CHAPTER 2

Structure and Background of the Ticket to Work Program

The ideas behind the TTW program are fairly simple, but the program itself has become fairly complex (Berkowitz 2003). The basic approach was developed by a panel formed by the National Academy for Social Insurance, which sought to make the rehabilitation system more effective by paying providers only when they enabled a beneficiary to earn his or her way off the rolls. The panel’s entire concept was summarized in the following few sentences:

Under the Panel’s plan, disability beneficiaries would receive a return-to-work ticket, akin to a voucher, that they could use to shop among providers of rehabilitation or return-to-work services in either the public or private sector. Once a beneficiary deposits the ticket with a provider, the Social Security Administration would have an obligation to pay the provider after the beneficiary returned to work and left the benefit rolls. Providers whose clients successfully returned to work would, each year, receive in payment a fraction of the benefit savings that accrued to the Social Security Trust Funds because the former beneficiary is at work and not receiving benefits (Mashaw and Reno 1996).

However, as this idea was translated into practice, the actual program became fairly complicated. Eligibility rules were established to avoid paying for services to beneficiaries who were expected to medically recover and exit the rolls anyway or for SSI recipients who had recently turned 18 but who had not yet been determined eligible for SSI as adults. Milestone payments were introduced to help providers finance services and encourage them to serve beneficiaries who would not be expected to leave the rolls quickly. Payment amounts were tied to overall average benefit payments rather than to each individual’s benefits. Because average monthly SSI benefits are lower than average monthly DI benefits, the payments to ENs for serving SSI-only recipients are lower than those for serving DI beneficiaries. To resolve arguments between beneficiaries and providers, SSA established a dispute resolution process. The agency also created new computer systems to track program participation and exits due to earnings as well as to pay providers.

This chapter describes the structure of the TTW program as it is implemented today (late 2003), including the key groups and organizations involved; the rules that guide its operations; and the context in which it has been established, including the service and payment system it is replacing and related initiatives that may help the program succeed. This description gives an overview of how the program is intended to operate. The chapters that follow describe how each element was implemented. Livermore et al. (2003) provide information about earlier implementation.

 

A. BASIC STRUCTURE OF TICKET TO WORK

This section begins with an overview of the roles and responsibilities of the major program stakeholders. It then describes the key processes and policies of the program, generally from the perspective of a beneficiary. It concludes with an explanation of the services that ENs provide and the program’s reimbursement policies.

 

1. Roles and Responsibilities of Major TTW Stakeholders

Conceptually, TTW is a fairly simple program. It begins with the disability beneficiaries who may, with varying degrees of assistance, be able to achieve economic self-sufficiency and thus leave the SSI or DI rolls. The program then revolves around two relationships. The first relationship involves the Ticket itself, which is essentially a promise of payment from SSA to an EN for providing services that move disability beneficiaries back to work and off the SSI/DI rolls. The second relationship, between a beneficiary and an EN, is governed by a voluntary agreement about services, called an Individual Work Plan (IWP). 1

 

Click here for Figure II.1

 

In reality, however, the success of the TTW program depends on multiple stakeholders carrying out many diverse and interrelated tasks according to specific rules and time frames. For instance, SSA provides a Ticket and related information to eligible beneficiaries and a list of those beneficiaries to the Program Manager. Beneficiaries take their Tickets to an EN, negotiate an IWP with the EN to specify a set of services that will get them working, and then participate in those services. Once they are employed, participants report their earnings to SSA and their EN; the earnings determine whether the beneficiary remains eligible for DI or SSI benefits and therefore help to determine the payments that ENs receive. ENs provide or arrange for services to beneficiaries and submit payment claims to the Program Manager. The Program Manager recruits ENs, notifies beneficiaries about ENs in their area, facilitates payments to ENs on behalf of SSA, and notifies SSA about any problems with EN performance. The responsibilities of the four major TTW stakeholders—SSA, the Program Manager, ENs, and beneficiaries—are identified below.

 

Click here for Figure II.2

 

a. SSA Responsibilities

SSA has overall responsibility for operating the TTW program. Within SSA, the Office of Employment Support Programs takes the lead, with substantial support from the Office of Information Management, the Office of Systems, and the Office of Operations, and additional support from numerous other SSA offices. Together, these various parts of SSA have the following responsibilities for the TTW program:

  1. Develop the program regulations
  2. Develop the systems within the agency to manage the program
  3. Develop the procedures required to administer the program
  4. Train SSA staff on the program procedures
  5. Identify all DI and SSI beneficiaries who are eligible to receive a Ticket
  6. Provide data on Ticket-eligible beneficiaries to the Program Manager
  7. Develop and update EN requests for proposals to recruit prospective ENs, and make EN contract awards
  8. Use a Government Printing Office contractor to mail a "Ticket Package" to every eligible beneficiary who lives in a state where TTW has been implemented
  9. Provide beneficiaries who contact SSA through its toll-free number or who visit an SSA field office with supplemental information on the TTW requirements and refer them to the Program Manager’s toll-free telephone number for more detailed information
  10. Inform beneficiaries of their rights and responsibilities when an EN elects to terminate an IWP after the EN has provided written notification to the beneficiary and the Program Manager, and the Program Manager has updated the SSA database
  11. Provide periodic opportunities for ENs to change their payment elections for prospective clients
  12. After receiving EN payment requests via the Program Manager, evaluate the work report for cash benefit effect, determine whether payment to the EN is appropriate, and authorize the appropriate payment amounts or deny the request

 

b. Program Manager Responsibilities

By law, the Program Manager is a private- or public-sector organization that enters into a contract to assist SSA in administering TTW. SSA may choose to contract with one or more entities to act as Program Manager(s). In September 2000, SSA contracted with MAXIMUS to serve as the Program Manager for a period of five years. The Program Manager is prohibited from directly participating in the delivery of employment services, vocational rehabilitation services, or other support services to beneficiaries with Tickets in the Program Manager’s designated service delivery area. The primary responsibilities of the Program Manager under TTW are to:

  1. Recruit and recommend potential ENs to SSA and ensure adequate service coverage in each state
  2. Design and maintain a system to collect, store, and report management information data supporting the TTW program
  3. Provide training on TTW to Program Manager staff, ENs, SVRAs, and SSA staff members
  4. Establish a toll-free telephone number through which to receive inquiries from beneficiaries, ENs, SVRAs, and other interested parties and provide detailed information on TTW program provisions
  5. Accept and process requests for Tickets on demand (that is, requests for Tickets by beneficiaries who live in a state where TTW has been rolled out but who have not yet been mailed a Ticket)
  6. Facilitate beneficiary access to ENs, including making lists of ENs available to beneficiaries and ensuring that information is in an accessible format
  7. Manage the Ticket assignment process by reviewing IWPs and resolving disputes between beneficiaries and ENs or SVRAs
  8. Ensure that beneficiaries have the ability to change ENs, and reassign Tickets based on beneficiaries’ choices
  9. Facilitate payments to ENs and ensure that they have complied with their SSA contract
  10. Monitor EN activities and inform SSA of problems with EN performance
  11. Monitor the selected ENs to ensure that service choices available to beneficiaries are adequate

 

c. Employment Network Responsibilities

Any interested entity may propose to serve as an EN for the TTW program, subject to approval by SSA. An EN may be a public or private organization, a single organization, or a consortium or organizations. Its scope may range from providing services in a single, small area to doing so nationwide. Employers may also become ENs. There is no limit on the number of ENs that may participate in TTW. It was anticipated that many organizations already serving persons with disabilities would step forward as ENs, but new organizations or existing organizations that have not previously provided a substantial set of services to people with disabilities may also participate. The primary responsibilities of ENs are to:

  1. Enter into an agreement with SSA
  2. Designate the geographic area(s) in which they will provide services, the types of services they will provide, and the types of beneficiaries they will serve.
  3. Select one of the two available payment systems (outcome or milestone-outcome)
  4. Provide the beneficiary with a comprehensive explanation of both the services they offer and the beneficiary’s responsibilities
  5. Verify Ticket-holder eligibility and whether any payments have been made to another EN
  6. Develop an IWP with each beneficiary and ensure that services provided are appropriate to the IWP
  7. Submit the appropriate documentation to the Program Manager, which assigns the Ticket
  8. Provide employment services, vocational rehabilitation services, or other support services to beneficiaries, either directly or by entering into agreements with other entities
  9. Submit claims for payments to the Program Manager with the documentation needed to support the claim for payment
  10. Notify the beneficiary and the Program Manager in writing when a beneficiary’s ticket is terminated

 

d. Beneficiary Responsibilities

To be eligible for a Ticket, a person must be receiving SSI or DI benefits and be between the ages of 18 and 64 (inclusive). Their impairments may be either permanent (improvement is not expected) or nonpermanent (improvement is either expected or cannot be accurately predicted). Two small groups (accounting for about six percent of all beneficiaries) are ineligible: (1) SSI beneficiaries who had been entitled to benefits under the childhood regulations but who have very recently turned 18 and have not undergone the process to determine whether they are disabled under the adult eligibility criteria and (2) both SSI and DI beneficiaries for whom medical improvement was expected at the time of benefit award but who have not passed at least one medical continuing disability review.

The primary responsibilities of beneficiaries are to:

  1. Obtain sufficient information to decide whether to participate in TTW, and if so, to select an appropriate EN
  2. Locate and contact, with the help of the Program Manager, an appropriate EN or SVRA willing to accept the Ticket
  3. Participate in the development of the IWP with the EN
  4. Participate in the activities described in the IWP and meet the "timely progress" requirements for active TTW participation
  5. Once employed, report earnings to SSA and the EN
  6. Inform the EN and the Program Manager in writing of a decision to dissolve the relationship with an EN

 

2. Mechanics of the TTW Program

a. Ticket Assignment

The sequence of activities a beneficiary would follow starts with receipt of a ticket—a red, white, and blue certificate stating SSA’s agreement to pay an EN for services provided when the beneficiary achieves prescribed earning objectives. First, the beneficiary must decide whether to seek services from an EN. (Because participation in TTW is voluntary, the beneficiary is free to choose whether to use the Ticket to seek services.) The Program Manager makes available a list of approved ENs in the beneficiary’s area, and beneficiaries may assign their Tickets to participating ENs in any month in which they meet program eligibility requirements. Beneficiaries cannot assign their Tickets to more than one provider at one time.

ENs are not obligated to accept a Ticket and may choose which beneficiaries they want to serve. In making this choice, they might consider, for example, their ability to help a particular beneficiary achieve sufficient earnings to generate Ticket payments. The beneficiary and the EN are free to negotiate the services provided in exchange for the Ticket. In order for a Ticket to be officially assigned, the EN and the beneficiary must co-develop and sign an IWP. Any participating beneficiary who is not satisfied with the services he or she is receiving may take the Ticket out of assignment and re-assign it to another provider that is willing to serve them, which would require developing and signing a new IWP.

Once a Ticket is assigned, the Program Manager initiates a series of reviews to determine whether the beneficiary is making "timely progress" toward self-supporting employment, which is defined as working at levels that will reduce or eliminate dependence on DI or SSI benefits. So long as beneficiaries are determined to be making timely progress, their Tickets are considered in use. This is significant because for these beneficiaries, SSA may not initiate a medical continuing disability review (CDR), the usual process for determining a beneficiary’s medical eligibility for continued benefits. Beneficiaries not eligible for Tickets, those whose Ticket are not in use, and those who do not meet timely progress requirements are not eligible for the CDR protection.

The first progress review takes place 24 months after Ticket assignment, excluding any months a Ticket was either not assigned to an EN or in inactive status (which is defined in the next section). The purpose of this review is threefold: (1) to determine whether the beneficiary is "actively participating" in his or her IWP, defined as engaging in activities outlined in the IWP on a regular basis and approximately in the timeframe specified; (2) to examine whether a goal in the IWP is to work at least three months at the substantial gainful activity (SGA) level by the time of the second review; and (3) to assesses whether the beneficiary can reasonably be expected to reach that goal.

 

Click here to view Figure II.3

 

The second and all subsequent reviews take place on an annual basis. During these reviews, beneficiaries are expected to meet progressively higher levels of employment for their Tickets to remain in active-use status and thus to extend their exemptions from medical CDRs. During the first 12-month review period, beneficiaries are required to work at least 3 months at the nonblind SGA level (currently $810 per month). During the second 12-month review period, they are required to work at least 6 months at the nonblind SGA level. During the third 12-month review period (and succeeding 12-month periods), they are required to work at least 6 months in each year2 and have earnings in each of those months that are sufficient to eliminate the payment of DI or federal SSI benefits. Although this overall process could involve multiple reviews, SSA anticipates that most TTW participants will not be subject to multiple reviews because those who begin working will very likely be working at levels that quickly move them off the SSI or DI rolls.

 

b. Placing a Ticket in Inactive Status and Reactivating It

Beneficiaries who have assigned their Tickets but are temporarily unable to participate or who are not actively participating during the first 24 months after Ticket assignment may place their Tickets in inactive status.3 To do this, they must submit a written request to the Program Manager along with a statement from the EN about the inactivity. As mentioned above, inactive-status months do not count toward the time limit for making timely progress toward self-supporting employment, and beneficiaries with Tickets in inactive status are subject to medical CDRs. If a beneficiary whose Ticket is still assigned but in inactive status wants to resume participation in the program, he or she notifies the EN, which in turn notifies the Program Manager. The Program Manager then contacts the EN after three months to verify active participation. Beneficiaries who are found not to be actively participating are notified of this finding by the Program Manager and become subject to medical CDRs unless the beneficiary requests a review of the decision.

Beneficiaries who fail to meet the timely progress requirement may submit a written request to the Program Manager to re-enter in-use status. The Program Manager determines whether a beneficiary meets the requirements to re-enter the program based on active participation and/or work activity for a specified length of time.

 

c. Dispute Resolution

In a program as complex as TTW, and with beneficiaries’ income and ENs’ revenues at stake, it should not be surprising that disputes may arise at various points in the process. Anticipating this problem, SSA has developed a three-step process for resolving disputes between beneficiaries and ENs (that are not an SVRA): (1) either party may seek resolution through the EN’s internal grievance process; (2) if the EN’s internal grievance process does not produce a resolution satisfactory to both parties, either party may seek resolution from the Program Manager; (3) if the beneficiary or the EN is not satisfied with the Program Manager’s proposed resolution, either party may request a decision from SSA. SSA’s decision on the dispute is final. In addressing disputes with ENs or other service providers, beneficiaries may engage the assistance of the SSA-funded Protection and Advocacy for Beneficiaries of Social Security (PABSS) programs, described later in this chapter.

Disputes arising between beneficiaries and SVRAs (even those acting as ENs) are governed by the dispute resolution provisions of the Rehabilitation Act. These provisions allow beneficiaries to pursue grievances through their state’s Client Assistance Program4 and provide opportunities to resolve disputes through formal mediation or an impartial hearing process.

Disputes arising between ENs and the Program Manager are subject to review under the Program Manager’s internal grievance process. If the grievance process does not result in a mutually agreeable resolution within 20 days, the Program Manager must refer the dispute to SSA for a decision. Like disputes between beneficiaries and ENs, SSA’s resolution is final in EN-Program Manager disputes.

 

d. Ticket Period of Use and Termination

The period during which a Ticket can be used ends after 60 outcome payments have been made to an EN. At any prior point, a beneficiary’s Ticket will be terminated if his or her eligibility for DI or SSI benefits ends for reasons other than work activity or earnings. Examples include medical improvement, conversion to the Social Security Old Age or Survivors programs, unearned income exceeding SSI eligibility limits, and death.

 

3. Services and Reimbursement

As mentioned above, services to beneficiaries under TTW are governed by a written, signed agreement between the beneficiary and the EN, known as an IWP. The IWP outlines the specific employment services, vocational rehabilitation services, and other support services that the EN and the beneficiary have determined are necessary to achieve the beneficiary’s stated employment goals (the ultimate goal being earnings at a level that takes the beneficiary off the disability rolls). The EN must submit a signed copy of each IWP to the Program Manager. The EN must also develop and implement the plan in a manner that gives the beneficiary the opportunity to exercise informed choice in selecting an employment goal. According to final program rules, an IWP must include statements addressing:

  1. The vocational goal developed with the beneficiary, including appropriate goals for earnings and job advancement
  2. The services and support necessary for the beneficiary to accomplish the goal(s)
  3. Any terms and conditions related to providing the services and support
  4. The fact that the EN may not request or receive compensation from the beneficiary for the cost of services and supports
  5. The conditions under which the EN may amend the IWP or terminate the relationship
  6. The beneficiary’s rights under TTW—including to privacy and confidentiality, to have a copy of the IWP, and to seek to amend the IWP—and of the remedies available to the beneficiary.

Services provided under TTW could vary substantially depending on beneficiaries’ needs. A beneficiary with well-developed work skills and substantial work experience might need only short-term assistance in identifying and getting interviews with appropriate employers. For such a person, an EN would function generally as a job placement firm. Some beneficiaries might need longer-term job training or vocational rehabilitation to develop skills that would enable them to get and keep a job with wages high enough to move them off the disability rolls. Others might need an EN to provide support services such as transportation and child care to help them remain and function effectively in the workplace.

When beneficiaries make progress toward and achieve approved employment objectives—that is, work for a specified numbers of months at the nonblind SGA level—ENs may be paid for those outcomes. Overall, the TTW reimbursement system marks a significant departure from the traditional cost reimbursement system for SVRAs, which is discussed later. Under the TTW program, ENs may choose to be paid under one of two payment systems: an outcome-only payment system or a milestone-outcome payment system. The former provides a potentially larger total payment, with all payments occurring only when the beneficiary is off the disability rolls; the latter provides somewhat lower total potential payments but up to four initial payments that begin while the beneficiary is still on the disability rolls but has achieved specific earnings milestones. The two plans were designed so that the maximum total amount of payments made to an EN with respect to a beneficiary under the milestone-outcome system would equal about 85 percent of the payout available under the outcome-only system. An overview of the two systems is provided in Table II.1

Table II.1: Outcome-Only and Milestone-Outcome Payment Systems, Based on 2003 Amounts

% of PCB*

SSI Ticket-Holder

SSDI Ticket-Holder

Outcome-Only Payment System

Outcome Achieved When:

The beneficiaries’ entitlement to Social Security disability cash benefits ends or eligibility for SSI cash benefits based on disability or blindness terminates due to work activity or earnings.

40%

$196 per Month

$328 per Month

Total outcome payments available (60 payments)

 

$11,760

$19,680

Milestone–Outcome Payment System

Must occur before the first Outcome payment month, and is achieved when the beneficiary works:

Milestone:

1. 1 calendar month above gross SGA

34%

$167

$279

2. 3 calendar months above gross SGA in a 12-month period

68%

$334

$557

3. 7 calendar months above gross SGA in a 12-month period

136%

$668

$1,114

4. 12 calendar months above the applicable SGA threshold amount in a 15-month period

170%

$835

$1,393

Total of the 4 milestone payments available

 

$2,004

$3,343

+60 (reduced) Outcome Payments

Same rules apply with regard to when an outcome is achieved as under the Outcome Payment Method.

Each outcome payment made to an EN will be reduced by an amount equal to 1/60th of the total Milestone payments made to that EN.

34%

Depending on the number of milestones achieved, outcome payments could range from $134 to $279

Estimated Total Available

Added together, the 4 Milestone Payments plus the 60 available months of reduced Outcome Payments should equal about 85% of the maximum possible under the Outcome Payment Method.

 

$10,044

$16,723

Source: http://www.yourtickettowork.org/selftraining/EN_Unit6_PaymentOptions.doc (accessed November 13, 2003).
Note 1 : The potential for outcome payments related to SSI beneficiaries may be affected by their monthly federal benefit calculation
Note 2: *The PCB is based on the cash disability benefits SSA paid in the prior calendar year. These formulas are updated annually. The PCBs for 2003 are $819 for SSDI and $491 for SSI. Individual payments have been rounded to the nearest whole dollar.

Under the outcome-only payment system, SSA makes up to 60 monthly payments to the EN, one for each month in which the beneficiary receives no DI or federal SSI benefit payments because of work or earnings.5 After DI/SSI benefits reach zero, an outcome payment occurs for any months in which the individual (1) has gross earnings from employment (or net earnings from self-employment) that exceed the level defined as substantial gainful activity (SGA) and (2) is not entitled to or eligible for any type of Social Security or SSI benefit. The months need not be consecutive. Monthly outcome payments are equivalent to 40 percent of the payment calculation base (PCB)—the prior calendar year’s national average monthly DI or SSI disability payment amount. In 2003, TTW monthly outcome payments to ENs were $328 for DI and $196 for SSI. For concurrent beneficiaries, outcome payments are based on the average DI amount.

Under the milestone-outcome payment system, SSA makes up to four payments to the EN, based on the beneficiary achieving certain self-sufficiency goals, or "milestones," while he or she is still receiving cash disability payments. The first milestone is achieved when the beneficiary has worked for one month and has earnings in that month that exceed the SGA level. The second milestone is achieved when the beneficiary has worked for 3 months within a 12-month period and has earnings for each of the 3 months in excess of the SGA level. The third milestone is achieved when the beneficiary has worked for 7 months within a 12-month period and has earnings over the SGA level for each of the 7 months. The fourth milestone is achieved when the beneficiary has worked for 12 months within a 15-month period and has earnings for each of the 12 months that are above the SGA level. Any of the months used to meet previous milestones can be included in the months used to meet subsequent milestones. In addition to the milestone payments, ENs choosing this option can also request monthly outcome payments after a beneficiary leaves the disability program rolls, although each outcome payment will be reduced by an amount equal to 1/60th of the milestone payments made to the EN with respect to a particular beneficiary.6

Each of the milestone payments is larger than the preceding one, reflecting the progressively greater accomplishments represented by successive milestones. The first milestone payment is equal to 34 percent of the PCB, as defined above. The second milestone payment is equal to 68 percent of the PCB for the calendar year in which the month of milestone attainment occurs. The third milestone payment is equal to 136 percent of the PCB for the calendar year in which the month of milestone attainment occurs. The fourth milestone payment is equal to 170 percent of the PCB for the calendar year in which the month of milestone attainment occurs. Monthly outcome payments under the milestone-outcome system are equal to 34 percent of the PCB for the calendar year in which the month occurs.

To obtain either an outcome or milestone payment, an EN must submit a request and proper documentation of the beneficiary’s earnings to the Program Manager. Detailed rules govern the type of earnings evidence that will be accepted and how it will be evaluated. Evidence is categorized as primary or secondary, reflecting the degree to which it can be relied upon as an accurate and complete record of earnings. Primary evidence consists of employer records—for example, pay stubs, employer wage statements, or oral statements by employers. Secondary evidence comes from other (third-party) sources such as state unemployment insurance, tax returns, employee business records, or employee statements of earnings. If the EN is unable or unwilling to submit the primary earnings evidence, it must wait until SSA investigates the reported earnings and develops the evidence necessary to process the claim. This can take substantial time, depending on field office workloads and beneficiary and employer cooperation. The EN can expedite the process by providing the primary earnings evidence up front.

The Program Manager encourages ENs to meet the requirements for primary evidence, as this will expedite the payment process. Evidence that does not meet the standards for acceptance (original, legible, unaltered, clearly identifying the beneficiary, and so on) must be further investigated by the Program Manager (by contacting the EN, beneficiary, or employer) or referred to the relevant SSA field office for continued development; both of these processes could substantially delay payment. The high standards placed on the evidence reflect its use as a key determinant of a beneficiary’s continued eligibility for benefits. With respect to primary earnings evidence, one issue that often must be addressed is that pay stubs may not contain all of the information that SSA needs to process the claim. The evidentiary requirements also differ depending on the program(s) from which the beneficiary is receiving benefits (DI and/or SSI) and the type of payment claim.7 As discussed in Chapter III, SSA is in the process of implementing changes intended to reduce the burden of collecting evidence after the third Ticket payment for a beneficiary has been made.

ENs may periodically elect to change their payment systems. They may change their initial payment system within 12 months after selecting it or within 12 months after TTW is rolled out in the state, whichever is later. Thereafter, ENs can switch payment systems no more frequently than every 18 months. However, payments made to ENs with respect to a particular beneficiary are always based on the payment system in place when the beneficiary’s Ticket was assigned. Consequently, ENs that select to switch payment systems may receive payments under both systems simultaneously.

SVRAs can choose whether to serve a given beneficiary under either of the two new payment systems or under the traditional payment system. If acting as an EN, the SVRA will be paid under the EN payment system it has elected (the outcome-only or milestone-outcome system). If acting as a traditional vocational rehabilitation provider, the SVRA will be reimbursed under the traditional payment system. This system is also used when SVRAs serve beneficiaries who have not been issued Tickets or beneficiaries who were receiving services from the SVRA before they became eligible for a Ticket and subsequently decide not to assign the Ticket to the SVRA.

 

B. PROGRAM CONTEXT

The success of the TTW program will be strongly influenced by the context in which it is implemented. This section provides background information on SSA’s traditional vocational rehabilitation payment system that TTW is replacing, describes the variety of private organizations that provide work-related services to disability beneficiaries, and discusses several public initiatives that help disability beneficiaries find and maintain employment. A number of the initiatives were designed specifically for individuals served by the TTW program.

1. Traditional Vocational Rehabilitation System

Since 1981, under SSA’s Vocational Rehabilitation Reimbursement Program (which we refer to as the traditional payment system), SSA has reimbursed SVRAs for services provided to SSA beneficiaries that result in specified employment outcomes. This payment system, which replaced an earlier block grant program, was designed to improve program outcomes and accountability. Under this system, the state Disability Determination Service applied a set of criteria to individuals awarded SSI or DI benefits. Individuals who appeared to be good candidates for rehabilitation were referred to the SVRA and were then required to participate in the program or risk losing their benefits. (While legally binding, however, this provision was seldom enforced.) Beneficiaries could also apply on their own, without being referred. SSA reimburses SVRAs for reasonable and necessary costs of services provided to disability beneficiaries if such services result in the person’s achieving work at the level of SGA for 9 months in a 12-month period.

For reimbursement, SVRAs must submit evidence that the beneficiary has returned to work at a level exceeding SGA for 9 months in a 12-month period. SVRAs typically track beneficiary earnings through state administrative data systems rather than through contact with the beneficiary or the beneficiary’s employer. They commonly use quarterly state Unemployment Insurance (UI) wage data to prove that a beneficiary achieved the required level of income. If the quarterly wages divided by three are at least $100 above SGA ($200 over SGA if no information on impairment-related work expenses is available), SSA considers the SGA criterion to be satisfied in each of the 3 months. If the evidence does not meet the $100/$200 tolerances, SSA submits a request to the beneficiary’s field office to further develop the earnings report. If SVRAs are unable to submit any evidence of earnings, quarterly new hire wage data are used for SSI and concurrent cases. These data are also based on UI records and are submitted by states primarily for purposes of enforcing child support orders. By law, SSA is not permitted to use these data for DI cases. If new hire data cannot be used and the claim appears to be at SGA but does not meet the tolerances, the claim sits in a wage holding file until annual wage information is obtained from the IRS.

An examination of SVRA claims and payments (Livermore et al. 2003) reveals that the number of claims allowed grew substantially and more or less steadily from about 2,200 in 1984 to over 11,000 in 1999. As the number of approved claims rose, so too did SSA’s payments, from just over $4 million in 1984 to over $100 million during each of the four most recent years for which data are available (1998-2001). In 2001, the average cost per claim allowed was $12,668. Note that this amount falls between the total amount of payments available for serving SSI and DI clients under both of TTW’s payment systems (Table II.1). Thus, SVRAs can receive more money for providing assistance to certain beneficiaries under TTW than under the traditional payment system (assuming the beneficiary’s work activity generates all possible milestone and/or outcome payments). Moreover, the government will be assured that the beneficiaries actually leave the disability rolls rather than just working at SGA for nine months.

For many years, SVRAs remained the only real option that SSA disability beneficiaries had for rehabilitation services. Until 1996, SSA could only refer disability beneficiaries to non-SVRA providers if an SVRA declined to participate in the program or terminated or limited its participation. But because all SVRAs participated in the program, there were effectively no alternatives.

New regulations implemented in 1996 attempted to give SSA more flexibility in the referral process by initiating the Alternate Participant Program. An alternative participant is any public or private agency (except a participating SVRA), organization, institution, or individual with whom SSA entered into a contract to provide vocational rehabilitation services. Under this program, the option of serving an SSA beneficiary is still offered first to SVRAs, but if the SVRA does not respond within a given time period, an alternative participant can take the case. For various reasons, however, such as limited marketing of the program to beneficiaries and the difficulties that providers have had in tracking beneficiary employment and earnings, the Alternative Participant Program never successfully served a large number of beneficiaries. From 1999 to 2001, only 21 out of just 27 claims submitted were paid under the program.8

The TTW program dramatically changes the rehabilitation options for SSA disability beneficiaries. When TTW is rolled out in a state, its set of ENs and SVRAs replaces the old system, and SSA ceases to make referrals to the SVRA system. Although SVRAs can continue to use the traditional payment system, they can only do so if the beneficiary assigns his or her Ticket to the SVRA. Although SVRAs may be obligated to serve certain individuals who have not assigned their Tickets to the SVRA, they will not be eligible for payments from SSA unless a Ticket is assigned. In addition, the Alternative Participant Program is being phased out in states as TTW is being phased in. Once a state becomes a Ticket state, alternative participants in the state can no longer accept new referrals under the terms of the Vocational Rehabilitation Reimbursement Program. Alternative participants in Ticket states do, however, have the option of becoming ENs under the Ticket program. From this perspective, TTW is more than just two new options for paying for successful beneficiary rehabilitation. It is more appropriately thought of as the entirety of SSA’s efforts to finance employment support services for people with disabilities, encompassing remnants of the earlier program but changing it in fundamental ways.

 

2. Private Providers

In addition to the nationwide public SVRA system, many private entities have, for many years, provided services to persons with disabilities who wish to enter or return to the labor force. These providers may be nonprofit or for-profit organizations, either large or small. They may serve one geographic area or many, and they may focus on clients with one particular disability or on clients with different disabilities. Many of them may have already been serving SSA disability beneficiaries through agreements with SVRAs; others may have served similar populations but through other assistance programs such as those sponsored by the U.S. Departments of Labor, Education, or Health and Human Services. Examples include Goodwill Industries, The ARC, and, more recently, the Department of Labor’s One-Stop Career Centers. Many of these providers may be seen as potentially good EN candidates. Indeed, the Program Manager has targeted such providers for recruitment, and the potential for an income stream from milestone or outcome payments may prompt them to expand or modify their business plans to get involved with TTW.

 

3. Related Initiatives

TTW has not been implemented in a vacuum. SSA and other federal agencies have launched a number of initiatives intended to assist people with disabilities in finding and maintaining employment by addressing three of the barriers described in Chapter I: financial disincentives, limited knowledge or information, and misinformed or uninformed employers. Many of these initiatives were authorized or mandated by the Ticket Act and some can be used outside of the TTW program. Below, we briefly describe several initiatives most likely to be relevant to beneficiaries participating in TTW.

 

a. Initiatives Addressing Financial Disincentives

Expedited Reinstatement of Benefits. Section 112 of the Ticket Act authorizes the expedited reinstatement of DI and SSI disability benefits. In essence, former DI/SSI disability beneficiaries may be eligible to request a reinstatement of benefits if their eligibility was terminated because of work activity in the past five years and if their impairments are the same as or related to the impairments for which they previously qualified for benefits. Section 112 provides that beneficiaries filing a request for expedited benefit reinstatement may receive provisional benefit payments for up to six months while the redetermination of eligibility is being made and, except in cases of fraud or deliberate attempts to deceive, cannot be required to repay these payments if reinstatement is subsequently denied.

Removal of Work Activity as a Trigger for Disability Reviews. Section 111 of the Ticket Act means that SSA will not use a beneficiary’s work activity as a signal to initiate a disability review. This new protection applies just to DI beneficiaries (including those who concurrently receive SSI) who have received benefits for at least 24 months and does not require the beneficiary to be using a Ticket. These beneficiaries are still subject to the regularly scheduled disability reviews, but no longer need to worry that work activity by itself will trigger a review of their disability status.

Expanded Medicare and Medicaid Coverage. One of the biggest issues associated with entering the labor force and earning an income is its potential impact on a person’s eligibility for medical insurance. The Ticket Act has several provisions related to public health insurance for people with disabilities.

All DI beneficiaries are eligible for Medicare after 24 months on the DI rolls. Furthermore, if they leave the DI rolls after obtaining Medicare eligibility, they could retain such coverage for an additional 36 months (the Medicare Extended Period of Eligibility). Section 202 of the Ticket Act extends that 36-month period by an additional 4.5 years for most working people with disabilities. Most DI beneficiaries will therefore be able to keep their Medicare coverage for at least 8.5 years after they return to work (including a 9-month trial work period that would occur before they exit the DI rolls because of work). The act also allows DI beneficiaries who have undergone medical screening and secured a Medigap policy—a commercial health insurance policy that provides benefits supplemental to Medicare—to suspend the premiums and benefits of the Medigap policy if they have employer-sponsored coverage. During the extended period of eligibility, workers are able to take advantage of employer-sponsored benefits, an important incentive to work. They may reinstate their Medigap policy without a penalty if their employment attempts fail and they request reinstatement within 90 days of being terminated from the employer’s plan. This provision is potentially significant because it will not require re-application or pose a risk that the applicant might be unable to pass the medical screening.

The Ticket Act also sought to expand Medicaid coverage to beneficiaries leaving the rolls, which is particularly important for SSI beneficiaries, almost all of whom are eligible for Medicaid. In particular, the Ticket Act made it easier for states to create a Medicaid Buy-In program that would allow disabled workers to purchase Medicaid coverage on a sliding-fee basis. One of the most noteworthy changes is that states can now continue to offer the Medicaid Buy-In to workers with disabilities even if they are no longer eligible for SSI because of medical improvement (although no states have fully implemented such a provision at this time). As of August 2003, 28 states have opted to establish Medicaid Buy-In programs, and many more are in the process of establishing such programs (Ireys, White, and Thornton 2003).

Section 203 of the Ticket Act established grants to states, called Medicaid Infrastructure Grants, to assist them in developing Medicaid Buy-In programs and to support other state activities that promote employment among people with disabilities. The grants are administered by the Centers for Medicare and Medicaid Services (CMS). If states are to qualify for such grants, their Medicaid programs must cover (or must be in the process of establishing coverage for) personal assistance services capable of supporting full-time competitive employment, which reflects the Ticket Act’s intent to provide support that promotes employment of people with disabilities. Because Medicaid programs have typically not been connected with employment issues, CMS is encouraging grantees to take a broad look at the programs and policies that affect the employment of people with disabilities in their states as well as the potential for interagency collaboration in developing and implementing Medicaid Buy-In programs. These infrastructure grants, awarded to 37 states as of August 2003, offer substantial administrative support for state programs, from $500,000 to $1.5 million per year.

Section 204 of the Ticket Act provides funding for states to conduct the CMS-administered Demonstrations to Maintain Independence and Employment. These demonstrations allow states to experiment with programs that provide Medicaid coverage to workers with significant impairments that, without medical assistance, will result in an inability to work. These programs attempt to intervene early with medical coverage for appropriate treatments and disease management so that individuals can maintain employment and independence. Although Congress appropriated $250 million for this initiative, only a few, small efforts have thus far been launched. As of August 2003, funding for four demonstrations has been awarded: Mississippi and the District of Columbia received funds to serve persons with HIV/AIDS; Rhode Island was funded to serve persons with multiple sclerosis; and Texas received funds to serve people with schizophrenia, bipolar disorder, and major depression. As of October 2003, only Mississippi and the District of Columbia had implemented their demonstrations.

SSA Demonstrations. SSA plans to implement several demonstration programs to change employment options and the incentives for disability beneficiaries. One of these is known as the $1 for $2, or DI Benefit Offset Demonstration. Section 234 of the Ticket Act authorizes SSA to conduct demonstrations to evaluate the impact of altering the DI program so that benefits are reduced by $1 for each $2 of the beneficiary’s earnings above a set level, rather than benefits ceasing entirely once earnings exceed the SGA and the trial work period has been completed. The Office of Policy (2001) released a draft implementation plan for the demonstration projects in 2001, and in August 2002, the Ticket to Work and Work Incentives Advisory Panel (2002) released an advice report to the commissioner of SSA regarding the statutory requirements and design issues related to the demonstrations. In September 2003, SSA published a Request for Information seeking comments from firms that might potentially implement the demonstration. Responses to this request were due to SSA by October 15, 2003.

A second demonstration planned by SSA is the Early Intervention Demonstration Project. Authorized by Section 301 of the Ticket Act, this demonstration will evaluate whether providing return-to-work services to DI applicants before they are awarded benefits increases the rate of return to work, thus offsetting the cost of service provision with the money saved were these applicants to return to work rather than receive DI benefits. The demonstration will provide applicants with a one-year cash stipend and three years of Medicare benefits as well as access to employment supports and services. Three models of intervention will be tested in New Mexico, Vermont, and Wisconsin, respectively, with approximately 100 enrollees each. The demonstration is expected to begin in late spring or early summer 2004.9

A third SSA demonstration is the Youth Transition Process Demonstration. In late September 2003, SSA funded seven cooperative agreements for demonstration projects intended to improve employment outcomes for youth with disabilities. The purpose of the projects is to design, implement, and evaluate approaches to improving the transition from school to work for youth ages 14 to 25 who receive SSI, DI, or Childhood Disability Benefits. Projects may also serve youth at risk of receiving such benefits, including those with a progressive condition or a prognosis for decreased functioning and those who may become eligible for benefits at age 18, when deemed parental income no longer applies. The projects are implementing a variety of strategies intended to increase coordination between various federal and state service, support, and benefit programs (including secondary and postsecondary education programs) in order to effectively prepare and support youth with disabilities to achieve maximum economic self-sufficiency through employment. Cooperative agreements have been awarded to California, Colorado, Iowa, Maryland, Mississippi, and New York (two projects).

All of these SSA demonstrations have the potential to interact with the TTW program, although final regulations about how they will interact have not yet been developed.

 

b. Initiatives Addressing Beneficiary Knowledge

Area Work Incentive Coordinators and Work Incentive Liaisons. Section 121 of the Ticket Act required SSA to "establish a corps of trained, accessible and responsive work incentives specialists" to assist disability beneficiaries who want to start or continue working. In response to this mandate, SSA ran a pilot program from July 2000 through September 2001, which involved 32 employment support representatives serving 54 sites (in SSA field offices) across the country. Employment support representatives received six weeks of intensive training on SSA work incentive provisions and related issues. In addition to informing beneficiaries about work incentives, employment support representatives conduct outreach and provide information to the general disability community. SSA evaluated the pilot in November 2001 and considered it in determining how best to provide information and services to beneficiaries who want to work, given the resources available. The result was the plan to implement Area Work Incentive Coordinators and Work Incentive Liaisons program.

As discussed in the next chapter, SSA adopted a plan to hire 57 Area Work Incentive Coordinators, which has already been expanded to 58 and can be increased to 70, as the need arises. These full-time staff will provide expertise on Ticket-related and other work incentives for every 20 to 30 field offices. Additionally, each field office will designate an existing staff person as a work incentive liaison. The area work incentive coordinators were selected and, after successfully completing their training, finished training the work incentives liaisons by September 30, 2003. The liaisons will be delegated work-incentive responsibilities in addition to their existing duties; field office managers will guide the liaisons to prioritize work incentive and other assignments.

Benefits Planning, Assistance, and Outreach. The purpose of the Benefits Planning, Assistance, and Outreach (BPAO) initiative is to provide SSA disability beneficiaries with accurate and timely information about SSA work incentives and other federal efforts to remove regulatory and programmatic barriers to employment for persons with disabilities. Authorized by Section 121 of the Ticket Act, 116 BPAO programs provide services to SSA beneficiaries in all 50 states, the District of Columbia, and five territories. Through the end of August 2003, the programs collectively employed over 400 benefits specialists and have served over 77,000 individuals since implementation in late 2000. BPAOs are not affiliated with SSA offices. Benefits specialists work with individual beneficiaries to explain the myriad of regulations, provisions, work incentives, and special programs that may affect an individual’s decision to enter or re-enter the workforce. The specialists do not tell beneficiaries what to do or make specific recommendations; they allow beneficiaries to make their own informed decisions based on complete and accurate information. In addition, they support individuals who choose to enter employment by helping them comply with all relevant regulations and reporting procedures.

Protection and Advocacy. The SSA-funded Protection and Advocacy for Beneficiaries of Social Security (PABSS) program is in its third year of operation. This program, authorized by Section 122 of the Ticket Act, is being administered by the 57 existing Protection and Advocacy systems (P&As).10 PABSS staff members attend the same training as BPAO staff, and nonprogrammatic technical assistance is provided to them through an SSA contract with the National Association of Protection and Advocacy Systems. PABSS staff members also receive training and technical assistance on Social Security programmatic issues through either one of three university-based regional training centers. PABSS projects assist beneficiaries with legal issues, employment issues, the IWP development process, and disputes with ENs and other agencies. They also provide referrals and information about vocational rehabilitation, employment services, and SSA’s work incentives.

Initially, PABSS programs were not allowed to represent beneficiaries in overpayment cases with SSA. However, SSA amended the PABSS grant terms and conditions in June 2003 to allow them to do this. PABSS staff may now accompany beneficiaries to SSA offices to provide assistance in matters involving appeals of work-related program decisions and overpayments caused by work and earnings.

Department of Labor Disability Program Navigators. The Disability Program Navigators initiative is one of several joint initiatives recently announced by SSA and the Department of Labor (DoL) to assist people with disabilities who want to work. This initiative creates a new position, called a "navigator," within One-Stop Career Centers. Navigators link people with disabilities to employers as well as BPAOs and similar types of organizations. In addition, navigators provide information about SSA work incentives, the TTW program, and ENs. SSA and DoL are providing funding in a number of pilot states to test the navigator program. The results of the pilot test will inform a future decision about expanding the program nationwide. The grants have been awarded, and training for the navigators began in November 2003.

 

c. Initiatives Addressing Employer Knowledge or Attitudes

Ticket to Hire. The Ticket to Hire program is a joint initiative of SSA and DoL intended to help employers locate and recruit skilled employment candidates with disabilities from the TTW program. It operates as a specialized unit of a larger DoL program called Employer Assistance Referral Network (EARN). Ticket to Hire is actively working with employers in every Phase 1 and Phase 2 state. Employers in Phase 3 states are becoming involved through EARN until TTW is rolled out in their state. Many SVRAs and ENs are collaborating with Ticket to Hire to better serve their participants.

Ticket to Hire functions as an intermediary between employers and ENs. Employers can contact Ticket to Hire to provide information on job vacancies. Ticket to Hire shares the job vacancy information with appropriate ENs in the employers’ areas. To preserve employer anonymity, Ticket to Hire passes the EN contact information onto the employer. The employer contacts the EN to follow up with the candidates it is interested in interviewing.

The program’s main functions are to provide information and promote job matching. It offers employers information and resources on disability employment issues including, reasonable accommodation issues and tax incentives for employing individuals with disabilities. The program also seeks to help participating employers reduce both the time and cost of recruiting qualified job candidates as well as the amount of time ENs must devote to job development.


Notes:

1 The service plan prepared by an SVRA is known as Individual Plan for Employment (IPE), the name for SVRA agreements with clients before TTW. Since IWPs and IPEs are essentially the same thing, for the sake of simplicity we hereafter use the term IWP to refer to either type of plan. Return to text.

2 Months of employment need not be consecutive during any review period. Return to text.

3 Beneficiaries may not place their Tickets in inactive status following completion of the 24-month review period. If they need to cease participation after that point, their Tickets are not terminated; rather, these beneficiaries are subject to a finding that they are not making timely progress toward self-supporting employment and thus lose eligibility for the CDR protection. Return to text.

4 Each state has a Client Assistance Program, an independent entity that provides advocacy services ranging from information and referrals to representation during court actions. Return to text.

5 The point at which beneficiaries' federal payments reach zero is different in each program. In general, DI beneficiaries receive zero benefits when monthly earnings, after consideration of applicable work incentive provisions, are over the level defined as SGA-$800 per month in 2003-and the nine-month trial work period and three-month grace period have been completed. For SSI beneficiaries who have no non-SSI income besides earnings, federal cash benefits are reduced to zero when all earnings, net of disregards, are at least twice the full SSI benefit. If an SSI beneficiary has other income, then the amount of earnings required to reduce the federal cash benefit to zero can be less than twice the full SSI benefit. The amount of earnings required to reduce the federal SSI benefit to zero will also be affected by numerous other factors, including the living arrangement and the couple versus individual rate. Return to text.

6 As under the outcome payment option, monthly payments under this option are payable for a maximum of 60 months, and the months need not be consecutive. Return to text.

7 For DI beneficiaries, SSA requires information on the period in which the wages were earned. For SSI beneficiaries, SSA requires information on the date that the wages were paid. Also, for all milestone payments and for outcome payments after benefits terminate for work or earnings, SSA requires information on the date that the wages were earned. Return to text.

8 As per data provided by Leo McManus, SSA Office of Disability, and cited in Livermore et al. 2003. Return to text.

9 Additional information on the Early Intervention program can be found at http://www.disabilityresearch.rutgers.edu/. Return to text.

10 There is one P&A in each of the 50 states and the District of Columbia, and there are others in various territories and one designed to serve American Indians. Return to text.