The Individual Service Plan (ISP) in Wisconsin is a crucial document used in Medicaid waiver programs to outline the services and support an individual requires. This plan is tailored to meet the unique needs of each participant, ensuring that they receive appropriate care in their preferred living arrangement. Understanding the ISP process is essential for individuals and families navigating long-term care options.
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The Individual Service Plan (ISP) form in Wisconsin plays a crucial role in the Medicaid Waiver programs, ensuring that individuals receive tailored services that meet their specific needs. This comprehensive document captures essential information such as the individual's name, Medicaid ID, and current living arrangements. It also outlines the services provided, including start and end dates, unit costs, and authorized units of service. The ISP emphasizes the participant's rights, allowing them to choose between various service options and providers. Additionally, it includes a section for emergency contact information and verification of updates or reviews, ensuring that the plan remains relevant and effective. Understanding this form is vital for participants and their families, as it directly impacts the quality and type of care they receive through community-based services.
The Individual Service Plan (ISP) Wisconsin form is designed to outline the specific services and supports that an individual will receive under the Medicaid Waiver programs. This form is essential for ensuring that individuals with disabilities or long-term care needs have access to the services that best meet their unique circumstances. It serves as a roadmap for care, detailing everything from the types of services to be provided, to the frequency and duration of those services.
The ISP form is typically completed by a Support and Service Coordinator or Care Manager. This professional works closely with the individual and, if applicable, their guardian or family members to gather necessary information and preferences. It is crucial that all parties involved have a voice in this process, as the plan should reflect the individual’s needs, preferences, and goals.
The ISP form requires a variety of information to ensure comprehensive planning. This includes:
Each of these components is vital for creating a personalized and effective service plan.
The ISP should be reviewed at least every six months, or more frequently if there are significant changes in the individual's needs or circumstances. Regular reviews ensure that the services provided remain relevant and effective. During these reviews, the Support and Service Coordinator will discuss any necessary adjustments to the plan, ensuring that it continues to meet the individual's evolving needs.
When filling out and utilizing the Individual Service Plan (ISP) Wisconsin form, several important aspects should be considered to ensure a smooth process. Here are key takeaways:
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Understanding the Individual Service Plan (ISP) in Wisconsin can be challenging, and several misconceptions often arise. Here are four common misunderstandings regarding this important document:
Addressing these misconceptions is vital for ensuring that individuals and their families fully understand the purpose and functionality of the Individual Service Plan in Wisconsin. Clarity in this area can lead to better outcomes and a more personalized approach to care.
DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSIN
Division of Long Term Care
F-20445 (07/2014)
INDIVIDUAL SERVICE PLAN – MEDICAID WAIVERS
1 Waiver Program
1a Plan Type
1b Current ISP Date
2 Medicaid ID or MCI
CIP II
CIP II CRI.MFP
CIP II-DIV
COP-W
New
Recertification
Number (as applicable)
Six Month Review
CIP 1A
CIP 1B
CLTS
ISP Update
3
Individual’s Name
4
Address (street)
4a
City, State, Zip Code
4b Date of Birth
5
Mailing Address (If Different)
6
Telephone
7
Email
8 Initial Service Plan
9 Functional Screen
Development Date
Date
10
Cost Share Amount
11
Level of Care
12 Parental Fee (If
13
Personal Discretionary
14 [Reserved]
15 Start Up/One-
16 Waiver Cost/Day
Applicable)
Funds Available
Time Cost -Total
Total
17
Prior Living Arrangement-
18
Prior Living Arrangement-Name/Type
19
Current Living Arrangement-
20 Current Living Arrangement-Name/Type
HSRS Code (CLTS- N/A)
21
Waiver Agency
22 Agency Telephone
No.
23
Support & Service
Coordinator/Care Manager
24 SSC/CM Telephone
(SSC/CM)
No./Ext.
25
Mailing Address (Agency)
City
State
Zip
26
Mailing Address (SSC/CM)
27
E-mail Address (Agency)
28
E-mail Address (SSC/CM)
29
Name – Parent(s) or Guardian
30
Telephone No. (Home)
31 Telephone No. (Work)
32
Mailing Address (Street/PO Box)
33
34
35 Zip
36
E-mail Address
37
Telephone No. (Cell)
IN CASE OF EMERGENCY, NOTIFY:
38
Name
39
Telephone (Preferred/Primary No.)
40
Email Address
41
Address
42 City
43
44
45 Relationship
F-20445 Page 2
62 Service Code #
63 Service Name
64
65
Outcome No.
Service Provider Name Address and
(F-20445A #5)
Telephone No.
(Email, cell phone no., if known)
65a
Start Date
65b
End Date
66
Unit Cost ($/hr; day)
67
Authorized Units of Service and Frequency
(#/day or week or month)
68
69
Daily Cost (total
Funding
yearly ÷ 365 days)
Source
70 PARTICIPANT INFORMED – R IGHTS AND CHOICE (Review REQUIRED at initial plan development and recertification.)
I have been informed that I have a RIGHT TO CHOOSE between a nursing home or ICF-IDD and community services through a Medicaid Home and Community Based Service Program.
I have been informed of my CHOICES in the waiver programs, including my right to CHOOSE the TYPE OF SERVICES I receive under my service plan.
I understand that I have CHOICES in the waiver programs, including my right to CHOOSE from available, qualified providers that will provide the services outlined in my plan.
I have been informed verbally and in writing of my rights and responsibilities in the Medicaid Waiver Programs and I understand these rights and responsibilities.
I have been informed verbally and in writing of my RIGHT TO REQUEST A HEARING should I disagree with decisions made about my ELIGIBILITY to participate in the HCBS program.
I have been informed verbally and in writing of my RIGHT TO REQUEST A HEARING should I disagree with decisions made that would DENY, REDUCE OR TERMINATE the services I receive.
By my signature below I indicate I have chosen to accept community services through a Medicaid Home and Community Waiver Program.
71 UPDATE/REVIEW VERIIFICATION - APPLIES TO PLAN REVIEW OR ISP UPDATE ONLY
The SIX MONTH ISP Review was completed with the participant/guardian on the date below and there are no changes to the ISP at this time.
The SIX MONTH ISP Review was completed with the participant/guardian on the date below and agreed upon changes to the ISP are included herein.
The ISP was UPDATED on the date below to reflect changes (additions, increases or reductions) to planned services or providers or to units/frequency of service.
SIGNATURES: ISP Signature Requirements apply at the time of plan development, review and recertification.
SIGNATURE - Participant
Date Signed
SIGNATURE – Support and Service Coordinator/Care Manager
SIGNATURE – Guardian/Authorized Representative/Parent
SIGNATURE - Guardian/Authorized Representative/Parent
SIGNATURE - Witness
SIGNATURE – Witness
DISTRIBUTION: Original – DHS; Copy - County Care Manager/Support and Service Coordinator; Copy – Individual; Copy - Authorized Representative
F-20445 Page 3B
CIP II/COP-W CBRF VARIANCE REQUEST [CHECK (√) THE TYPE OF VARIANCE REQUESTED) NOT APPLICABLE TO CIP 1A/B OR CLTS
A variance to the 20-bed CBRF size limitation for an individual that is elderly
A variance to allow waiver funding for an individual that is elderly to reside in a CBRF connected to a nursing home
BY SIGNING BELOW, THE SUPPORT AND SERVICE COORDINATOR / CARE MANAGER ATTESTS TO THE FOLLOWING:
1.The environment is non-institutional and the facility operates in a manner than enhances resident dignity and independence, and
2.The facility is the preferred residence of the applicant/participant or his/her legal representative.
DISTRIBUTION: Original – DHS; Copy - County Care Manager/Support and Service Coordinator; Copy – Individual; Copy - Legal Representative