Free Instructions - Individual Service Plan - Medicaid Waivers - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20445I (08/2008)

STATE OF WISCONSIN

INSTRUCTIONS ­ INDIVIDUAL SERVICE PLAN ­ MEDICAID WAIVERS
No. Title Description

1

Waiver Program Plan Type

1a

2 3 4 4a 4b 5 6 7 8

Medicaid ID Number Individual's Name Address (street) City, State Zip code Mailing address (if different) Telephone E- Mail Service Plan Development Date Functional Screen Date Cost Share Amount

The Waiver program in which person is enrolled. Check only one of the Medicaid Waivers listed in the field. "New" refers to persons who are first enrolling in the waiver; "Annual Recertification" refers to a new plan updated by at least having new signatures and submitted to comply with waiver recertification requirements; "Update" means the plan replaces an earlier plan and shows some form of change such as in the type of services to be received by the participant or that there has been a change in provider. "CLTS Crisis" refers to plans associated with crisis slots only in CLTS waivers. "CLTS Pilot" applies only to the CLTS Waiver. Enter the 10 digit Medicaid number assigned to the person listed on the plan. Enter his/her full legal last name, first name, middle initial and suffix (e.g., Jr.) The place where the waiver applicant/participant resides. Use 5 digit code The address the person receives personal mail if different from where they reside. The area code and telephone number at the place the person resides. The e-mail address of the participant. If the person does not have an e-mail, another e-mail address that can be used to transmit e-mail messages. The date on which the service planning process was initiated and the initial service plan was accepted by all parties involved in its development. Note: This is the earliest date on which waiver services may begin. Enter the Long Term Care Functional Screen completion date. The amount of money the waiver participant must contribute to the cost of waiver-covered services each month. The amount is based on the F-20919 Form or CARES. Excludes parental fee (See Field No. 12). The level of care as determined by the long term care functional screen (Adult or Children's LTC-FS) or the approved BIW level of care. The amount parents are required to contribute to the overall cost of waiver covered services for their dependant child. Applies to all Waivers that serve children. The amount of the individual's personal funds available to the individual for use to pay for non-waiver personal discretionary items and services such as recreational activities. The use of these funds is determined by the waiver participant and/or authorized by their guardian, if any and not by the county or the provider. These funds may be managed by a third party rather than by the county or the waiver service provider. This amount is what remains after the participant pays for the actual cost of their room and board at their residence. The use of this field changes with the time period to which the plan applies. START UP COSTS When the waiver participant starts on the waiver, field 15 in the person's initial individualized service plan is to be used for "start up" costs. At this point in time, these may include one time costs for items needed for the person to live in the community or for services necessary to plan and implement plans that occur prior to the point the person starts on the waiver. Such services must be covered by the waiver but delivered, not more than 90 days or 180 days, depending on the applicable waiver, (See waiver manual, Chapter IV for details.) prior to the person's waiver plan development date.

9 10

11 12 13

Level of Care Parental fee (if applicable) Personal Discretionary Funds

14 15

Reserved for Future Use Start Up/One Time Costs Total

F-20425I Page 2 No. Title Description

Start up costs must be included in the person's initial individual service plan during an episode of services to be eligible for reimbursement and may not be included in subsequent plans during the current episode of services. The initial plan is defined as the plan that takes effect on the "service plan development date" of an episode of services. Start up costs listed in the participant's initial plan are limited to waiver covered services necessary for the person to start community services and live in the community. Include all start up costs in field 15 including costs incurred under any services such as housing start up, support and service coordination and any of the services that involve the purchase of items such as home modifications and adaptive aids. Also includes costs for initial consultations/evaluations needed from various experts such as behavior specialists, occupational/physical therapists, etc. when the person first moves from an institution and the cost of approved specialized training. ONE-TIME COSTS In all plans after the first plan, field 15 must be used for one-time costs only. Onetime costs are defined as costs incurred after the initial plan that pay for items or services that are anticipated to be purchased on a one time or time-limited basis and which are not anticipated to continue or recur. One-time costs are typically items used as adaptive aids, home modifications done after a services have been provided or for time limited consultations needed to respond to a transitory situation that, when resolved, will not need to be addressed with the subject services. Do not include one-time costs for items such as adaptive equipment here if the item is covered or is expected to be covered by the Medicaid card (state plan). Items or services covered by Medicaid or other non-waiver sources (e.g., COP) need be specified in the plan using fields 63-69 for each such one time item or service. The recurring cost of maintaining equipment purchased and used as an adaptive aid cited should be considered to be ongoing costs and not included in this field. The amount entered in this field should be in total dollars and is not expressed as a cost per day. The totals should be the amount anticipated for the period covered by the current plan. The total cost of the ongoing waiver-covered services listed in Field 68 of the service plan. Do not include any start up, one-time or administrative costs that may be claimed by the agency during the current year or at the end of the year in this total. The type of residence in which the person resided immediately prior to their start in the Waiver. The type of residence in which the person is expected to reside when he or she begins waiver services. The name of the county, tribal or contract agency currently responsible for managing the individual's waiver services. A change in this element requires the submission of a revised/updated service plan. The phone number which the agency identifies as the primary number to use to contact agency staff/officials about this individual.

16

Waiver Cost/Day Total

17/ 18 19/ 20 21

HSRS code/Prior Living Arrangement-Name/Type HSRS code/Current Living Arrangement- Name/Type Waiver Agency (Waiver Contact) Agency Telephone No.

22

F-20445I Page 3 No. Title Description

23

24

25 26 27 28 29

Support & Service Coordinator/Care Manager Name Support & Service Coordinator/Care Manager Telephone numbers: Office and Cell Mailing Address (Agency) Mailing Address of SSC/CM E-mail address of Agency E-mail address of SSC/CM Name- Parent(s) or Guardian

Include area code

Include zip code Include zip code

30 31 32 33 34 35 36 37

38 39 40 41 42 43 44 45 62

Telephone No. (Home) Telephone No. (Work) Mailing Address (Street/ PO Box) City State Zip Code E-mail address Telephone No. (Cell) IN CASE OF EMERGENCY NOTIFY: Name Telephone No. (Home) Telephone No. (Work) Address City State Zip Relationship Service/SPC Code number

If the participant is a minor, list the guardian if the guardian is different than the parent. If there is no guardian, list the parent. For adults, always list the guardian if there is a guardian or enter the word "self" if the person is his or her own guardian. Include area code Include area code

Include area code

Name of the person designated as the waiver participant's emergency contact. (include area code) (include area code)

63

Service/SPC Name/ Informal Supports Outcome Number Service Provider Name, Mailing address, Phone (Include E-mail address, Cell phone number, if known) Start Date

64 65

Word that best describes how the emergency contact is related (family, friend, family friend, neighbor, etc) to the participant. The three or five digit SPC code assigned to the particular service listed in the plan using the HSRS codes. This code only applies to services that are covered by the waiver. Medicaid card (State Plan) services and informal supports do not have an HSRS SPC number. The name of the service being planned for the participant. Use the HSRS name or, if the service is not a waiver service, a name that describes the type of service planned. This field should also include all informal supports. From the F-20445a (Field 5), enter the number of the individual outcome that this service is provided to meet. The individual/agency name of the service provider. Use the name that appears on any license or certification if any.

65A

65B

End Date

The date on which approved services are to begin. See Medicaid Waiver Manual for instructions on this definition. http://dhs.wisconsin.gov/bdds/waivermanual/index.htm The date on which the identified services will stop (if applicable).

F-20445I Page 4 No. Title Description

66

Unit Cost and type ($/hour; day)

67

68 69

Authorized Units of Service and Frequency (#/day, week or month) Daily Cost Funding Source including cost share

The cost per unit of service for the service provided. Consult HSRS (desk card or handbook) for the types of units assigned to each Waiver covered service. http://dhs.wisconsin.gov/HSRS/index.htm For Medicaid card services, use the billing rate anticipated to be received. The number of units of service the county authorizes for this participant during a specified period of time. (E.g., days per month authorized for adult family home). The total cost of the Waiver, Medicaid, COP or other program funded service, annualized, divided by 365 days. Enter any of the funding sources listed here. If the funding source is not on the list, write in other and explain or list the source. Includes: Medicaid Card, BIW-state match, BIW-local match, CIP 1A-State, CIP 1A-Local, CIP 1B-State, CIP 1B-Local, CLTS-DD, CLTS-MH, CLTS-PD, COPW/CIP II, COP, COR, Community Aids (CA), Cost share, participant funds (SSA, SSI, etc.) and local sources listed below. NOTE: Any funding source that includes the word local means there are county sources of funds that are being used to match the federal funds. After the word local, the specific source of the match must be identified. The following local sources of funds may be used for local match or may also fund services that are not covered by the waiver but are being provided and listed in the plan: Act 405, Family Support Program (FSP), CA, COP or County general fund revenues derived from such sources as local property tax and local sales tax. Summary of notifications: Right to choose waiver program/institutional services. Notification of participant rights and responsibilities. Notifications must be given to all applicants/participants verbally and in writing. The Waiver program participant signature is required if participant is age 14 or over and the person is capable of signing the form. Date the plan was signed by the participant.

70

Notifications

Participant Signature Date Signed Parent/Guardian/Authorized Representative Signature Date Witness Signature (identify) Date Witness Signature (identify) Date Support & Service Coordinator Care Manager Signature Date

Date the plan was signed by the guardian or authorized representative. Date the plan was signed by the witness. Date the plan was signed by the witness.

Date the plan was signed by the support and service coordinator/ care manager.