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

Participant name: First and Last	DOB: Choose date	Primary phone #: Include area code

Participant address: Street Address	City, State: City, State	Zip: Zip code

Alternate contact #: Include area code	Email: Enter email	PPL ID: Enter ID	Medicaid ID: Enter #

☐Mailing address same as participant street address

Mailing address: Street 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 participant address
Guardian address: Street 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 Annual Assessment: Choose date	Date of Revised Assessment: Choose date

Service Plan Start Date	Service Plan End Date
Ex: Annual, Revised Assessment, or Other change	Always the 1st of the month	Always the last of the month
Initial Start or New Start if Changed (always include)	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date
Choose type	If Other, provide explanation	Start date	End date

♦MCOs: You must reauthorize Community Service Coordination for 12 months with each Annual Service Plan.♦

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: Enter zip code

Estimated monthly cost: *$0.00	(34 hours x $40) / 3 = $453.33 *Enter this amount in estimated monthly cost if participant will receive Pre-Voc Services
Pre-Voc services are capped at 34 hours over a 3 month period. The participant will need reevaluated and another service plan completed if they require an extension of these hours.

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: Enter zip code

Estimated monthly cost: *$0.00	(34 hours x $32) / 3 = $362.66 *Enter this amount in estimated monthly cost if participant will receive IL Skills Training
IL Skills Training is capped at 34 hours over a 3 month period. The participant will need reevaluated and another service plan completed if they require an extension of these hours.

Transportation – Vendor/Agency invoice, Participant reimbursement, or PAS payment based on EVV

Vendor/Agency or Participant – Who is to be paid	Invoice or reimbursement?	Description/details of transportation – Monthly cost, capped amount, bus, pass, etc. (Receipt required for reimbursement and an invoice needs # of provided trips.)	Monthly Cost
Vendor/Agency	Choose method	Description	$0.00
Vendor/Agency	Choose method	Description	$0.00
Vendor/Agency	Choose method	Description	$0.00
PAS	PA Hourly	Description/details of transportation	Cost per hour	Number of hours per month	0.00
PAS	Hourly - EVV	Description	$15.00	$ 0.00
PAS	Hourly - EVV	Description	$15.00	$ 0.00
PAS	Hourly - EVV	Description	$15.00	$ 0.00
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: Enter zip code

SE Hours per month: *up to 13.25/month	SE Cost per hour: $50.00
Monthly SE support cost: $ 0.00

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: Enter zip code

# of assessed monthly PAS hours: Total nights per month: $85/night Monthly cost of PAS services: $ 0.00 Monthly Enhanced 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 participant.**

Enhanced Services (ES) – Agency-Directed (if the provider agency is different than above OR if the participant is self-directing PAS and using agency ES)

PAS Agency: Provider name	Phone #: Include area code	Email: Enter email

Provider address: Street address	City, State: City, State	Zip code: Enter zip code

Total nights per month:	$85/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.

Personal Assistance Services (PAS) – Self-Directed

Total monthly assessed PA hours: Enter hours

Name of PA and relationship to the participant	Total hours per month	Hourly wage	Cost to employer/hour	Total cost per month
First and last name	Choose one.	$16.50	$ 0.00
First and last name	Choose one.	$16.50	$ 0.00
First and last name	Choose one.	$16.50	$ 0.00
First and last name	Choose one.	$16.50	$ 0.00
First and last name	Choose one.	$16.50	$ 0.00
First and last name	Choose one.	$16.50	$ 0.00
Total	$ 0.00

Enhanced Services – Self-Directed – $85/night

Total nights per month: Enter nights

Name of PA and relationship to the participant	Total nights per month	Total cost per month
First and last name	Choose one.	$ 0.00
First and last name	Choose one.	$ 0.00
First and last name	Choose one.	$ 0.00
First and last name	Choose one.	$ 0.00
First and last name	Choose one.	$ 0.00
First and last name	Choose one.	$ 0.00
Total	$ 0.00

Supplemental Services – Services in place of PAS hours

Vendor/Agency – Who is to be paid	Category of service – meal services, PERS, or Med minder	Description/details of service(s) provided – Example: breakdown of meals = $6.04 x how many meals, etc.	Monthly Cost
Vendor/Agency	Category	Service Code	Description	1-time cost? $0.00 Service code	$0.00
Vendor/Agency	Category	Service Code	Description	1-time cost? $0.00 Service code	$0.00
Vendor/Agency	Category	Service Code	Description	1-time cost? $0.00 Service code	$0.00
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.♦

♦You must use a fresh copy of this Service Plan each time it needs revised to prevent remnant data from corrupting the calculations.♦

Monthly Cost	Units/hours	Service Code
Pre-Vocational Services	$ 0.00	# of hours	T2047 U3
Independent Living Skills Training	$ 0.00	# of hours	H2014 U3
Supported Employment	$ 0.00	# of hours	H2023 U3
Transportation	$ 0.00	# of hours if applicable	T2003 U3
PAS - Agency-directed	$ 0.00	# of hours	S5125 U3
PAS - Self-directed	$ 0.00	# of hours	S5125 U5
Supplemental Services (only available with PAS)	Enhanced Services	$ 0.00	# of nights	T2025 U3
Home-Delivered Meals	$0.00	*Copy from above if applicable	# of meals	S5170 U3
PERS (1 unit if needed)	$0.00	*Copy Monthly Fee from above if applicable	Enter unit	S5161 U3
Medication Reminder/Dispenser (1 unit if needed)	$0.00	*Copy Monthly Fee from above if applicable	Enter unit	T1505 U3
Total Monthly Cost	$ 0.00
1-Time Costs
PERS Install	$0.00 *Copy from above if applicable	S5160 U3
Medication Reminder/Dispenser Install	$0.00 *Copy from above if applicable	T1505 U5

STEPS Service Plan Agreement

I agree:

To follow the STEPS Program Policy Manual.

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.

Participant/Representative Signature	Date

Approval Signature of MCO	Date