Social Security Administration
Ticket to Work and Work Incentives Advisory Panel Meeting
June 22, 2001

Deborah Morrison called the meeting to order at approximately 1:30 p.m. She turned the meeting over to Sarah Wiggins Mitchell, Panel Chair.

The following Panel members were present:

Sarah Mitchell, Chair
Steve Start
Jerome Kleckley
Frances Gracechild
Thomas Golden
Bryon MacDonald
Susan Webb
Richard Burkhauser
Kris Flaten
Stephanie Lee

TWWIIA Advisory Panel Staff present were: Marie Strahan, Theda Zawaiza, Gordon Richmond, and Deborah Morrison

Other SSA Staff present included: Stephen Fear, Ken McGill, Michael Maloney, Jim Courtney and David Nguyen.

Members of the public in attendance were: Bennie Howard, Richard Anderson, Leigh Ann Sumners, Elmer Bartels, Cheryl Bates-Harris, Elena Casas, Jacques Chambers, Julie Clark, Jim Czechowic, Suan Fliegel, Mary Foley, Kara Freeburg, Mike Furches, David Gallegos, Nelly Garay, Getha Heather, Tom Gloss, Julia Grant-McMullen, Bill Hafner, John Hennessey, Cande Hernandez, Joanne Hutchinson, Phil Jordan, Diane Kess, Kathy Mario, Dottie Masturzo, Susan Maxwell, Pam Mitchell, Scott Muller, Sandra Nelson, Daniel O'Brien, Kendall Paget, Donna Preston, Mark Ravenscraft, Gloria Roche, John Ryan, James Sawyer, Ava Schaffer, Tom Scheurich, Beth Schultz, Robin Smith, Jack Stratton, Lee Suzanne, Melissa Swartz, Micheal Weinstein, Joani Werner, and Wendy Williams.

Ms. Mitchell reviewed the agenda, which includes deliberations on the Advice Report, discussion of the SSA evaluation of demonstration projects, and administrative issues.

Final Advice Report: Ms. Mitchell proposed that the Panel first consider areas of agreement and then move to areas of disagreement. She said that Panel members had called her expressing concern about the way the recommendations were categorized as "critical or not critical to the success of the Ticket program" during the last meeting. Based upon these concerns, Ms. Mitchell stated her feeling that the issues should not be categorized in the final report. Ms. Gracechild moved that the recommendations not be categorized in the final report. Ms. Webb seconded the motion. Mr. Start stated that, although he was the originator of the motion to place recommendations in these categories, he now felt that the recommendations should not be categorized. Dr. Burkhauser asked for the opportunity to vote on all the recommendations on this teleconference. Mr. Golden commended the staff on capturing in the report the array of concerns the Panel had expressed, especially under the transition issue. Ms. Gracechild's motion passed unanimously.

The Panel considered each of the recommendations.

Recommendation I: All SSA disability beneficiaries with a medical improvement expected (MIE) designation should be eligible to participate in the Ticket program.

Ms. Gracechild moved to support the recommendation and Mr. Start seconded it. Dr. Burkhauser suggested that the word "adult" be added so the recommendation would read, "All adult SSA disability beneficiaries," to clarify that children will not participate. Ms. Flaten suggested that it be clarified that the motion applies to disability beneficiaries. Ms. Webb clarified that this recommendation relates only to MIEs. Mr. MacDonald pointed out that the first vote the Panel took when it convened was to include 16-18 year olds in the Ticket program. Several Panel members felt that the word "adult" should not be included, so that Issues One and Two are kept separate. Mr. MacDonald asked if any MIE reviews were conducted for beneficiaries under age 18. Ms. Strahan said she would seek an answer to this question. The consensus of the Panel was to add the word "adult". The motion to adopt this recommendation passed unanimously.

Recommendation 2: Sixteen (16) and seventeen (17) year old beneficiaries should be eligible to participate in the Ticket program.

Several Panel members suggested that the words "including those with MIE designation," should be added. Lee stated her opposition to Recommendation 2. She also stated that explanation for Panel members who had opposed this recommendation had not been clearly enough stated in the Advice Report, in the discussion section of this recommendation. Ms. Lee and Ms. Mitchell asked to work with staff on the language. Ms. Zeitzer will contact interested Panel members. Ms. Lee asked for that portion of the March meeting transcript that discussed Recommendation 2. A vote was taken on the original recommendation. Mr. Kleckley, Ms. Gracechild, Mr. MacDonald, Mr. Golden Mr. Start, Ms. Flaten, and Ms. Mitchell voted yes, and Dr. Burkhauser, Ms. Webb, and Ms. Lee voted no. The motion passed.

Recommendation 1B was considered. Ms. Strahan read this recommendation as follows: "Eighteen (18) year old beneficiaries who participate in the Ticket Program should receive the same protection from redetermination as other Ticket users receive against CDRs." This recommendation was voted down at the March Panel meeting. Mr. Golden moved and Ms. Gracechild seconded a motion to adopt this recommendation. Ms. Flaten stated that the appropriate language for "redetermination" is "adult medical review." The redetermination only applies to income, resources, and deeming. Mr. McGill stated that he would clarify the appropriate language. Mr. Start spoke in support of this issue and added that the actuaries' estimates do not adequately reflect savings for serving this group and enabling them to return to work. Ms. Flaten expressed concern that use of the ticket would push back the time of medical review until well into adulthood if the medical review is delayed until the ticket expires. Mr. MacDonald pointed out that costs of serving this population are modest. Mr. Start stated that no provider will serve a 16-18 year old if there is a potential that they will be determined ineligible for benefits at age 18, and make the provider ineligible for ticket payments. Dr. Burkhauser stated his opposition to this recommendation, because it would necessitate SSA scrutinizing the ticket providers up front, the way it now scrutinizes rehabilitation providers. Ms. Webb also stated her opposition, pointing out that the Ticket program was intended to be an adult program and beneficiaries need to be qualified for the adult program to participate. Ms. Gracechild felt that the cutoff age between children and adults is quite arbitrary; e.g. children are eligible for parents' health insurance until they are 23. She felt that everyone should have access to the ticket. Mr. MacDonald felt that there was no net gain for refusing to give youth a Ticket. These consumers will not have providers available to them in the Ticket program. Mr. Start added that the sooner people are engaged in looking for work, the higher the probability of an employment outcome. Mr. Kleckley, Ms. Gracechild, Mr. MacDonald, Mr. Golden, Ms. Flaten, Mr. Start, and Ms. Mitchell voted yes, Dr. Burkhauser and Ms. Webb voted no and Ms. Lee abstained. The motion passed.

Recommendation 3: SSA should conduct a cost benefit analysis on the feasibility of a beneficiary receiving more than one ticket within a period of disability and [a period of eligibility]. The agency should assess the potential [cost] impact of beneficiaries using more than one ticket in its "Adequacy of Incentives" report due to Congress at the end of the Ticket implementation period.

Ms. Gracechild moved and Dr. Burkhauser seconded the motion to support Recommendation 3. Ms. Lee questioned why this issue should be raised in the Adequacy of Incentives Report. Ms. Webb said that the report is supposed to look at how ENs are motivated to accept tickets. Ms. Lee felt that the recommendation was important but should not be included in the Adequacy study. A friendly amendment was made and accepted to state that "The agency should assess the potential [cost] impact of beneficiaries using more than one ticket in the agency's overall evaluation report due to Congress... This motion passed.

Recommendation 4: An employment network (EN) should be required to retain staff that are otherwise qualified based on education or direct services experience, such as employees with a college degree in a related field, including but not limited to vocational counseling, education, human resources, human relations, social work, teaching, or psychology or employees with equivalent experience. SSA should not require licensure and/or certification that would exclude employers or other types of providers qualified to work with people with disabilities such as those who offer non-traditional supports that result in employment. The key criterion should be whether the entity is capable of successfully providing the service agreed to by the EN and the beneficiary. SSA should delete Section 411. 315 (c). [The State agency certification process should not be used to limit who can participate as an EN in the Ticket program].

Ms. Webb moved and Mr. MacDonald seconded a motion to adopt this recommendation. The motion passed.

Recommendation 5: Section 411.325(g) and Section 411.325 (h) should be deleted from the list of EN reporting and collection requirements. Section 411.325(g) currently requires ".among other things, submitting to the Program Manager, on an annual basis, a financial report that shows the percentage of the employment network's budget that was spent on serving beneficiaries with Tickets."

Ms. Webb moved and Mr. MacDonald seconded a motion to adopt this recommendation and the motion passed.

Recommendation 6: The Panel recommends that timely progress be defined by the terms and conditions of the IWP, as agreed to by the beneficiary and EN and that the reporting mechanism be the annual report in Section 411.325(e). Ms. Webb moved and Mr. MacDonald seconded a motion to adopt this recommendation and the motion passed.

Recommendation 7: SSA should permit other individualized service delivery plans to be used as a substitute to the IWP provided they meet the minimum requirements detailed in the statute. Ms. Webb moved and Ms. Gracechild seconded a motion to adopt this recommendation and the motion passed.

Recommendation 8: SSA should re-write Section 411.385 to make it clear that an SSA beneficiary [whether a youth or adult] with a Ticket who applies for [or is receiving] State Vocational Rehabilitation services has a choice in deciding whether to assign his/her Ticket to the State VR agency, to assign it to another EN, or not to assign it at all. [An 18-year old who is already receiving VR services and then receives a ticket from SSA should not be assumed to be using it with the State VR system].

Mr. Start moved and Mr. Kleckley seconded a motion to adopt this recommendation. Mr. MacDonald suggested that the words, "to clarify" be substituted for "to make it clear that". This motion passed. Ms. Strahan pointed out that the language in the summary of recommendations is different than the language in the recommendation in the body of the report. Staff will make these consistent, using the recommendations in the body of the report.

Recommendations 9-17

Recommendation 9: All beneficiaries should have access to P&A services.

Recommendation 10: Mediation should be available as an avenue for resolving disputes but it should not be mandatory. It should be an option available to the parties to the dispute, after the matter has been considered for resolution by the Program Manager.

• All parties must agree to enter into mediation.
• Mediation should be external to the Social Security Administration and should not be provided or paid for by protection advocacy agencies. Mediation is a more efficient and cost-effective way to resolve disputes.
• Participation in the mediation process should not bar a party's access to further appeals.
• The Social Security Administration should set aside additional funds to support the use of mediation for all parties.
• The Social Security Administration should look at other successful mediation program models such as those established at EEOC and the Department of Justice.

Recommendation 11: All decisions by the Social Security Administration involving disputes between or among all parties should, at the option of the parties, be subject to external review by either the Social Security Administration's administrative review process and/ or judicial review.

Recommendation 12: Information about protection and advocacy services and how to access them should be available at any time to all beneficiaries seeking or using SSA or other work incentive programs, including the Ticket. Specifically, a beneficiary should receive a formal notice of the availability of protection and advocacy services when he or she is issued a ticket and at the following junctures in the process:

• When he or she applies to the employment network for services;
• At the signing of his or her individual work plan;
• In the event his or her services are decreased, suspended or terminated; or
• When he or she filed a complaint against the network.

Recommendation 13: The beneficiary's filing of a complaint against an EN should, with the beneficiary's consent, trigger a notice to the protection and advocacy agency regarding the dispute to allow for an inquiry by the protection and advocacy agency as to the beneficiary's wish for protection and advocacy assistance.

Recommendation 14: Notices from the EN and the protection and advocacy agency, the beneficiary's IWP and any other documents should be in [accessible format and, where practical, in] the beneficiary's primary or accessible language of communication.

Recommendations #15: Timelines for dispute resolution should be follows:

• Employment networks should have fifteen working days to resolve a complaint filed by a beneficiary. If not resolved satisfactory, the beneficiary should be permitted to request a review by the Program Manager.
• The request for review, with the submission of all supporting documentation by both parties, should be submitted within ten (10) working days after the beneficiary receives the employment network's decision.
• The Program Manager should complete its review and render a decision within fifteen working days, unless the parties agree to mediation.
• If the parties agree to mediation, mediation should commence within ten (10) working days after the Program Manager receives the parties' request for mediation and should be completed within twenty (20) working days after it is scheduled.
• The Social Security Administration should have no more than twenty (20) working days to resolve individual appeals.
• All disputes involving Employment Networks, State vocational rehabilitation agencies, and the Program Manager must be resolved within sixty (60) working days, including Social Security Administration review and issuance of a decision.

Recommendation 16: During the appeals process, services and supports to the beneficiary should be continued at the same level; that is, services and supports should not be reduced or suspended by the Employment Network without the beneficiary's consent.

Recommendation 17: All parties in a dispute should have access to all information that is being considered and used to render a decision in the dispute.

Mr. MacDonald moved and Ms. Webb seconded a motion to adopt recommendations 9-17. The motion passed.

Recommendation 18: SSA Ticket implementation staff should re-evaluate the proposed payment structure to determine the feasibility of adopting a system that pays at least four milestone payments: 1) at the signing of the IWP; 2) at 3 months of SGA; 3) at 7 months of SGA; 4) at 12 months of SGA. A second-tier of the milestone system would be a system in which milestones would be individualized for beneficiaries who need significantly more supports.

Specifically the system would:

a) Pay a minimal milestone when a beneficiary and employment network signs an IWP;

b) Pay an additional milestone payment equal to the first two proposed (i.e., 3 and 7 months of SGA) at the end of 12 months of SGA;

c) Amortize the milestone payments over the entire 60-month outcome-only payment period rather than the 12 months proposed;

d) Pay a greater overall percentage of the outcome-only payment option under the milestone/outcome payment option than the proposed 85%;

e) Equalize the monthly outcome payments under the milestone/outcome payment period rather than the graduated method proposed in the NPRM;

f) Provide individualized milestones for individuals with a need for on-going support services, individuals who need high-cost accommodations, individuals who earn a sub minimum wage, and individuals who work and receive partial cash benefits along the lines of systems already in use in Massachusetts, Oklahoma and other states. (These systems use the individualized planning process to determine if and when a different set of milestones is necessary, and establish a plan for payments and accountability for the payments.)

Ms. Lee moved and Mr. Start seconded a motion to adopt this recommendation. Ms. Webb felt that the recommendation should be made stronger, to say, "SSA should adopt a payment structure to pay at least four milestone payments." Ms. Lee agreed, and suggested that the words "ticket staff" should be removed, and language substituted to say, "SSA should adopt a system that pays at least four milestone payments". The portion of the recommendation proposing the "second tier", should be made into a separate recommendation. Dr. Burkhauser suggested that Recommendation 18 should be broken up into these two motions and this friendly amendment was accepted. The first motion, related to the four milestone payments, should be followed by items a-e above. Ms. Gracechild felt that the words, "a greater overall percentage," in item d should be substituted with "98 percent". In response to a question as to whether the Actuary had addressed this issue, staff drew the Panel's attention to Appendix D, letter of April 11. There are costs of alternative milestone payment models described, but this specific issue is not addressed. Ms. Mitchell suggested that the word, "significantly" be added to "greater overall percentage," and that "SSA should consider at least 95 percent" be added at the end of the sentence. With these additions, the motion passed.

The second part of this recommendation, related to a second tier of the milestone system, was considered. This recommendation should include item f. Ms. Lee suggested that the recommendation read, "SSA should also immediately consider the adoption of a second-tier of the milestone system, in which milestones would be individualized for beneficiaries who need significantly more supports. The amended motion was adopted.

Recommendation 19: All beneficiary employment outcomes in the Ticket Program are valued. Any saving to either the Disability Insurance Trust Fund or the general fund should be viewed as outcomes. Therefore the Panel urges SSA to interpret "benefits not payable" as a reduction in benefits rather than zero cash benefits.

Ms. Webb moved and Mr. Kleckley seconded a motion to adopt this recommendation. Dr. Burkhauser stated his discomfort with this recommendation. Mr. Kleckley, Ms. Gracechild, Mr. MacDonald, Ms. Webb, Mr. Start, Ms. Lee, and Ms. Mitchell voted yes and Dr. Burkhauser voted no.

Recommendation 20: Because the Title II and Title XVI programs are distinctly different from each other with differing processes and timelines, SSA should develop two milestone [outcome] payment systems; one for SSI beneficiaries and another for SSDI beneficiaries, that take into account the differences between the two programs [and that factor into consideration, issues of concurrent beneficiaries]. ([For example,] see attachment C - Seifert and O'Brien models).

Mr. MacDonald moved and Mr. Kleckley seconded a motion to adopt this recommendation. Dr. Burkhauser pointed out that there was no data or policy analysis to support this recommendation. He also said he felt this recommendation was very vague. There was discussion as to whether the milestone models presented by Mr. Seifert and Mr. O'Brien should be included in the appendix. Mr. MacDonald and Mr. Start felt that the report should make clear that they were included as an illustration, but not endorsed by the Panel. Mr. Kleckley, Ms. Gracechild, Mr. MacDonald, Ms. Webb, Ms. Flaten, Mr. Start, Ms. Lee, and Ms. Mitchell voted yes, and Dr. Burkhauser voted no. The motion passed.

Recommendation 21: SSA should commission a full cost benefits study to evaluate the Ticket program. Such a study should begin with a more complete view of the direct savings to the SSA trust fund, but should also consider savings to the Federal treasury and increased productivity to the nation as a whole. Such a study would at a minimum consider the impact of increased FICA contributions by working beneficiaries, reduced use of Medicare, cash trust fund savings by beneficiaries who work but who only receive partial cash benefits and estimated trust fund savings beyond 60 months. The study should also consider reduced use of all other government transfers and increased taxes paid. It should consider the addition to net national product of increased work. It should evaluate costs and benefits from SSA's point of view, from the view of the Federal government, from the view of the beneficiary and from society as a whole.

Ms. Flaten moved and Dr. Burkhauser seconded a motion to adopt this recommendation. Ms. Flaten asked that "General Fund" be substituted for "Trust Fund" in two places, since this recommendation dealt with the SSI program. This was accepted as a friendly amendment and the motion passed.

Recommendation 22: SSA should resolve the conflict between Sections 411.510 and 411.390 regarding VR's choice of payment systems for beneficiaries who are already clients of VR.

Mr. MacDonald moved and Mr. Start seconded a motion to adopt this recommendation. The motion passed.

Ms. Strahan suggested that all recommendations be listed in numerical order, not designating any as an A or a B under a parent recommendation. She asked for permission to turn the matrix of comments into a narrative, using the language of the actual comments. She also asked if recommendations One and Two could be switched around, so that the first recommendation would be strong and unequivocal. Dr. Burkhauser asked if he could assist with crafting the discussion under Recommendation Two. Ms. Strahan asked to include Mr. McGill's early memo with the projected roll-out dates and the Office of the Actuary memorandum in the Appendix. All of these suggestions were accepted.

Ms. Mitchell moved to the discussion of the Other Issues section, containing the Overpayments and DAC issues. She felt this section should go at the end of the report. It was agreed to move it to the end of the report, following the recommendations.

Ms. Lee was concerned that SSA's guidance to the field regarding the DAC issue was not sufficient, since an advisory to the field does not carry the same weight as regulations. Ms. Lee expressed her desire to work with staff on raising this issue in the report.

Evaluation Report and Recommendations: Ms. Webb reported that several people had made excellent presentations at the committee's teleconference call and asked that the minutes from the committee meeting be distributed to the Panel.

Ms. Webb stated that SSA staff asked for the Panel's input in three areas: the income disregard on the one for two demonstration, whether current incentives should be included, and whether the income reporting period should be monthly or annually. With regard to the income disregard on the one for two demonstration, the committee recommended that SSA look at multiple income disregard levels for several types of beneficiaries, including concurrent beneficiaries and working beneficiaries. There was discussion as to whether participation in the demonstration should be mandatory. Ms. Ms. Lee expressed concern about the committee's recommendation of mandatory participation in the demonstration. Ms. Webb asked if the recommendations could be sent by email and approved by the Panel in a written vote.

Ms. Webb read her second and third recommendations. The committee recommended that all existing Title II and Title XIV incentives should be continued for SSI, SSDI and concurrent beneficiaries in the demonstration projects. The third issue is whether the accounting period should be based upon monthly or annual earnings. The committee recommends that it should be based on monthly earnings. Ms. MacDonald and Ms. Flaten moved and seconded committee recommendations Two and Three. The motion passed. Mr. MacDonald said there were still major issues to deal with in the evaluation committee. There is a meeting scheduled for July 9.

Staff will explore the possibility of expanding the July 9 committee conference call to the entire Panel for further deliberation on these recommendations. Ms. Lee said that she would be unable to make this meeting. She stated that she would vote against Recommendation One if she were present.

Ms. Strahan stated that the report will be finalized by June 29. There will be two to three weeks required for printing. She reminded the Panel that disclosure forms should be sent into the office immediately.

Ms. Morrison closed the meeting at 4:30 p.m.