CHAPTER 3
TTW EARLY IMPLEMENTATION

The Ticket to Work program is now a reality. SSA has developed all the required systems and the program has been fully rolled out in 33 states and the District of Columbia. It will be rolled out in the remaining states and the U.S. territories starting in November 2003. As of September 2003 SSA had mailed over five million Tickets, and more than 2,600 Tickets were in assignment. Most assignments were to state VR agencies (SVRAs) under the traditional payment system (84 percent), and many of these assignments are from beneficiaries who were existing SVRA clients prior to TTW. Remaining assignments were to about 250 of the almost 800 participating Phase 1 and Phase 2 ENs or, in a small share of cases, to SVRAs acting as ENs, predominantly under the milestone-outcome payment system (13.1 percent of all assignments, versus 3.4 percent for outcome only). As of early August 2003, 70 ENs and SVRAs acting as ENs have received payments under the two new payments systems totaling about $220,000, on behalf of 240 beneficiaries.

In this chapter, we describe and discuss the early experience of the Ticket rollout. The discussion is based on:

  • Site visits and interviews conducted between July and November of 2002 with SSA staff, the Program Manager, ENs, and SVRAs in Phase 1 states (previously reported in Livermore et al. 2003)

  • Site visits to SSA conducted in August and September 2003

  • The findings from an EN Summit, convened by SSA’s Ticket to Work and Work Incentive Advisory Panel in May 2003, as summarized in Livermore (2003)
  • Analysis of the SSA Office of Information Management (OIM) Ticket Universe file
  • Ticket payment data provided by SSA’s Office of Employment Support Programs
  • EN and Ticket assignment data reported by the Program Manager

 

The qualitative process information available for this report provides a good indication of overall activities, but is not fully representative of all recent experience. A more detailed assessment will be made in 2004 when we have completed the full round of EN and SVRA site visits, including interviews with providers in Phase 2 states. The quantitative information, in contrast, is more current and covers all TTW Phase 1 and Phase 2 states.

This section focuses on the operational developments SSA has made during the past 12 months. The early experience of creating the TTW rules and procedures and the initial rollout in the Phase 1 states was covered in the preliminary process analysis (Livermore et al. 2003). Using that report as background, we focus on the issues that remain in flux, particularly the system for making Ticket payments and the improvements SSA continues to make in the administrative data systems required to manage the program. Overall, it is clear that SSA has made great progress in developing a system that diverges dramatically from past agency practice. TTW has required SSA to develop new systems to integrate information from the SSI and DI programs on a scale never before attempted. In doing so, SSA has not only made the TTW program fully operational (although some rough edges remain), but it has also begun to produce a new way of seeing things at SSA that could have long-term effects on the way the agency deals with its disability beneficiaries.

In reviewing the rollout experience, we begin with the schedule. We then turn to the early experience with the TTW operational systems from the perspectives of SSA, the Program Manager, the SVRAs, and ENs. We also present monthly participation statistics for the Phase 1 and 2 states. Statistics on participant characteristics appear in Chapter IV.

 

A. ROLLOUT SCHEDULE

The Ticket Act was passed and became P.L. 106-170 on December 19, 1999. Throughout 2000 and 2001, SSA prepared to implement the program (Table III.1) in phases. Phase 1 was implemented in 13 states beginning in February 2002, and Phase 2 in another 20 states plus the District of Columbia beginning in November 2002 (Table III.2). Phase 3 of the program will be implemented in the remaining 17 states and the U.S. territories beginning in November 2003. TTW was initially to be rolled out in early 2001, but the actual rollout was substantially delayed because the final program rules were delayed in publishing. Tickets were released gradually in the Phase 1 states. Based on the terminal digit of the eligible beneficiaries’ Social Security numbers, Tickets were mailed to eligible beneficiaries according to the following schedule:

  • February 2002 - 10% of eligible beneficiaries
  • April 2002 - 20% of eligible beneficiaries
  • May 2002 - 30% of eligible beneficiaries
  • June 2002 - 40% of eligible beneficiaries

 

Table III.1: TTW Implementation Milestones Leading up to the Phase 1 Ticket Release

Time Period
Implementation Activity or Milestone
December 17, 1999 Ticket Act enacted, establishing the Ticket to Work Program.
2000
Throughout year SSA Office of Employment Support Programs (OESP) begins to develop principal policies and rules in consultation with SSA deputy commissioners.
August to December Draft Notice of Proposed Rule Making (NPRM) negotiated with the Office of Management and Budget
September 29 The Program Manager contract was signed with MAXIMUS, Inc.
November 13 Selection of 13 Phase 1 states announced
December 28 NPRM published, starting the 60-day public comment period.
2001
Throughout year Recommendations for resolving major issues raised by public comments on the NPRM were considered by deputy commissioners.
February 26 NPRM public comment period ended. SSA received public comments from over 400 interested parties, including federal, state, and local agencies; employers; organizations and advocates for people with disabilities; rehabilitation service providers; disability beneficiaries; and others.
April 13 Requests for Proposals on EN contracts were published.
October to December Draft final Ticket to Work regulations negotiated with OMB.
December 28 Final Ticket to Work regulations published.
2002
February Selection of 2 and 3 states announced
February 5 Tickets were released to eligible beneficiaries in the Phase 1 states.
Source: Livermore et al. (2003).

 

Table III.2: States and Territories Included in Each Phase of TTW Implementation

Phase 1: 13 States, Implemented February 2002
Arizona
Colorado
Delaware
Florida
Illinois
Iowa
Massachusetts
New York
Oklahoma
Oregon
South Carolina
Vermont
Wisconsin
Phase 2: 20 States + the District of Columbia, Implemented November 2002
Alaska
Arkansas
Connecticut
District of Columbia
Georgia
Indiana
Kansas
Kentucky
Louisiana
Michigan
Mississippi
Missouri
Montana
Nevada
New Hampshire
New Jersey
New Mexico
North Dakota
South Dakota
Tennessee
Virginia
Phase 3: 17 States + the U.S. Territories, to be Implemented November 2003
Alabama
California
Hawaii
Idaho
Maine
Maryland
Minnesota
Nebraska
North Carolina
Ohio
Pennsylvania
Rhode Island
Texas
Utah
Washington
West Virginia
Wyoming
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
Virgin Islands
Source: www.ssa.gov/work/ticket_states_announcement.html, accessed August 19, 2003.

The exception to the Phase 1 rollout schedule was the State of New York. Because of the events of September 11, 2001, Ticket mailings in New York were significantly delayed relative to those in other Phase 1 states. New York had only 20 percent of Tickets mailed as of the end of June 2002. Another 20 percent were mailed in July. The remaining 60 percent were mailed monthly in equal 20 percent increments through October 2002. Although Tickets were mailed incrementally, at any time after February 6, 2002, a Ticket-eligible beneficiary in a Phase 1 state could contact the Program Manager to request a Ticket, regardless of when his or her scheduled Ticket mailing date. This is referred to as "Ticket on Demand." During the initial Ticket mailing period (through June 2002), approximately 6,500 beneficiaries received Tickets on demand. 1

SSA implemented Phase 2 in a manner similar to Phase 1, except that Tickets were released more slowly over a longer period. In November 2002, 10 percent of Phase 2 Ticket-eligible beneficiaries were mailed Tickets. No Tickets were mailed in December 2002. Ticket mailings resumed again in January, with an additional 10 percent of Ticket-eligible beneficiaries being mailed their Tickets each month from January through September 2003. SSA made the rollout schedule for Phase 2 more gradual than that of Phase 1 because of problems encountered due to the high volume of Tickets being mailed during two of the Phase 1 implementation months. During the months of May and June 2002, when Ticket mailings represented 30 and 40 percent of eligible beneficiaries in the Phase 1 states, the Program Manager staff experienced a volume of calls from beneficiaries induced by the mailings that substantially exceeded its telephone capacity. Many ENs also experienced high call volumes to which they were incapable of responding. The more gradual mailing schedule used in Phase 2 appears to have solved these problems. SSA is scheduling Ticket mailings in Phase 3 using the same, more gradual schedule used in Phase 2.

 

B. IMPLEMENTATION FROM A SYSTEM PERSPECTIVE

1. Social Security Administration

a. Implementation Challenges

After the Ticket Act was signed into law in December 1999, SSA immediately began preparation for implementing the program. Staff of the Office of Employment Support Programs (OESP) coordinated the efforts to develop the rules and regulations, systems, and administrative processes that would govern TTW. A tremendous effort was required to establish the basic infrastructure needed to administer TTW because the eligibility and payment rules meant that TTW interacted with every component of the SSI and DI programs. SSA staff interviewed for this report noted several challenges associated with the initial Phase 1 implementation.

Short Timeframe and Delayed Rollout. The Program Manager had less than 18 months to develop systems, train staff, and recruit ENs before the first Tickets were released in February 2002. While SSA ultimately had nearly two and a half years to prepare for rollout, the required tasks involved building agreement among numerous stakeholders and making substantial enhancements to SSA systems.

The delayed rollout allowed SSA and the Program Manager more time to test systems and recruit ENs, but also created inefficiencies. Attempts SSA and Program Manager made to be ready for targeted start dates that were subsequently delayed with little advanced notice may have resulted in less than ideal approaches to implementation tasks and the necessity to spend the extra time fixing and patching those approaches as the system that evolved. Specifically, having a one-year deadline followed by 18 months of extensions is not the same as having, with certainty, two and one-half years up front to plan and develop the systems and procedures. For example, an early decision was made to use SSA’s existing Continuing Disability Review Control File (CDRCF) as the central piece of software for administering TTW. But it proved difficult to modify this software to deal with all the issues surrounding TTW payments, which turned out to be considerably more complex than expected. SSA staff members that we interviewed believe, in retrospect, that given all the time that was ultimately available because of the delays, it would have been preferable to build the TTW system from the ground up instead of attempting to modify the existing systems.

Limited Resources to Implement Ticket Act Provisions. In addition to the systems and procedures that needed to be developed to administer TTW, SSA has been attempting to integrate the various provisions of the Ticket Act including Medicare extensions, expedited reinstatement, Medicaid buy-ins, CDR protections, SSA’s corps of work incentives specialists, and the Protection and Advocacy for Beneficiaries of Social Security (PABSS) and the Benefits Planning, Assistance and Outreach (BPAO) programs. This has required extensive outreach along with internal and external training, for which Ticket Act did not appropriate funds. Instead, funding for these activities has been allocated from SSA’s administrative budget, which was already under considerable pressure as SSA dealt with rising numbers of disability claims and the government-wide cap on administrative expenses.

Administrative and System Inadequacies. The Ticket Act has generated a significant level of activity within SSA related to return-to-work initiatives. This, in turn, has highlighted significant inadequacies in SSA’s enterprises surrounding return-to-work. According to SSA interviewees, the agency has needed to be brought up to speed to meet both internal and external expectations. Many of the inadequacies have undermined SSA’s ability to implement TTW and have had to be addressed. Our SSA interviewees believe that the Ticket Act has served as a catalyst to address return-to-work issues that have, in the words of one interviewee, "lain dormant within SSA for decades." These are predominantly systems issues related to administering CDRs, work and earnings documentation, and determining when benefits become zero for TTW payment purposes. Differences in DI and SSI program rules along with the lack of automation and coordination of functions between the two programs makes processing earnings information difficult and time consuming even for ongoing SSA activities. Many of the systems enhancements required to administer TTW will have the added benefit of improving the processing of beneficiary earnings information, whether or not the beneficiary participates in TTW.

In addition to administrative and systems issues identified with respect to general return-to-work, SSA staff note that TTW has all of the characteristics of an entitlement program in and of itself and cannot be viewed as a simple extension of the SSI and DI programs. SSA systems needed to be developed to accommodate these new eligibility rules and regulations. Some of the challenges faced by SSA in developing the administrative systems for TTW include:

  • Continuing Disability Review (CDR) Administration. One implementation issue important to TTW administration is how to address CDR suspensions and resumptions; in particular, understanding and defining the initiation of a CDR, particularly within the context of other key TTW concepts such as "reassignment of the Ticket," "Ticket in use," and "restarting the initial 24-month period of active use."

  • Collecting and Documenting Earnings Information. Collecting and accurately documenting earnings information is critical to the administration of TTW. In the past, SSA systems have not facilitated this activity and, historically, relatively few automated resources were devoted to disability work issue cases. 2

  • EN Payment System. Developing and administering the EN payment system has proven to be particularly challenging due to a number of complicating factors:

    • The outcome payment system presents a challenge because of the difficulty in determining the month when disability benefits equal zero. This is particularly difficult for DI beneficiaries, because of factors such as expedited reinstatement, provisional payments, the trial work period, and discrepancies between actual payments and what should have been paid (i.e., adjustments for past overpayments and underpayments). Retroactive payment adjustment entries are often made in the SSA administrative data files, changing payment history to reflect what it should have been, rather than what was actually paid, further complicating the process for determining Ticket payments. The payment system cannot handle over- and under-payments automatically; it must be done manually, so dealing with over- and under-payments will be problematic if there are a large number, as there might well be because of past delays in obtaining and posting accurate earnings documentation.

    • Milestone and outcome payments interact in that milestone payments cannot be made once the outcome payments have started (that is, once benefits equal zero). The payment system must address this interaction.

    • The interaction between DI and SSI payments for concurrent beneficiaries is a complicating factor. When DI benefits are stopped because of work or earnings, SSI benefits generally increase. SSA has had to develop an approach to integrate DI and SSI earnings and payment postings. This enhancement to the payment system was implemented as part of the Disability Control File in late November 2002.

    • The interaction between TTW and the traditional SVRA payment system must be recognized. SSA must be able to check for SVRA involvement prior to making TTW payments. If there have been requests for traditional reimbursement after a Ticket is assigned, then this precludes the Ticket payment. Conversely, a payment to an EN before a request for payment from VR will preclude payment to the VR.

    • Over time, individual beneficiaries may use multiple ENs, which means that Ticket payments may need to be split among multiple ENs.

 

b. Ongoing Implementation Activities

SSA was able to establish the basic infrastructure necessary to implement TTW when the first round of Tickets began to roll out in February 2002, and the agency has continued to develop and refine administrative processes to address inadequacies of the initial systems and procedures.

Rules and Regulations. In December 2001, SSA released implementing regulations to govern TTW, and throughout 2002, drafted regulations to clarify implementation issues related to TTW, including regulations to provide for expedited reinstatement of benefits for disabled workers, disabled adult children, and disabled widows/widowers. SSA also developed regulations to: protect beneficiaries who participate in a vocational plan with an EN or SVRA from payment cessation, end SSA’s requirement to refer new beneficiaries to the SVRA, and protect against using TTW work activity to determine disability in the CDR process. SSA is in the process of reviewing Ticket regulations on Ticket eligibility for individuals in the Medical Improvement Expected (MIE) category and beneficiaries between 16 and 18 years old. Development of revised regulations will be a significant SSA activity during 2004, with a number of Notices of Proposed Rule Making expected throughout the year.

Certification Payment Request Process. In response to EN concerns about the burden of tracking earnings and the monthly submission of earnings documentation for payment, SSA and the Program Manager have implemented the Certification Payment Request Process. This process is a simplified outcome payment request option available to ENs and to SVRAs that elect to be paid as ENs. These service providers can qualify if the following criteria are met:

  • If the EN or SVRA has selected the outcome-only payment method, it can use the Certification Payment Request Process after the ticket holder has achieved three continuous outcome months for which the EN has received payment.

  • If the EN or SVRA has selected the milestone-outcome payment method, it can use the Certification Payment Request Process after the ticket holder has achieved milestones and the EN has been paid for the milestones, based on three continuous months of substantial gainful activity followed immediately by the ticket holder meeting the requirements for an outcome month.

Where these criteria are met, an EN, or SVRA electing an EN payment method, may choose to request payment either by including evidence of earnings or by the Certification Payment Request Process.

To use the Certification Payment Request Process, the EN prepares a request for payment on business stationery and sends it to the Program Manager. The request must include seven pieces of information, including a statement agreeing to relinquish EN outcome payments incorrectly issued; it does not, however, require earnings documentation. SSA will make payments based on the Certification Payment Request provided no information in SSA’s records contradicts the request. SSA will conduct post-payment validation reviews to verify work or earnings.

Mediation and Alternate Dispute Resolution Services Pilot. A mediation pilot program was recently implemented in three Phase 1 Ticket states—Arizona, Florida, and Illinois. SSA awarded the contract on September 30, 2002 to Peninsula Mediation Center of Hampton, VA. Mediation/alternate dispute resolution services seek to negotiate disputes between beneficiaries and ENs in a way that is cost-effective, efficient, and non-adversarial. The mediation process strives to maintain the relationship between the beneficiary and EN after Ticket assignment, but also aims to sustain each party’s individual participation in TTW. The current TTW dispute resolution process has three rounds of appeal for beneficiaries and ENs: (1) an internal grievance procedure defined by the EN; (2) resolution by the Ticket Program Manager; and (3) a final decision by SSA. The mediation process may be implemented prior to resolution by the Program Manager if mutually agreed to by the disputing parties. The Program Manager will then contact the mediation pilot contractor, who provides free assistance to the EN and beneficiary in identifying the issues underlying the dispute and finding a mutual solution within 30 days. The mediation services are offered by the Program Manager, who serves as the liaison between the disputing parties and the mediation contractor. If mediation is not successful, the dispute proceeds to the Program Manager. SSA interviewees note that to date, there have not been any formal disputes between beneficiaries and ENs. Interviewees also note that to date, no disputes have arisen between ENs.

TTW Marketing Efforts. SSA is in the process of developing new materials and conducting activities to market TTW to beneficiaries. Examples of marketing techniques and strategies currently in development include: a video of beneficiary success stories that contains interviews with several Ticket beneficiaries who have successfully participated in the program; and working with ENs and advocates in local areas to bring beneficiaries together to learn about TTW. SSA also awarded a two-year Strategic Marketing Plan Contract to Fleishman-Hillard on September 30, 2003. This professional marketing firm will develop a strategic marketing plan and create marketing materials to support TTW and other employment support programs. Fleishman-Hillard will also pilot the marketing materials. Target audiences include DI and SSI beneficiaries, service providers, and employers.

Area Work Incentive Coordinators and Work Incentive Liaisons. During 2001, SSA conducted a pilot project that placed 32 Employment Service Representatives who specialized in SSI and DI work incentives in local field offices. An internal SSA report prepared in November 2001 reviewed the pilot and recommended that the Employment Support Representative be established as a permanent position with the broadest possible distribution nationwide. Due to cost and staffing considerations, however, SSA could not implement those positions on a national basis. As an alternative, SSA adopted a plan to hire 57 staff who will work full-time as Area Work Incentive Coordinators (AWICS). This has already been expanded to 58 AWICs and can be expanded up to 70, as the need arises. Each coordinator will provide expertise on Ticket-related and other work incentives to 20 to 30 SSA field offices. Additionally, each field office will designate an existing staff person as a Work Incentives Liaison. The Area Work Incentive Coordinators were selected and after successfully completing their training, finished presenting training to the Work Incentives Liaisons by September 30, 2003. The Work Incentives Liaisons will continue to be delegated work incentive responsibilities in addition to their existing duties, allowing office managers to better control the priority of work incentives assignments.

The Disability Control File (DCF).3 SSA had to develop a number of enhancements to its systems in order to accommodate TTW. The development has occurred, and will continue to occur in stages. The CDR Control File (CDRCF) was originally created to control all SSI medical CDRs; limited DI medical CDRs were later included. Initially, Ticket information and controls were added to the existing file. The Disability Control File (DCF) was later created from the CDRCF to house all disability information that was needed to manage work CDRs (that is CDRs initiated because a beneficiary has returned to work), medical CDRs (regularly scheduled reviews of a beneficiary’s conditions to ensure that they continue to meet the disability criteria) and the Ticket program. Activities controlled in the CDRCF were converted into the DCF and the DCF became the file for managing disability post-entitlement activity. The DCF holds relevant information about Ticket eligibility and information to administer the TTW. It also contains other post-entitlement disability information for SSI and DI beneficiaries, medical information, monthly earnings, and work CDR information. An important feature of the DCF is that it will act as the single repository for earnings information for both the SSI and DI programs. This level of SSI/DI data integration is a first at SSA.

Recently, SSA has developed the Modernized Return to Work (MRTW) software to collect and process information about DI beneficiary work and earnings. MRTW was developed by staff at the Chicago regional office, in collaboration with Wisconsin-based SSA staff, as a means to improve the accuracy and reduce the burden and complexity of work CDRs. The software automates the generation of forms verifying monthly earnings that are mailed to beneficiaries and employers. The software totals earnings if a beneficiary has multiple employers, computes gross earnings, and applies the appropriate indexed value for substantial gainful activity and any special conditions to derive total countable earnings per month and year. This amount is entered into a desktop application, called the Personal Computer Continuing Disability Review (PC-CDR), which calculates the trial work period, substantial gainful activity, and Extended Period of Eligibility months and generates notices for field personnel. The MRTW information can be fed into PC-CDR to complete the work CDR process. Currently, MRTW and PC-CDR are not integrated with the national DCF system, which means that field staff must re-enter earnings data into each system and that data maintained in MRTW are only available to the local field office using the software. Under an initiative referred to as eWork, SSA is in the process of combining the MRTW and PC-CDR. This new software will be an integrated DI "front end" management tool to the DCF. This front end will have considerably more detail and functionality than the DCF to help field offices process work reports; (e.g., employer information, earnings tracking, trail work period automation and tracking). The DCF will remain the repository of work information that affects Ticket status and disability benefit eligibility (data on work and medical CDRs, Tickets, earnings, and use of work incentives such as the trail work period). SSA expects to begin releasing eWork as a national system in spring 2004.

Higher Priority of Post-Entitlement Workloads. TTW has raised the importance of processing post-entitlement disability workloads. With a few exceptions, SSA has not historically placed a high priority on the processing of this workload.4 This is particularly the case for post-entitlement work-related issues in the DI program. The implementation of the Area Work Incentive Coordinators and Work Incentive Liaisons and the development of MRTW/eWork will greatly facilitate the processing of this workload in the future. According to field staff, SSA leadership is also sending the message that this is now a priority workload. In addition to the tools and extra training on work incentive issues that SSA has been developing and providing to field staff since implementation of TTW, SSA is in the process of developing a performance evaluation system that will give a higher weight to post-entitlement work. The new system is expected to be implemented in FY 2005.

 

c. Impact of TTW on SSA Regional and Field Office Operations

The bulk of the effort to develop and implement TTW fell on SSA central office staff and the Program Manager. SSA believed that the impact of TTW on field office operations would be minimal, and to date this has proven to be the case. Regional and field office interviewees indicate that field office workloads have not been significantly affected by TTW, and the need to respond to TTW-related inquiries has not been overwhelming.

Regional office interviewees note that, early on, they were asked to review and comment on the TTW rules and procedures developed by the central office. Their role in implementing TTW, however, has been mainly to build TTW awareness, understanding, and acceptance. Regional office staff use information provided by the central office obtained through conference calls, policy material, interactive video training, and information packets to educate field staff and external stakeholders. Regional offices have sponsored informational forums for representatives of Disability Determination Services, Medicare, Medicaid, and other advocate, service, and support agencies working with disability program beneficiaries. Regional offices have also assisted the Program Manager in conducting EN recruitment activities. The scope and frequency of these activities are limited by regional office budgets, which have not been expanded specifically to cover TTW implementation activities.

Once initial TTW phase-in activities in a state are completed, regional office involvement in TTW outreach and dissemination activities becomes more limited. The regional office continues to act as a resource for TTW-related information, technical assistance to field offices and external entities serving beneficiaries in the region, and acts as the communication link between central office and the field. Regional offices have also played a role in monitoring field processing of EN payment cases. In addition, central office staff will sometimes contact the regional office to inquire about the status of the processing of earnings issues for a particular EN payment case. With the implementation of the Area Work Incentive Coordinator position, SSA expects that regional office staff will become less involved in these activities. One of the roles of the coordinators will be to monitor the processing of disability work issue workloads in the field, both for EN payment and general workload processing purposes.

Field office interviewees note that the SSA central office has placed a high priority on preparing field staff for TTW. A series of 40 interactive video training programs were broadcast to field offices on work incentive provisions. One field office manager interviewed notes that in his 20 years with SSA, he has never before seen as much training and emphasis on work incentive issues. Nevertheless, the emphasis on the training did vary from office to office, and some staff did not attend the training.

In addition to the training on TTW and work incentives, field office staff have been affected by the implementation of the DCF. According to regional and field office interviewees, field staff encountered difficulties with the system when it was first implemented. Some found the interactive video training on the DCF confusing and overly detailed. Others were frustrated by the system’s limitations and the need to duplicate some data entry because of the lack of integration with MRTW. Many of the problems field staff experienced with the DCF are being addressed by the eWork initiative and other enhancements being developed. Field office staff believe that the upcoming release of the integrated system will significantly reduce the burden and complexity of work CDRs and contribute to the timely processing of this workload.

At present, field office staff report that they are spending their TTW-related time gathering and documenting earnings information. Although there have been relatively few EN payment claims to date at any particular field office, the ones that have been received are often complicated and require extensive effort to address. In some offices, requests are being received from BPAOs and ENs for wage and benefit information that can be used in benefits counseling. Early in Phase 1, such requests were most notable in offices that had an Employment Support Representative.

 

2. Program Manager

a. Implementation Challenges

MAXIMUS signed a contract with SSA on September 29, 2000, and began operating as the Ticket Program Manager. As with SSA, the Program Manager had to expend a large effort to establish the infrastructure needed to administer TTW. Program Manager interviewees note several challenges associated with the initial implementation.

Systems and Infrastructure. The Program Manager had about 18 months to develop and implement all the systems and procedures needed to perform its required TTW functions. During this period the Program Manager established:

  • The internal systems to administer TTW, referred to as MAXSTAR. The system includes the local area network, quality assurance systems, telephone/PBX systems, programming and data analysis for MAXSTAR, and website development and maintenance. The MAXIMUS Program Manager is completely segregated from the rest of the company, with its own server dedicated to MAXSTAR and housed off-site. System back up and duplication is located at a third, redundant site on the west coast. The Program Manager developed several databases for TTW, including a contact database, an EN database, a payment database, and a beneficiary database.

  • An interface with SSA that allows the Program Manager to have essentially the same data access authority as an SSA field office, with its own field office code and SSA hardware. In conjunction with SSA, a batch-file system was tailor-made to include all the SSA administrative data elements that the Program Manager needs to administer TTW. SSA provides daily updates to the main records for the DI and SSI programs, including changes to addresses, program eligibility, benefits, and TTW eligibility. The file includes only individuals eligible for a Ticket, and does not allow the Program Manager access to CDR diaries. The Program Manager passes information back to SSA as well, including data on: Tickets mailed, Tickets assigned, active/inactive status, and terminated Tickets. This system has provided efficient data exchanges between the Program Manager and SSA, while maintaining necessary levels of security and information privacy.

  • A TTW training curriculum for ENs and SVRAs, consisting of 14 topical modules. The Program Manager also conducts large group trainings when EN groups come together as well as EN web training sessions.

  • A call center staffed by approximately 50 information agents, five supervisors, and one manager. The call center operates from 8:00 a.m. to 10:00 p.m. (Eastern Standard Time) to answer calls from potential ENs, the general public, the media, SVRA staff, and beneficiaries. The call center has handled approximately 157,000 TTW-related calls as of early August 2003. This department also handles EN relations after a provider’s EN application has been approved. For EN contacts, specific information agents are assigned to geographic areas and to SVRAs. Beneficiaries contacting the call center, however, are routed to the first available information agent, who can pull up records for any previous calls from the beneficiary. Agents will give their names and extensions to beneficiaries if follow-up contact is desired.

  • A website (www.yourtickettowork.com) that contains extensive information about TTW for ENs, SVRAs, beneficiaries, and the general public. The website contains training and information resources for ENs, and program information, including a directory of ENs, for beneficiaries.

In addition to establishing the internal TTW systems, a major activity of the Program Manager was to conduct EN recruitment for Phase 1. Between April 2001, when the request for proposals for ENs was released, and the end of Phase 1, approximately 350 ENs had been enrolled. Phase 2 recruitment began in February 2002.

Program Manager staff reports that EN recruitment has been an enormous effort. Enrolling the first 240 ENs as of January 2002, required approximately 37,000 mailings, 14,000 phone calls, and 7,500 in-person contacts.

Program Manager interviewees note that while the delayed rollout allowed more time to test systems and recruit ENs, it also created staffing issues. Program Manager staff, particularly the call center agents, required re-training because they forgot what they had learned while they waited for TTW to roll out. It was also difficult to keep Program Manager staff fully occupied during the period before Tickets were mailed. The multiple "false starts" (delays to Ticket rollout and the request for EN proposals) also delayed marketing efforts. Furthermore, the events of September 11, 2001, caused all September, October and November EN marketing campaigns and other processing activities to be delayed until December 2001.

EN Recruitment. According to both SSA and Program Manager interviewees, a primary implementation challenge has been EN recruitment. A survey conducted for SSA by the Gallup Organization in 1999 revealed a high level of interest in TTW on the part of traditional providers. However, the stated interest of providers did not result in significant numbers of applicants, once the request for proposals was released. The TTW payment system was a big issue. Initially, Program Manager staff expected that once the final payment system was established and the fourth milestone payment added, more ENs would enroll, but these expectations were not entirely met. At the beginning of 2002, 200 ENs were enrolled to serve Phase 1 states. As of late October 2002, the number was near 400. Program Manager interviewees had anticipated a response in the range of 500-800 by late 2002.

Program Manager staff reports several factors that have contributed to the difficulty in recruiting ENs:

  • Delays in publishing the final rules and in issuing the request for EN proposals created uncertainty about the program among providers.

  • There is little public awareness about TTW and little published information available for reference. Thus, the Program Manager has spent substantial time educating providers about the program’s features, the benefits of participation, and the details of enrollment.

  • SSA did not anticipate that most providers would be engaged in contract work for SVRAs, rather than being set up to function more independently. According to the Program Manager staff, providers have relied on VR for their funding and are not experienced operating as independent businesses. Many smaller potential ENs are also inexperienced with an outcome reimbursement system and have asked the Program Manager for a business model. Program Manager staff believe that it will take time before expertise is gained and/or consultants become available to advise small enterprises on how they might be successful under TTW.

  • Providers perceive the payment system as risky. Providers are wary of not having start-up money to fund services, noting that many beneficiaries they choose to serve might be unsuccessful in their attempts to return to work. Providers are also concerned about the administrative difficulties of tracking earnings in order to receive payment.

  • Extreme variations in the state political landscapes (e.g., presence of a Medicaid Buy-In, VR posture, presence of TTW committees, coalition activity) have also presented a challenge to Program Manager marketing, along with the fact that different organizations involved in the program have competing priorities. Each state represents a new and different environment.

  • Marketing activities are easily influenced by the health of the existing economy and labor market. For example, the Program Manager began conducting a new outreach strategy to recruit ENs from the business community in March 2001, but after September 11, interest in the program waned due to the economic downturn.

Another Program Manager challenge in the Phase 1 implementation of TTW was devoting sufficient time and resources to help SVRAs solve issues related to the internal administrative changes and burdens associated with TTW so that they would help facilitate the program. SSA and Program Manager interviewees indicated that, early on, rumors abounded that SVRAs had "strong-armed" other community providers in ways that dissuaded them from participating as ENs. Program Manager staff noted that they had no direct evidence to substantiate those rumors, and that they have continuously worked closely with the Rehabilitation Services Administration and the Council of State Administrators of Vocational Rehabilitation to keep them apprised of the rumors. Program Manager staff noted, however, that many times "perception is reality" and that the perception that becoming an EN is an attack on the SVRA appears to be an issue. From the Program Manager’s perspective and role in EN recruitment, it is helpful when no such rumors exist in a state and when the perception is that the SVRA is either neutral towards or supportive of TTW.

EN Payments. Program Manager staff members responsible for EN claims reported some difficulty in conveying to EN staff the particulars regarding earnings evidence requirements, including the difference between primary and secondary evidence, and required elements of each. For example, some SVRAs have stated that they only have quarterly Unemployment Insurance data to submit. While such data provide secondary evidence of earnings, additional investigative development is required to verify earnings by SSA, and this will substantially delay payment.5 EN and SVRAs are encouraged by the Program Manager to meet the requirements for primary evidence because it will expedite the payment process (SSA wants primary evidence because it will be used to make decisions about an individual’s continued eligibility for benefits; secondary evidence is acceptable when decisions only affect the benefit amount). With respect to primary earnings evidence, one issue that often must be addressed is the fact that pay stubs may not contain all of the information necessary for SSA to process the claim. The evidentiary requirements differ depending on the program in which the beneficiary is entitled (DI and/or SSI) and the type of payment claim. For DI, SSA requires information on the period in which the wages were earned. For SSI, SSA needs 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 about the date that the wages were earned. These subtle differences, and the fact that employer pay stubs do not always reflect both pieces of information, complicate the EN payment process even when ENs have been diligent about collecting the earnings information from beneficiaries.

Upon receipt of a payment claim, the Program Manager must inspect the claim (ensure that it complies with primary or secondary evidence of earnings requirements) and submit the information electronically to SSA. During the development of TTW, staff approximated Program Manager claim processing time at three and a half hours per claim. According to Program Manager staff, actual processing time early on was closer to eight hours per claim. At interviews in October 2002, Program Manager staff responsible for processing EN claims were hoping to reduce their processing time to about five hours by the following year. This will be achieved through better education of ENs regarding claim requirements and stabilization of the process at the SSA.

Program Manager staff note that the payment process was initially slow for several reasons:

  • The first 100 payment claims underwent a full review by SSA. For these 100 payment requests, only SSA could authorize the payment. For future payment requests, the Program Manager will be able to authorize payment.
  • The first claims submitted by an EN are generally difficult because of the EN’s inexperience with the process and lack of knowledge of SSA’s primary evidence requirements.
  • The first payment for each beneficiary is often difficult and time consuming because retroactive adjustments to a beneficiary’s record may be necessary. The process becomes much easier after the first payment for a particular beneficiary.

In an attempt to alleviate problems and shorten the long delay for claims processing, the Program Manager is suggesting that ENs tell beneficiaries to contact their SSA field offices and submit the required employment information before the EN submits the first payment request. In order for SSA to adjust benefits in response to earnings information, beneficiaries must report their employment status and earnings to SSA. Reports of earnings to the EN do not replace the requirement that beneficiaries report earnings to SSA directly, so that beneficiaries must report earnings to both places. In October 2002, Program Manager staff were also developing a one-page EN training module on payments, which will be distributed to all ENs.

 

b. Ongoing Implementation Activities

EN Recruitment. EN recruitment continues to be a challenge for the Program Manager, which has added additional marketing staff and continues to conduct extensive recruitment activities nationwide. Program Manager staff members have conducted over 90 EN recruitment fairs and over 200 informational presentations to provider audiences since beginning operations in 2000. Program Manager interviewees note that they have aggressively marketed TTW to about 50,000 organizations. At the time of our interview in September 2003, the Program Manager had successfully recruited just over 1,000 providers to operate as ENs. While EN recruitment has always been difficult, Program Manager representatives note that it has become even more difficult as the program has rolled out and providers have gained experience with the program. Recruiting ENs for TTW continues to be a "hard sell" for several reasons. The two primary reasons are that the payment system is perceived as too risky and the program is seen as too complex. In addition, many service providers remain wary about jeopardizing their existing funding streams with TTW revenue. In particular, funding from state VR agencies and state Medicaid programs might be at risk. Finally, many service providers are experiencing difficulty finding jobs for their clients in the current economy. This, combined with the reasons noted above, makes participation in TTW unattractive.

The Program Manager has also found it necessary to devote substantial effort to retaining ENs. Since the beginning of the program, 38 providers have terminated their EN status. Some of these providers have gone out of business or merged with other organizations, but others are unwilling to continue participating as an EN. In some cases, the terminating ENs have been losing money by devoting resources to the program without experiencing an adequate return. In other cases, the ENs decided that they were not in a position to service TTW clients, and rather than remain in "on hold" status indefinitely, they preferred to withdraw. The Program Manager found it necessary to develop "on hold" status for ENs because many providers that had signed up to be ENs were not yet prepared to take Tickets, and others taking Tickets were at full capacity. On hold status allows providers to remain as ENs, however, their contact information is not provided to beneficiaries. The Program Manager will periodically check in with the ENs on hold to determine whether they are willing and able to take Tickets.

EN Training. The Program Manager continues to update and enhance its training materials and formats. In addition to the training resources that have always been available to ENs (web downloads, web-based blackboard trainings, in-person trainings for larger groups) it has developed and made available to ENs a video DVD of the basics of TTW administration. The Program Manager has also recently developed the EN Capitalization Project to assist ENs in finding upfront sources of capital to serve clients under TTW. The nature of the EN payment system is prohibitive to smaller organizations that lack capital or diverse funding sources. By providing ENs and potential ENs with information on fostering additional funding sources through grant writing, foundations, private financial capital, and capitalizing on existing resources, SSA hopes to enable greater participation in the program by employment and support services providers. The Program Manager will organize the information into training modules, develop a directory of funding sources, and arrange to train ENs and potential ENs in eight sessions from October 2003 to February 2004.

Program Manager representatives we interviewed also noted the EN’s ongoing need for technical assistance. While some of this can be provided and facilitated by the Program Manager, interviewees believed that technical assistance and the sharing of best practices needs to grow out of ENs interacting with and learning from each other. The Program Manager has noticed a few EN associations or similar organized efforts beginning to form and views this as a very positive development.

EN Payments. Program Manager interviewees note that many ENs are still experiencing difficulty with the payment process. The Program Manager often must work extensively, one-on-one, with ENs to help them understand what earnings evidence is needed for claims payment. The Program Manager does not deny payment claims that have insufficient documentation. Instead, staff will contact the EN and attempt to get the evidence required to process the claim. If the EN is working with the Program Manager to try to resolve the issues but is unable to, the Program Manager will submit the claim to SSA with the evidence available. SSA must then develop the earnings information and this can significantly delay the processing of the claim.

Program Manager staff report that, as of the end of August 2003, 1,424 payment requests have been submitted. Of these: 55 percent have been paid; 14 percent are under active development by the Program Manger; and 14 percent are under development by SSA. The remaining 17 percent are claims referred to as "technical denials." While the Program Manager does not have authority to deny claims, those considered "technical denials" are claims that clearly do not meet payment requirements and that have not been withdrawn by the EN. Examples include insufficiently documented claims indicating earnings far too low to trigger payment (e.g., $100 per month), and claims that appear to be provider invoices for services delivered to Ticket holders.

Systems. Program Manager interviewees note that they continue to work with SSA to address problems with the systems used to administer the program. Some of the issues currently being addressed relate to Ticket eligibility. The system sometimes erroneously terminates Ticket eligibility when beneficiaries go into suspended status (i.e., when cash benefits go to zero due to work). Such terminations do not permit further TTW-related actions in the system, like EN payments or Ticket reassignments.

 

3. State VR Agencies6

TTW implementation created many challenges for State Vocational Rehabilitation Agencies (SVRAs). During initial rollout in the Phase 1 states, SVRAs moved quickly to learn about the program, develop administrative procedures and modify data systems, train staff, and change the way they interacted with Ticket-holder clients on their caseloads and applying for SVRA services. In this section, we review the extent to which SVRAs are serving Ticket holders, both under the traditional SSA VR payment system and the new payment options. In addition, we discuss issues related to SSA guidance to SVRAs on program implementation, describe common TTW implementation strategies across multiple states, and summarize concerns related to the development of VR-EN collaborative agreements.

 

a. SVRA Participation in TTWThe vast majority of beneficiaries participating in TTW have assigned their Tickets to an SVRA. Of the 24,462 Ticket assignments reported through August 29, 2003, 21,670 (89 percent) had been made to SVRAs. SVRA assignments to date have been equally divided between individuals already on state agency caseloads (termed "pipeline" cases) and new clients to SVRAs. The fact that SVRA Ticket assignments constitute nearly 90 percent of all TTW activity to date reflects the dominant role SVRAs have traditionally played in providing employment services to beneficiaries, a role that they continue to assume under TTW.

In over 80 percent of the Phase 1 and 2 states, two-thirds of all Ticket assignments have been made to SVRAs (Table III.3). Examples of states in which a relatively low percentage of Ticket assignments have been made to SVRAs include Nevada (52 percent of assignments to the SVRA), Arkansas (52 percent), Arizona (54 percent), and Mississippi (54 percent). Examples of states in which the overwhelming number of Ticket assignments have been made to SVRAs include Vermont (99 percent), South Dakota (99 percent), Oklahoma (99 percent), Delaware (97 percent), and South Carolina (96 percent).

Under TTW, SVRAs are allowed to choose whether to serve an individual under the traditional SSA VR payment system, or under one of the EN payment mechanisms. To date, 84 percent of Ticket holders served by SVRAs are served under the traditional SSA payment system. Only one SVRA (Oklahoma) has assigned a large number of Tickets under its EN payment mechanism. As discussed further in Chapter V, this SVRA is making a concerted effort to identify clients for whom the agency is likely to obtain more revenue under TTW than under the traditional payment system. In general, these are relatively lower-costs clients who might work enough to achieve some milestone payments, but are unlikely to work at levels sufficient to generate payment under the traditional payment system.

Table III.3: Ticket Assignments to State VR Agencies* (August 29, 2003)

State

Total Number of Tickets Assigned in State

Number of Tickets Assigned to VR

Percentage of Tickets Assigned to VR

Phase I

Arizona

539

289

53.6

Colorado

349

320

91.7

Delaware

456

443

97.1

Florida

1,214

804

66.2

Georgia

287

218

76.0

Iowa

616

555

90.1

Illinois

4,074

3,839

94.2

Massachusetts

617

521

84.4

New York

6,169

5,801

94.0

Oklahoma

1,018

1,007

98.9

South Carolina

1,244

1,197

96.2

Vermont

267

265

99.3

Wisconsin

1,750

1,634

93.4

Phase 2

Alaska

25

21

84.0

Arkansas

109

57

52.3

Connecticut

238

220

92.4

District of Columbia

63

46

73.0

Indiana

128

95

74.2

Kansas

114

77

67.5

Kentucky

197

175

88.8

Louisiana

591

546

92.4

Michigan

1,517

1,416

93.3

Missouri

367

288

78.5

Mississippi

266

143

53.8

Montana

86

85

98.8

North Dakota

10

9

90.0

New Hampshire

19

10

52.6

New Jersey

242

172

71.1

New Mexico

32

28

87.5

Nevada

194

101

52.1

Oregon

259

192

74.1

South Dakota

190

188

98.9

Tennessee

714

525

73.5

Virginia

364

273

75.0

Total

24,325

21,560

88.6

Source: Program Manager Ticket Assignment Report 9-2-03.
*Does not include 137 Ticket assignments of beneficiaries residing in Phase 3 localities. Of these, 110 were assigned to SVRAs.

b. Pipeline and New Cases

SVRAs work with three types of SSA beneficiaries—individuals who are not eligible for TTW (non-Ticket cases), individuals who were already clients of the SVRA at the time they became Ticket eligible (pipeline cases), and individuals who become Ticket eligible before they become clients of the SVRA (new cases). SSA has provided guidance to the SVRAs on providing services to each of these groups through Transmittal 17 of the Vocational Rehabilitation Providers Handbook (SSA, 2002). Current SSA guidance for each of these three categories is briefly described below.

Non-Ticket cases are beneficiaries who are not eligible for a Ticket. SVRAs are not allowed to serve these individuals as an EN. SVRAs can serve non-Ticket cases under the traditional payment program and receive reimbursement when all SSA guidelines for the program are met. They can also serve these individuals using their regular non-SSA funds.

Pipeline cases are beneficiaries who first become Ticket eligible after developing and signing an Individual Plan for Employment (IPE) with an SVRA. Pipeline beneficiaries have three options: (1) assign the Ticket to the SVRA; (2) assign the Ticket to an EN; or (3) not assign the Ticket to any entity. If a beneficiary assigns the Ticket to the SVRA, the SVRA can use either the traditional payment or its selected EN payment system. Ticket assignment in pipeline cases occurs when the beneficiary and the SVRA both sign an IPE and the State Agency Ticket Assignment Form (Form 1365), and the SVRA submits the form to the Program Manager.

If a pipeline beneficiary does not assign his or her Ticket to the SVRA, the agency can still serve the individual under the traditional payment system, but only if program requirements for payment are met before SSA makes a payment to an EN to whom the beneficiary has assigned the Ticket. This provision has led SVRAs to devote considerable resources to contacting Ticket holders on their existing caseloads, explaining the Ticket program to those individuals, and encouraging them to assign their Tickets to the SVRA, as opposed to a non-SVRA EN.

New cases are beneficiaries who first become eligible for TTW before signing an IPE with the SVRA. A new case beneficiary can assign a Ticket to the SVRA by signing Form 1365. If the beneficiary does not sign Form 1365, however, the unsigned form can be submitted along with the front and last page of the IPE if both the beneficiary and SVRA representative have signed the IPE.

SVRAs have expressed concern about SSA guidance on new cases. The guidelines allow SVRAs to submit a signed IPE for Ticket assignment for beneficiaries who have not knowingly agreed to assign their Tickets to the SVRA. As a result, the guidance is viewed by some SVRAs as violating the principle of informed consent, and many SVRAs are very reluctant to use this type of "automatic assignment." In situations where a beneficiary signs an IPE but declines to assign the Ticket to the SVRA, the agency must either use the automatic assignment provision or risk losing the opportunity to receive any type of SSA payment for the beneficiary.

SVRAs have also expressed a concern that the SSA guidance on new cases may limit beneficiary choice in Ticket assignment. For example, if at some future point the beneficiary wants to assign his/her Ticket to an EN other than the SVRA currently holding this Ticket, the beneficiary will have to initiate a reassignment request to the Program Manager. However, if the SVRA is already eligible to receive a payment under the Ticket program for this beneficiary, the value of the Ticket for reassignment is potentially limited because the TTW payments would have to be shared with the SVRA.

 

c. SVRA Implementation Strategies

SVRAs used a number of strategies to prepare for the Ticket rollout. Among the 13 Phase 1 states, several SVRAs were initially very excited about TTW and had expressed an interest in being part of the initial rollout. Others were less enthusiastic. SVRAs that initially embraced TTW believed that they possessed a strong state infrastructure, including the presence of Medicaid Buy-In programs, strong benefits planning networks, State Partnership Initiative projects, DOL Work Incentive Grants, and high quality service delivery systems that would enable them to effectively operate within the new program. SVRAs in other states expressed concern about the possible success of TTW and their ability to implement the program successfully. In anticipation of TTW rollout, most SVRAs participated in national meetings and received technical assistance from SSA and the Program Manager, developed state-specific TTW implementation teams, prepared staff development programs, participated in regional conference calls sponsored by SSA regional offices, modified data systems to allow tracking of Ticket holders, and conducted outreach to potential ENs.

SVRAs have developed internal organizational structures and allocated resources to respond to a demand for services by TTW recipients. Implementation strategies have varied considerably, based primarily on the size of the state, the anticipated demand for services, and prior experience with the SSA cost reimbursement program. Some SVRAs have established centralized TTW units, staffed by individuals solely responsible for TTW activities. Others have chosen more decentralized implementation designs where TTW duties were added to the work assignments of staff members already responsible for a number of different activities. Common implementation strategies have included development of call centers (although most states establishing these centers have closed them due to a lack of demand), centralized TTW units responsible for all aspects of implementation, identification of a single Ticket coordinator or regional Ticket counselors, and decentralized implementation procedures where all beneficiaries are referred to local SVRA offices.

SVRA personnel have consistently expressed a concern that many beneficiaries contacting them lack basic information about TTW. SVRA staff describe contacts from beneficiaries who believed that the Ticket entitled them to an immediate job, who did not know that participation was voluntary, who did not want to work, who believed they could exchange their Tickets for cash, or who believed their benefits to be in jeopardy. Many interviewees expressed frustration regarding the perceived lack of information provided to beneficiaries by SSA and the Program Manager, despite extensive marketing of TTW by the Program Manager and other events sponsored by SSA. SVRA staff generally believe that the Program Manager is responsible for basic TTW education, but acknowledge the challenges inherent in explaining a complicated program to SSA beneficiaries. Many believe that the letter accompanying the Ticket mailing could contain additional information that would inform beneficiaries about many of the key areas of TTW, such as CDR protection, the Medicaid buy-in (where applicable), Benefit Planning Assistance and Outreach services, and expedited reinstatement of benefits.

From the SVRA perspective, the need to explain basic aspects of TTW to numerous beneficiaries creates an administrative burden and increases the costs of participating in the program. After explaining the TTW program to beneficiaries who frequently were not interested in participating in the program, several SVRAs began to develop more systematic screening protocols and to refer individuals to local Benefits Planning Assistance and Outreach programs for more information and counseling. However, most agencies have not attempted to develop concise, effective screening tools.

In addition to the burden on staff associated with providing beneficiaries with basic information about TTW, many SVRAs have expressed dissatisfaction with the amount of information they are able to obtain about Ticket holders. The elimination of SSA referral of beneficiaries to SVRAs and the lack of access to data on beneficiaries that was available to SVRAs pre-TTW have affected SVRA methods for client outreach and recruitment. In addition, SVRAs are no longer permitted to advertise or keep informational materials in SSA field offices. SVRAs have also expressed some concern about the administrative resources that must be devoted to the Ticket assignment, earnings tracking, and EN payment claim submission process.

Aside from the new administrative procedures associated with TTW, early interviews with staff at SVRAs suggested that the program has not caused a major change in the nature of the services offered and provided by SVRAs. Some SVRA interviewees have noted, however, that TTW has brought about a greater emphasis on Social Security benefits planning and work incentive issues that have required SVRA staff to become more knowledgeable about and sensitive to these issues. The evaluation will continue to track the extent to which the targeting, nature, or intensity of SVRA services is affected by TTW.

 

d. VR/EN Agreements

A key issue in the initial rollout of TTW was the development and implementation of agreements between SVRAs and ENs. Final Ticket regulations require that if a beneficiary assigns a Ticket to an EN, and the EN wishes to refer the individual to the SVRA for services, the SVRA and the EN must negotiate and sign a VR/EN agreement. VR/EN agreements have been developed in all Phase 1 and many Phase 2 states. While TTW regulations allow each EN to negotiate an individualized agreement with the SVRA, in practice, most SVRAs have developed a standard agreement that is used with all ENs.

VR/EN agreements generally address referral and information sharing procedures, the financial responsibilities, the terms under which the EN will reimburse the SVRA for providing services, and dispute resolution procedures. Existing VR/EN agreements vary widely in terms of (1) the specific service costs that the SVRA will attempt to recoup from the EN, (2) the procedures used to determine how SSA payments to ENs are shared between the SVRA and the EN, and (3) the mechanisms used by the SVRA to encourage ENs to provide ongoing support and employment retention services to beneficiaries.

From the perspective of SVRAs and the Rehabilitation Services Administration (RSA), the principle of "comparable benefits" should guide the development of VR/EN agreements. RSA regulations define comparable benefits as "services and benefits that are provided or paid for, in whole or in part, by other Federal, State, or local public agencies, by health insurance, or by employment benefits."7 The principle of comparable benefits implies that, in situations where services can be paid for by other entities, SVRAs are not required to use agency funds to support these services.

RSA has interpreted TTW to be a comparable benefit under the federal VR regulations. Initial RSA guidance to states provides that "Should the individual seek services both from an SVRA and a non-VR agency EN, then the SVRA may view the services provided by the EN as a comparable service and benefit under section 101(a)(8) of the Rehab Act and 34 CFR 361.53. Yet the SVRA should not discontinue all services to the individual unless it is clear (not "assumed") that the individual intends to receive all necessary services through that EN."8

The comparable benefits principle has been the basis for SVRA development of VR/EN agreements. However, many VR/EN agreements contain provisions that go beyond the current guidance provided by the RSA. Examples of issues under the comparable benefits principle addressed in some VR/EN agreements include the following:

  • Should any service an EN indicates it can provide in its application to SSA be considered a comparable benefit? Recent guidance by the RSA indicates that such an interpretation is too broad and that comparable benefit determinations must be made on an individual-by-individual level. However, a number of current VR/EN agreements preclude SVRA funding for any and all services specified on an EN’s application to the Program Manager.
  • Are SVRAs permitted to require ENs to reimburse the SVRA for administrative costs, including counseling and guidance, in addition to direct employment support services? In at least one state, case management counseling services, normally a part of an SVRA’s Individual Plan for Employment, become the required responsibility of the EN.
  • Can SVRAs collect a share of SSA payments to an EN over and above the actual amount expended by the SVRA on behalf of a beneficiary? In at least two states, the VR/EN agreement requires the EN to share payments with the SVRA even after all costs have been repaid by the EN.
  • Are SVRAs permitted to require ENs to reimburse the SVRA for its expenditures, even before the EN begins to receive Ticket payments from SSA? In at least one state, the VR/EN agreement requires the EN to reimburse the SVRA for the total cost of all services, even if the EN stops receiving TTW payments before being fully reimbursed.

In some states, dozens of ENs have signed VR/EN agreements with the SVRA. In others, few, if any, ENs have entered into agreements. The lack of signed VR/EN agreements in many states might be due to several factors. Some ENs, particularly national ENs, may not see a need to sign an agreement with an SVRA. Other ENs may view the terms of the agreements as financially unfavorable. In some instances, the SVRA may not be aggressively pursuing the development of agreements with non-VR ENs, preferring to encourage the assignment of all Tickets to the SVRA.

 

e. Summary

Despite initial concerns about the impact of TTW on existing funding streams and administrative procedures, many SVRAs appear to have increased their emphasis on providing services to SSA beneficiaries. In addition, SVRAs continue to receive the overwhelming majority of Ticket assignments, in spite of their concerns about the relationship between TTW and the SSA traditional payment system, Ticket assignment and program implementation procedures, and SVRA relationships with other ENs. While many SVRAs still have significant concerns about the future of TTW, it appears that the program has not had the significant negative effect on SVRAs that many had feared.

 

4. Employment Networks

TTW represents a significant change in the business practices for ENs that are traditional providers of rehabilitation services, as are most. The primary changes relate to the nature of the payment system and to provider relationships with SVRAs.

With respect to the payment system, many traditional providers have relied on funding from an SVRA and other sources that, while outcome-based in some respects (depending on the state), typically finance services up-front and over shorter time periods. TTW payment is wholly based on outcomes and is extended over a long period. For many providers, such a payment structure is not a good fit with pre-existing financial systems, services, and/or expected outcomes for their traditional clients.

TTW has changed the nature of the relationships between SVRAs and ENs that were vendors to the SVRA before TTW. Prior to TTW, these vendors relied heavily on the SVRA in their state for clients and funding. However, TTW establishes a mechanism under which providers might directly obtain both SSA funding and beneficiary clients without involving the SVRA as an intermediary. Potentially they may become a competitor to an SVRA even though they might continue to be a vendor to the SVRA.

ENs that are non-traditional providers or have never been vendors to an SVRA face their own challenges, which vary depending on past experience and other lines of business. Some are providing other types of services to beneficiaries (e.g., health care), and run into issues with blending funds from other sources with Ticket money. Others provide employment services, but have not served the beneficiary population in the past and see this as an opportunity to do so. Some have, or have sought, funding for start-up costs and capital from other sources. It appears to be rare for these ENs to have developed relationships with SVRAs.

We will develop a more comprehensive assessment of this issue later in the evaluation when we have interviewed a much larger variety of ENs. In the remainder of this section, we describe what we have learned to date about: factors that affect provider participation as ENs, early EN experiences enrolling Ticket holders, early payment outcomes, and EN/SVRA relationships from the EN perspective. It should be noted that most of the following discussion is drawn from interviews conducted in 2002 (Livermore et al. 2003).

 

a. Factors Affecting EN Participation

Many providers enrolled as ENs because it was relatively costless to do so, but without strong intentions to accept Ticket assignments in the immediate future. The simple EN application procedure and the ability to accept Tickets on a voluntary, case-by-case basis make enrollment as an EN appear low risk to providers. Providers can slowly develop experience with the program and determine whether it has the potential to cover their expected costs and make it possible for the provider to expand the services it offers and/or the clients it serves.

Although many providers have elected to enroll as ENs in both Phase 1 and Phase 2 states, and SSA has accepted almost all EN applications, relatively few ENs have accepted Tickets (Table III.4)—just 38 percent of ENs in Phase 1 states, and 30 percent in Phase 2. Even fewer are accepting large numbers of Tickets (Figure III.1). As of late July 2003, of the 131 ENs that had assignments and operated in the Phase 1 states, only 30 had more than 10 assignments, 7 had more than 50, 5 had more than 100, and 1 had over 300.9 Of the 152 additional ENs that had assignments and operate only in the Phase 2 states, 24 had more than 10 assignments, 2 had more than 50, and 1 had more than 100.10

 

Table III.4: ENs and ENs with Ticket Assignments, by Phase and State
(as of August 29, 2003)

 

State

 

ENs

ENs with Assignments
Number
Percent
Phase I (13)
Arizona
25
10
40
Colorado
18
5
28
Delaware
5
3
60
Florida
65
25
38
Illinois
63
21
33
Iowa
29
13
45
Massachusetts
46
17
37
New York
103
38
37
Oklahoma
8
1
13
Oregon
28
13
46
South Carolina
16
7
44
Vermont
2
0
0
Wisconsin
26
10
38
Total - Phase I
434
163
38
Phase 2 (21)
Alaska
3
1
33

Arkansas

15

4

27

Connecticut

11

3

27

District of Columbia

7

3

43

Georgia

20

4

20

Indiana

29

4

14

Kansas

17

5

21

Kentucky

18

6

33

Louisiana

14

5

36

Michigan

56

16

29

Mississippi

5

2

40

Missouri

33

13

39

Montana

8

1

13

Nevada

14

5

36

New Hampshire

4

2

50

New Jersey

26

10

38

New Mexico

10

1

10

North Dakota

5

1

20

South Dakota

3

1

33

Tennessee

16

9

56

Virginia

26

7

27

Total - Phase 2

340

103

30

National ENs

10

6

60

Source: The Program Manager, Summary Ticket Rollout Status Report #80, September 2, 2003.

Click here for Figure III.1

 

Based on interviews with ENs and feedback given at the EN Summit, the main reasons for low participation are issues with the payment system, the complexity and administrative burden of the program, and a lack of knowledge on the part of providers about how to operate successfully under the program.

Payment System. Many ENs do not believe that TTW payments, as currently structured, would cover their costs, but were willing to enroll as an EN and would participate in the future if the payment system were to become more lucrative. The lack of funding to cover up-front costs, the belief that beneficiaries will not achieve long-term outcome goals, limited service capacity, and uncertainty regarding whether TTW payments would jeopardize other funding sources all contribute to many ENs currently accepting few or no Tickets. EN Summit participants recommended that SSA:

  • Shorten the length of the payment period and provide larger payments early in the period
  • Base payment on the average of SSI and DI benefits combined rather than have separate systems for the two programs
  • Reduce the difference in total payments between the milestone-outcome and outcome payment systems
  • Provide payments for partial success, at earnings less than necessary to reduce benefits to zero
  • Allow all ENs to choose between outcome-only and milestone-outcome payments on a case-by-case basis

These changes would likely increase SSA’s Ticket costs for individual beneficiaries and some would make the program more complex and costly to administer. Further, it is likely that some of these recommendations would require new legislation. It is difficult to predict the net effect of these recommendations on program savings because implementation would likely expand Ticket participation and increase competition between ENs.

Combining Funding Sources. The nature of the TTW payment system makes it necessary for many providers to seek and use other sources of funding in order to provide any services upfront and to provide more intensive and ongoing services in general. Some ENs, however, are concerned about the implications of receiving TTW revenue after funding has been received from other sources. Some ENs receive substantial support from state agencies, including state Medicaid, mental health, and developmental disabilities agencies. They would like to use TTW revenue to provide additional services that would improve their clients’ earnings, but are concerned that the other agencies will consider TTW funds as duplicative of their funds or services and therefore not provide reimbursement. For example, because Medicaid is payer of last resort, many providers believe that they are not allowed to accept Ticket payments, or if they do, these payments must offset the service costs billed to Medicaid. These providers have chosen not to serve clients under TTW in order to keep their Medicaid funding our of jeopardy (Livermore et al. 2003).

Administrative Burden. EN’s concerns about complexity and administrative burden center on screening beneficiaries who seek services and on filing earnings reports to ensure payment. To some extent, concerns about screening reflect the high volume of phone calls that ENs in Phase 1 states received when Tickets were initially mailed. In general, ENs found that many callers were poorly informed about how the Ticket works and lost interest once the EN answered their questions. One of the EN Summit recommendations to SSA was to address this problem through beneficiary outreach efforts. Many ENs were also very concerned about how to identify accurately those beneficiaries who were likely to increase their earnings sufficiently to trigger payments. An EN must track and document the earnings of its Ticket clients to assure that it will receive the appropriate payments. EN staff that we interviewed expressed varied perceptions regarding the feasibility and anticipated level of effort required to track earnings. Several interviewees reported that their existing systems would already support or could be modified to support TTW’s long-term earnings tracking requirements, and some had developed sophisticated tracking systems. More than half of interviewees, however, reported significant concerns about the feasibility and/or appropriateness of tracking client earnings. One of the recommendations of the EN Summit was for SSA to develop software that ENs could use to track case status. ENs also expressed considerable concern about the timeliness of payments, and possible payment denials, once wages are reported. These latter concerns appear to stem from the fact that SSA has lacked procedures to adequately document beneficiary earnings on a monthly basis and make adjustments to benefits in a timely manner. As discussed earlier in this report, SSA has undertaken several initiatives to address this issue. At the time we conducted the first-round EN interviews (in 2002), few ENs had extensive experience with requesting payments. The mechanics of SSA’s payment system were the topic of much discussion at the EN Summit, and the ENs made numerous suggestions to improve them, including:

  • Drop requirements for wage reporting after a beneficiary loses their cash benefits due to earnings
  • Develop a method to base payments on estimated earnings, not verified earnings
  • Develop a method to use existing sources of administrative data (e.g., unemployment insurance reports) to determine earnings
  • Develop methods for full or partial payment based on presumptive eligibility, with retroactive verification required
  • Eliminate the requirement that beneficiaries report earnings to both SSA and the EN
  • Develop uniform definitions of earnings for purposes of SSI and DI eligibility continuation
  • Implement procedures to process earnings reports in a more timely fashion to reduce overpayments

While SSA has recently altered the wage reporting requirements, various issues would need to be addressed in order to implement the additional EN recommendations. For example, reporting lags inherent in using third-party wage reports such as IRS or state unemployment insurance data will result in significant delays in EN payments. Because EN payments are based in part on savings to the Federal government resulting from beneficiary payments being reduced to zero, basing EN payments on estimated earnings could result in overpayments to ENs and the requirement that ENs pay back SSA for months when Ticket holder benefits were not actually zero. These and other problems will need to be addressed for SSA to implement the above recommendations.

TTW Service Models. Few ENs interviewed in 2002 had developed business plans or conducted formal assessments of the potential costs and revenues associated with TTW. Many view TTW as just another potential funding source for the traditional services they provide, and do not intend to change their service delivery approach or invest substantial resources into operating under TTW. The large majority of ENs have elected the milestone-outcome payment system, primarily because it provides payments sooner than the outcome-only system, and also because ENs are not confident (and in some cases, do not expect) that clients will achieve long-term employment above SGA. At the EN Summit, ENs recommended that SSA conduct an EN capitalization study, develop training materials that would help them learn how to be financially successful, and develop a means for ENs to identify and share best practices. As noted previously, SSA has recently funded an EN capitalization project to address this concern. A few ENs interviewed in 2002 had conducted financial assessments of the expected costs and revenues associated with TTW and, at that time expected to eventually generate revenues sufficient to cover their costs. We interviewed two of these ENs approximately one year later, and as discussed further in Chapter V, neither were covering their costs during the first year of TTW, and one had substantially curtailed its participation in the program.

 

c. Early Experiences Enrolling Ticket Holders

Marketing and Screening. Most ENs interviewed in 2002 were not actively marketing their services to beneficiaries. Those interviewed indicated that they receive a large number of unsolicited phone inquiries from beneficiaries who obtain their names and contact information from the Program Manager. They also noted that the number of phone calls from beneficiaries was overwhelming when Tickets were first mailed. As noted previously, SSA has since slowed the rollout schedule for the Phase 2 and 3 states.

Many EN interviewees reported experiencing difficulty responding to beneficiary inquiries about TTW and screening for appropriate candidates. Most callers appear to have a poor understanding of TTW when they contact ENs, and EN interviewees report spending a considerable amount of time explaining the program and dispelling beneficiary misconceptions. Common misconceptions include beneficiaries believing that: their Tickets can be directly exchanged for jobs, ENs are required to accept their Tickets, and ENs must provide funding for SVRA services. Beneficiaries are also often surprised to learn that ENs only want to accept Tickets from those who are willing and able to eventually earn enough from work to lose their disability benefits. Several ENs noted beneficiary characteristics that they look for in deciding whether or not to accept a Ticket. Such characteristics include: a desire for full-time employment, the ability to earn above $8 per hour, the ability to be quickly placed in employment (few significant barriers to entering employment), and needs consistent with the services offered by the EN.

Some EN interviewees described approaches they had developed to minimize the burden of educating beneficiaries about TTW and identifying appropriate candidates. These approaches include the following:

  • Developing key screening questions and criteria, which are applied prior to spending time educating beneficiaries about the program. For example, ascertaining whether beneficiaries are willing to work full time, are immediately available for job interviews, and the number of job interviews they are willing to do per week. Responses consistent with a strong desire to work are indicators of appropriate candidates.

  • Holding group orientation sessions for those meeting initial screening criteria to describe the purpose of the program and to emphasize how the EN will be paid, or not paid, based on beneficiary work outcomes.
  • Developing specific criteria for unassigning Tickets and incorporating those requirements into the individual work plan agreement with the beneficiary. Examples of criteria used by ENs to unassign Tickets include missed appointments or job interviews, being a no-show for a job, and losing contact with the counselor.

Ticket Assignments. Early in TTW implementation, a few ENs were accepting a substantial number of Tickets and appeared to be experiencing some success. These ENs had several traits in common: they had established processes for selecting motivated and seemingly employment-ready Ticket holders; they were very selective about whose Tickets to accept, indicating that only 10 to 30 percent of Ticket holders screened resulted in an assignment; they offered very limited services and focused on interview skills, resume writing, and job placement; and they adhered to policies for unassigning the Tickets of beneficiaries who did not appear to be actively engaged in the program.

 

d. Early EN Experiences with Employment and Payment Outcomes. At the time of the initial site visits (2002), few ENs had placed beneficiaries in employment or had received payments. As of early August 2003, a total of 673 outcome or milestone payments had been made to 70 ENs in both Phase 1 and 2 states, on behalf of 240 Ticket holders. Most ENs serving Ticket holders working at levels that make the ENs eligible for payments have only a small number of such clients, and just a few have a substantial number of clients that make them eligible for payments (Figure III.2). Of the 67 ENs that received a payment, 35 had received payment for only one Ticket holder and 60 had received payments for five or fewer Ticket holders. One had over 30 Ticket holders working at levels that generated EN payments. In summary, most ENs with payments have received only small amounts thus far, although a very few have received substantial sums (Figure III.3); 27 ENs had received less than $1,000, and 57 ENs had received less than $5,000. Only four had received more than $10,000, including one with more than $30,000. The 10 ENs receiving over $5,000 to date have received 57 percent of all payments made. Only three SVRAs acting as ENs had received milestone or outcome payments, for 28 Ticket holders, as of August 2003. Of the $29,000 in payments to SVRAs, 93 percent went to one SVRA.

 

Click here for Figure III.2

 

Payments to date are very low relative to the number of Tickets assigned and it remains to be seen whether they will eventually increase to a level that will make it financially viable for many providers to serve beneficiaries as ENs. Some of the ENs we re-interviewed as we prepared this report described negative experiences with the payment system (see Chapter V). We were unable to obtain access to payment data in time to conduct an analysis of payment delays and refusals for purposes of this report, but we will include this information in future reports.

 

Click here for Figure III.3

 

A few ENs interviewed in 2002 mentioned the extended length of time it took for SSA to process claims for payment, noting delays of 90 to 120 days. As discussed in Chapter V, this issue was again raised during our interviews with ENs in 2003. According to SSA staff, payment delays can be attributed to several factors:

  • Until June 2003, it was impossible for SSA field offices to identify Ticket payment cases from the administrative systems and, therefore, field employees could not identify these workloads until they were brought to their attention by regional or central office coordinators.
  • What is generally depicted as a simple verification of earnings information posted by the Program Manager is, in reality, most often a full work activity CDR with a determination of Trial Work Period months and SGA, and frequent development of earnings that occurred several months before the Ticket in-use date.
  • Often, the earnings information submitted by the ENs is incomplete.

e. Relationships with State VR Agencies.  The initial 2002 site visits indicated that most ENs had not signed agreements with their state’s VR agency. We do not have up-to-date complete information on signed agreements, but it appears that, except in a few states, signed agreements are relatively rare and instances where beneficiaries are served jointly under such agreements even rarer. As noted previously, the reasons appear to include the following: (1) ENs do not see a need to enter into agreements with SVRAs, either because they do not expect to use SVRA services, or because they do not believe an agreement with the SVRA is necessary for the EN to use SVRA services for Ticket clients; (2) ENs do not view the terms of the agreements as favorable to them; and (3) the SVRA is not aggressively encouraging ENs to sign the agreements.In virtually every Phase 1 state, the SVRA-EN agreement was developed by the SVRA and then submitted to ENs to accept or reject. In a few instances, ENs or groups of ENs were formally or informally involved in the agreement development process. With a few exceptions, it appears that SVRAs are developing one agreement for all ENs in the state, rather than agreements tailored to individual ENs, and are largely prescribing the content of the agreements. At the EN Summit, participants recommended that SSA (1) explore possibilities for allowing beneficiaries to use SVRA services under the traditional payment system, then subsequently permit use of the Ticket with an EN; (2) implement guidelines to govern SVRA-EN agreements to promote equitable, long-term financial joint ventures with shared risk and responsibility; and (3) assess the policies articulated in the Transmittal 17 amendment to SSA’s VR Provider Handbook related to the requirements of Ticket assignments to SVRAs, particularly to ensure that beneficiaries would not have their Tickets assigned to an SVRA without their knowledge and consent.


Notes:

1Program Manager Summary Ticket Roll Out Status Report #19, July 1, 2002. Return to text.

2SSA's new automated system, eWork, will automate the collection and documentation of earnings information and is scheduled to be piloted starting November 2003. Return to text.

3As we were finishing this report, SSA re-named this file as the Integrated Disability Management System. Return to text.

4In recent years, SSA has made the processing of medical CDRs and SSI re-determinations high priority. Return to text.

5Some SVRAs acting as ENs complained that they wanted to continue using third-party reporting information to process earnings for Ticket clients. SVRAs were initially required to submit the same earnings documentation as other ENs. Later, SSA allowed SVRAs to submit third-party earnings information; e.g., from state Unemployment Insurance data, in lieu of pay stubs. However, if SSA must wait for primary evidence to become available via IRS, the delay in payment can be up to two years. Return to text.

6Most of this discussion is drawn from interviews with Phase 1 SVRAs conducted in 2002 and reported in Livermore et al. (2003). We will conduct another round of interviews in early 2004 to update this information.Return to text.

7Federal Register (January 17, 2001). 66(11), 4384, 34 CFR 361.5(b)(1)(i)(A and B). Return to text.

8Pasternak, Robert (May 20, 2003). Testimony to the Ticket to Work and Work Incentive Advisory Panel Quarterly Meeting, Washington, DC. Return to text.

9These assignments include some assignments from beneficiaries in Phase 2 states. Return to text.

10By definition, all assignments to the ENs are from the Phase 2 states. Return to text.