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 Annual Assessment: Choose date	Date of Revised Assessment: Choose date
Service Plan Start Date	Service Plan End Date
Type Example: Annual, Revised Assessment, or Other change	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.♦

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
Estimated monthly cost: *$0.00	(34 hours x $40) / 3 = $453.33 *Enter this amount in estimated monthly cost if member will receive Pre-Voc Services
Remaining hours: (*Only if provider changes before hours are completely used)	Start Date: Start date	End Date: End date
Pre-Voc services are capped at 34 hours over a 3 month period. The member 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: Zip code
Estimated monthly cost: *$0.00	(34 hours x $32) / 3 = $362.66 *Enter this amount in estimated monthly cost if member will receive IL Skills Training
Remaining hours: (*Only if provider changes before hours are completely used)	Start Date: Start date	End Date: End date
IL Skills Training is capped at 34 hours over a 3 month period. The member will need reevaluated and another service plan completed if they require an extension of these hours.

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

Vendor/Agency or Member – Who is to be paid	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	Choose method	Description	$0.00
Vendor/Agency	Choose method	Description	$0.00
Vendor/Agency	Choose method	Description	$0.00
PAS – Use Provider Pay Rates for Service Plan chart for hourly wage (Same Start/End dates as PAS)	Description/details of transportation	# of hours per month	Hourly wage	Cost to employer/hr.	0.00
First and Last	Description	$15.00	$ 0.00
First and Last	Description	$15.00	$ 0.00
First and Last	Description	$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
SE Hours per month: *up to 13.25/month	SE Cost per hour: $50.00	Start Date: Start date	End Date: End date
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: Zip code
# of assessed monthly PAS hours: @ $16.50/hour	Total nights per month: @ $85/night (enter # manually on page 5)
Monthly PA Services cost: $ 0.00	Monthly Enhanced Services cost: $ 0.00
All PAS Start and End dates are on same timeline as Pre-Voc, IL Skills, or Supported Employment
♦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 (if the provider agency is different than above OR if the member is self-directing PAS and using agency ES{rare})

PAS Agency: Provider name	Phone #: Include area code	Email: Enter email
Provider address: Street Address	City, State: City, State	Zip code: Zip code
Total nights per month: @ $85/night (enter # manually on page 5)	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:	All PAS Start and End dates are on same timeline as Pre-Voc, IL Skills, or Supported Employment
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	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 hours:	0	Total cost:	$ 0.00

Enhanced Services – Self-Directed – $85/night

Total nights per month: 1 (enter # manually on page 5)	All PAS Start and End dates are on same timeline as Pre-Voc, IL Skills, or Supported Employment
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	Choose one.	$85.00	$ 0.00
First and last name	Choose one.	$85.00	$ 0.00
First and last name	Choose one.	$85.00	$ 0.00
First and last name	Choose one.	$85.00	$ 0.00
First and last name	Choose one.	$85.00	$ 0.00
First and last name	Choose one.	$85.00	$ 0.00
Total nights:	0	Total cost:	$ 0.00

Supplemental Services – Services in place of PAS hours (only available for members who qualify for PAS services)

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. (enter # of units manually on page 5)	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
*MCOs – Supplemental Services should be authorized for at least 6 months or up to 1 year based on initial plan Start Date.	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.♦

♦Some information must be entered manually by the Community Service Coordinator.♦

♦Please ensure that all manually entered Monthly Hours/Units are correct, where applicable.♦

Monthly Cost	Number of Hours or Units	Service Code
Pre-Vocational Services *CSC – Enter 34 as monthly hours unless provider changed then enter remaining hours	$ 0.00	# of hrs.	T2047 U3
Independent Living Skills Training *CSC – Enter 34 as monthly hours unless provider change then enter remaining hours	$ 0.00	# of hrs.	H2014 U3
Supported Employment	$ 0.00	0	H2023 U3
Transportation	$ 0.00	0	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 *CSC – Copy monthly cost & # of meals from above if applicable	$0.00	# of meals	S5170 U3
PERS (1 unit if needed) *CSC – Copy monthly cost from above if applicable	$0.00	Enter unit	S5161 U3
Med Minder/Dispenser (1 unit if needed) *CSC – Copy monthly cost from above if applicable	$0.00	Enter unit	T1505 U3
Total Monthly Cost	$ 0.00
1-Time Costs
PERS Install *CSC – Copy 1-time cost from above if applicable	$0.00	S5160 U3
Medication Reminder/Dispenser Install *CSC – Copy 1-time cost from above if applicable	$0.00	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.

Member/Representative Agreement Signature	Date

MCO Service Plan Approval Signature	Date