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Fill in Your Individual Service Plan Wisconsin Template

The Individual Service Plan (ISP) in Wisconsin is a critical document used in Medicaid Waiver programs to outline the specific services and supports an individual requires. This plan is tailored to meet the unique needs of each participant, ensuring they receive appropriate care in their preferred living environment. Understanding the ISP is essential for individuals and families navigating long-term care options in Wisconsin.

Table of Contents

The Individual Service Plan (ISP) in Wisconsin is a crucial document designed to outline the specific needs and services required for individuals enrolled in Medicaid waiver programs. This form serves as a roadmap for care, detailing essential information such as the individual's name, address, and Medicaid ID, as well as the type of waiver program they are participating in. It includes sections for documenting the individual's living arrangements, support coordinators, and service providers, ensuring that all parties involved have a clear understanding of the care plan. Notably, the ISP emphasizes the individual's rights and choices, allowing them to select from various services and providers tailored to their unique circumstances. Regular reviews and updates of the plan are mandated to ensure that the services remain relevant and effective, fostering an environment where individuals can thrive in their chosen living situations. Furthermore, the form includes provisions for emergency contacts and verification of participant rights, reinforcing the commitment to informed decision-making and advocacy for those receiving services. In essence, the ISP not only facilitates personalized care but also empowers individuals by placing them at the center of their service planning process.

Sample - Individual Service Plan Wisconsin Form

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

Individual’s Name

Address (street)

City, State, Zip Code

4b Date of Birth

Mailing Address (If Different)

Telephone

8 Initial Service Plan

9 Functional Screen

Development Date

Date

Cost Share Amount

Level of Care

12 Parental Fee (If

Personal Discretionary

14 [Reserved]

15 Start Up/One-

16 Waiver Cost/Day

Applicable)

Funds Available

Time Cost -Total

Total

Prior Living Arrangement-

Prior Living Arrangement-Name/Type

Current Living Arrangement-

20 Current Living Arrangement-Name/Type

HSRS Code (CLTS- N/A)

Waiver Agency

22 Agency Telephone

No.

Support & Service

Coordinator/Care Manager

24 SSC/CM Telephone

(SSC/CM)

No./Ext.

Mailing Address (Agency)

City

State

Zip

Mailing Address (SSC/CM)

E-mail Address (Agency)

E-mail Address (SSC/CM)

Name – Parent(s) or Guardian

Telephone No. (Home)

31 Telephone No. (Work)

Mailing Address (Street/PO Box)

City

State

35 Zip

E-mail Address

Telephone No. (Cell)

IN CASE OF EMERGENCY, NOTIFY:

Name

Telephone (Preferred/Primary No.)

Email Address

Address

42 City

State

Zip

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

Unit Cost ($/hr; day)

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	Date Signed

SIGNATURE – Guardian/Authorized Representative/Parent	Date Signed	SIGNATURE - Guardian/Authorized Representative/Parent	Date Signed

SIGNATURE - Witness	Date Signed	SIGNATURE – Witness	Date Signed

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.

SIGNATURE - Participant	Date Signed	SIGNATURE – Support and Service Coordinator/Care Manager	Date Signed

SIGNATURE – Guardian/Authorized Representative/Parent	Date Signed	SIGNATURE - Guardian/Authorized Representative/Parent	Date Signed

SIGNATURE - Witness	Date Signed	SIGNATURE – Witness	Date Signed

DISTRIBUTION: Original – DHS; Copy - County Care Manager/Support and Service Coordinator; Copy – Individual; Copy - Legal Representative

↓ Individual Service Plan Wisconsin PDF

File Specs

Fact Name	Description
Form Purpose	The Individual Service Plan (ISP) form is used to outline the services and supports available to individuals under Medicaid Waivers in Wisconsin.
Governing Law	This form is governed by Wisconsin Statutes Chapter 46, which pertains to the provision of long-term care services and supports.
Review Frequency	Participants must undergo a six-month review of their ISP to ensure that services remain appropriate and effective.
Participant Rights	Individuals have the right to choose their services and providers, as well as the right to request a hearing if they disagree with eligibility or service decisions.

Individual Service Plan Wisconsin - Usage Guidelines

Completing the Individual Service Plan (ISP) Wisconsin form is a crucial step in ensuring that individuals receive the appropriate services and supports they need. Following the steps outlined below will help streamline the process and ensure that all necessary information is accurately captured.

Identify the Waiver Program: Begin by selecting the appropriate waiver program from the options provided at the top of the form.
Specify the Plan Type: Indicate whether this is a new plan, recertification, or a six-month review.
Enter Current ISP Date: Fill in the date of the current Individual Service Plan.
Provide Medicaid ID or MCI: Enter the Medicaid identification number or the MCI number, as applicable.
Complete Individual’s Information: Fill in the individual's name, address, city, state, zip code, and date of birth.
Mailing Address: If the mailing address differs from the residential address, provide it here.
Contact Information: Enter the individual's telephone number and email address.
Initial Service Plan: Indicate if this is the initial service plan.
Functional Screen Development Date: Fill in the date when the functional screen was developed.
Cost Share Amount: If applicable, indicate the cost share amount for services.
Level of Care: Specify the level of care required by the individual.
Parental Fee: If applicable, provide the parental fee information.
Personal Discretionary Funds: Indicate the amount of personal discretionary funds available.
Prior Living Arrangement: Describe the individual's prior living arrangement, including the name/type and HSRS code.
Current Living Arrangement: Provide details about the current living arrangement, including the name/type and HSRS code.
Waiver Agency Information: Enter the name and telephone number of the waiver agency.
Support & Service Coordinator/Care Manager Details: Fill in the name, telephone number, and mailing address of the Support & Service Coordinator or Care Manager.
Emergency Contact: Provide the name, telephone number, email address, address, and relationship of the emergency contact.
Service Codes and Provider Information: For each service, enter the service code, name, provider name, address, telephone number, start date, end date, unit cost, and authorized units of service.
Participant Rights: Ensure that the participant acknowledges their rights and choices regarding services.
Update/Review Verification: If applicable, indicate whether the six-month review was completed and if there are any changes to the ISP.
Signatures: Collect signatures from the participant, Support & Service Coordinator, guardian, and witnesses as required.
Distribution: Make copies of the completed form for distribution as outlined at the end of the document.

Your Questions, Answered

What is the Individual Service Plan (ISP) Wisconsin form?

The Individual Service Plan (ISP) Wisconsin form is a document used to outline the services and supports needed for individuals enrolled in Medicaid waiver programs. It details the participant's needs, preferences, and the services they will receive to ensure their well-being and quality of life.

Who needs to complete the ISP form?

The ISP form must be completed for individuals who are applying for or are already enrolled in Medicaid Home and Community-Based Services (HCBS) programs. This includes participants in various waiver programs, such as CIP II, CLTS, and others.

What information is required on the ISP form?

The ISP form requires detailed information, including the individual's name, address, Medicaid ID, date of birth, current living arrangements, and contact information for the participant and their support coordinator. It also includes specific service codes, service providers, and details about the services being provided.

How often should the ISP be reviewed?

The ISP should be reviewed at least every six months. During this review, the participant or their guardian will discuss any changes in needs or services. If updates are necessary, they will be documented on the form.

What rights do participants have regarding their ISP?

Participants have the right to choose between various service options, including community services or institutional care. They can select from qualified providers and are informed of their rights and responsibilities within the Medicaid waiver programs. Participants also have the right to request a hearing if they disagree with decisions regarding their eligibility or services.

What happens if changes are needed in the ISP?

If changes are required, the support coordinator will work with the participant or guardian to update the ISP. This may involve adding, reducing, or changing the frequency of services. The updated information will be documented on the ISP form.

Who signs the ISP form?

The ISP form must be signed by the participant, their guardian or authorized representative, and the support and service coordinator. Witness signatures may also be required. These signatures indicate agreement with the content of the plan and the services to be provided.

What is the purpose of the cost share amount listed on the ISP?

The cost share amount reflects any financial contribution that the participant may need to make toward their care. This amount is determined based on the individual’s financial situation and is included in the ISP to ensure transparency regarding funding for services.

Where is the completed ISP form submitted?

The completed ISP form is submitted to the Department of Health Services (DHS) and copies are provided to the county care manager or support coordinator, the individual, and their authorized representative. This ensures that all parties involved have access to the most current service plan.

Common mistakes

Incomplete Personal Information: Failing to provide all required personal details, such as the individual's name, address, and date of birth, can lead to delays in processing the form.
Incorrect Medicaid ID: Entering an incorrect Medicaid ID or MCI number can result in significant issues with eligibility verification.
Missing Signatures: Not obtaining all necessary signatures, including those of the participant, guardian, and care manager, can invalidate the form.
Omitting Service Details: Failing to specify the services required, including start and end dates, can lead to confusion and unmet needs.
Ignoring Cost Share Information: Neglecting to fill out the cost share amount can complicate financial assessments and service delivery.
Not Updating Changes: Failing to document changes during six-month reviews can result in outdated service plans that do not reflect current needs.
Inaccurate Emergency Contact Information: Providing incorrect or outdated emergency contact details may hinder timely assistance in critical situations.
Neglecting Participant Rights: Not reviewing or acknowledging the participant's rights and choices can lead to misunderstandings about their options.
Ignoring Agency Information: Omitting or incorrectly entering the waiver agency's contact information can delay communication and support.

Documents used along the form

The Individual Service Plan (ISP) Wisconsin form is a vital document used in the Medicaid waiver process to outline the services and supports an individual requires. Alongside this form, several other documents are commonly utilized to ensure a comprehensive approach to service delivery. Each of these documents plays a crucial role in supporting the individual’s needs and preferences.

Functional Screen: This document assesses an individual's needs and determines their eligibility for services. It evaluates various factors, including physical and mental health, daily living skills, and support requirements. The results help in developing a tailored service plan.
Service Authorization Form: This form is essential for approving specific services outlined in the ISP. It details the type of services, duration, and frequency, ensuring that providers have the necessary authorization to deliver the agreed-upon supports.
Emergency Contact Form: This document lists critical contact information for family members or guardians in case of an emergency. It ensures that essential individuals can be reached quickly, facilitating timely support when needed.
Rights and Responsibilities Acknowledgment: This form informs individuals about their rights and responsibilities within the Medicaid waiver program. It serves as a record that the individual understands their options and the services available to them, promoting informed decision-making.

Each of these documents complements the Individual Service Plan, creating a robust framework for delivering personalized care. Together, they ensure that individuals receive the support they need while respecting their rights and preferences.

Similar forms

The Individualized Education Program (IEP) is a document similar to the Individual Service Plan in Wisconsin. It is specifically designed for children with disabilities and outlines the educational goals and services that will be provided to support their learning. Like the Individual Service Plan, the IEP is developed collaboratively with input from parents, teachers, and specialists. Both documents emphasize the importance of tailoring services to meet the unique needs of the individual, ensuring that they receive appropriate support in their respective environments.

The Personal Support Plan (PSP) also shares similarities with the Individual Service Plan. The PSP is often used for individuals with developmental disabilities and focuses on enhancing their quality of life through personalized support. Both plans involve a comprehensive assessment of the individual's needs and preferences, and they serve as a roadmap for the services and supports required. The collaborative approach in both documents ensures that the individual's voice is heard and prioritized in the planning process.

The Service Plan for Home and Community-Based Services (HCBS) is another document akin to the Individual Service Plan. This plan is tailored for individuals who require assistance in their homes or community settings due to disabilities or health concerns. Like the Individual Service Plan, the HCBS Service Plan outlines specific services, goals, and support strategies, emphasizing the individual's right to choose their preferred services and providers. Both documents aim to promote independence and enhance the individual's ability to live in the community.

The Comprehensive Assessment and Service Planning (CASP) document is also comparable to the Individual Service Plan. The CASP is utilized in various healthcare settings to assess an individual's needs comprehensively. It includes input from healthcare providers, family members, and the individual themselves. Similar to the Individual Service Plan, the CASP focuses on identifying strengths and challenges, guiding the development of a tailored support plan that addresses the individual's unique circumstances.

The Treatment Plan, commonly used in mental health services, bears resemblance to the Individual Service Plan as well. It outlines the therapeutic goals and interventions for individuals receiving mental health support. Both documents are developed collaboratively, with input from the individual and their support team. They share the common goal of providing targeted services that promote recovery and well-being, ensuring that the individual's needs and preferences are central to the planning process.

Finally, the Individualized Family Service Plan (IFSP) is another document similar to the Individual Service Plan. The IFSP is specifically designed for infants and toddlers with developmental delays and their families. It focuses on the child's developmental needs and the family's resources and supports. Like the Individual Service Plan, the IFSP emphasizes collaboration among family members and service providers, ensuring that the child's needs are met holistically and that the family is actively involved in the planning and implementation of services.

Dos and Don'ts

When filling out the Individual Service Plan (ISP) Wisconsin form, it is essential to follow specific guidelines to ensure accuracy and compliance. Below are key actions to take and avoid:

Do ensure all personal information is accurate. Double-check the individual's name, address, and Medicaid ID to prevent delays in processing.
Do provide clear and detailed descriptions of services. Clearly outline the services required, including start and end dates, to facilitate proper support.
Do review participant rights and choices. Make sure the participant understands their rights to choose services and providers.
Do obtain all necessary signatures. Ensure that all required parties sign the document to validate the plan.

Don't leave any sections blank. Incomplete forms can lead to processing issues or delays.
Don't provide vague descriptions. Avoid using general terms; specificity is crucial for effective service planning.
Don't forget to keep copies. Always retain copies of the completed form for personal records and future reference.
Don't rush the process. Take the time to thoroughly review the form before submission to ensure accuracy.

Misconceptions

Misconceptions about the Individual Service Plan (ISP) Wisconsin form can lead to confusion regarding its purpose and function. The following are six common misconceptions:

The ISP is only for individuals with severe disabilities. Many believe that the ISP is exclusively for those with significant disabilities. However, it is designed for a wide range of individuals who require support, regardless of the severity of their condition.
Once completed, the ISP cannot be changed. Some individuals think that the ISP is a static document. In reality, it can be updated and reviewed regularly to reflect changes in the individual's needs or circumstances.
The ISP is only a financial document. While the ISP does include financial information, its primary purpose is to outline the services and supports an individual needs. It focuses on the person’s goals, preferences, and the resources required to achieve them.
Participants have no input in the ISP process. There is a misconception that the ISP is created without the participant's involvement. In fact, individuals are encouraged to actively participate in the development and review of their plan to ensure it meets their needs.
The ISP guarantees services will be provided immediately. Some people believe that completing the ISP guarantees immediate access to services. However, availability of services depends on various factors, including funding and provider availability.
The ISP is a one-time requirement. Many assume that once the ISP is completed, it does not need to be revisited. In truth, regular reviews and updates are necessary to ensure the plan remains relevant and effective over time.

Key takeaways

Filling out the Individual Service Plan (ISP) Wisconsin form is an important step in accessing Medicaid waiver services. Here are some key takeaways to keep in mind:

Understand the Purpose: The ISP outlines the services and supports an individual will receive, ensuring they meet their unique needs.
Complete All Sections: Fill out every section of the form accurately. Missing information can delay the approval process.
Review Rights and Choices: Participants should be informed about their rights, including the choice between nursing home care and community services.
Document Emergency Contacts: Include reliable emergency contacts. This information is crucial for ensuring safety and quick response in case of emergencies.
Keep a Copy: After submitting the form, retain a copy for personal records. This will help in future reviews or updates.
Regular Reviews: The ISP requires regular updates and reviews, typically every six months, to ensure services remain appropriate.
Involve Key Stakeholders: Engage family members or guardians in the process. Their insights can help tailor the services to the individual’s needs.
Know Your Rights: If there are disagreements regarding eligibility or service provision, participants have the right to request a hearing.

By keeping these points in mind, individuals and their families can navigate the ISP process more effectively, ensuring access to the necessary services and supports.