 months of my enrollment in STEPS and will be reduced by a minimum of ¼ on a quarterly basis with a goal of closing this service by the end of the second year.

To have a viable Individualized Emergency Backup Plan in the event a provider or Personal Attendant fails to show up.

I understand:

That using services outside of the approved Service Plan and/or confirmed Medicaid Fraud or abuse may lead to involuntary disenrollment in STEPS and I will be barred from participating in the future.

That if I purchase assistive services/technology that have not received prior approval by the Program Manager I will be responsible for paying for these costs myself.

Copies of this approved Individualized Service Plan will be shared with the fiscal manager, my MCO, the STEPS Program Manager, KDHE, and the providers that I have chosen to deliver my supports and services.

My Community Services Coordinator and MCO Care Coordinator are required by Kansas law to report concerns if they feel I am being abused, neglected, exploited, or taken advantage of by someone with power over me.

All STEPS information about me is private. I allow STEPS to give information about my participation in the program and my Individualized Service Plan to the Centers for Medicaid and Medicare Services, the Social Security Administration, the Kansas Department of Health and Environment, and the Kansas Department for Children and Families.

All information from surveys and program records will only be about groups of people and will be used for research purposes only.

No person shall, on the grounds of race, color, national origin, age, disability, religion, or sex, be excluded from participation in, be denied the benefits of or be subject to discrimination under any program or activity of the Department for Children and Families or Kansas Department of Health and Environment.

Member/Representative Agreement Signature	Date

MCO Service Plan Approval Signature	Date