Social Security Administration
Ticket to Work and Work Incentives Advisory Panel Quarterly Meeting
February 6 - 8, 2001

Tuesday, February 6, 2001

Introduction and Welcome: Deborah Morrison called the meeting to order at approximately 9:30 a.m. She announced that this will be a three-day public meeting and that Sarah Mitchell will preside. The following panel members were present: Sarah Mitchell, Thomas Golden, Kris Flaten, Stephanie Lee, Susan Webb, and Bryon MacDonald.

The following staff and members of the public were present: Ilene Zeitzer, Deborah Jackson, Gordon Richmond, Tamara Allen, Deborah Morrison, Wayne Walch, Andrew Sperling, Paul Seifert, Andrea Harles, Charlie Harles, Kara Freeberg, Christine Irwin, Britta Taylor, Pam McCue, Susan Prokop, Tom Sherek, Martin Suskin, John Briskowski, Ken McGill, Ilene Baylinson, Bob Weather, John Hennessey, Joe Hickman, Beverly Raleigh, and Stephen Fear. Other SSA staff were also present.

Ms. Mitchell reviewed the agenda. This morning will be devoted to public testimony. After lunch, there will be briefings by SSA staff, followed by a legislative report from House and Senate staff. Wednesday morning will be devoted to panel deliberations, including a discussion of the public hearings recently held and the advice report. These deliberations will be continued in the afternoon. On Thursday morning, the panel will hear from Maximus, the program manager and will continue deliberations. Thursday afternoon will be devoted to a presentation from HCFA, additional deliberations and a business meeting. Upcoming meeting times will also be discussed.

Public Comment:

Paul Seifert: IAPSRS: Milestone and Outcome Payments.
Mr. Seifert reviewed a handout on how milestones would effect SSI beneficiaries. He stated that Social Security was not taking much risk on putting beneficiaries to work. Providers were taking the risk under the SSA proposed regulations. SSA is willing to share about $900 with providers after SSA saves about $2700. He also pointed out that Congress has infused the SSI program with a sliding scale income offset over the last 30 years. Congress intended that some outcome payments should be made when the beneficiary's benefits reduce and should be payable until the person reaches SGA. He proposed an alternative system that pays providers for reduced benefits, pays the provider earlier, and encourages the provider to help the beneficiary obtain a higher wage job. His proposal provides more incentives for providers to work with SSI beneficiaries. Mr. Seifert said that his handout contained a slight error. He would bring a corrected handout on Wednesday.

Mr. Seifert stated that the last page of the handout was developed by Dan O'Brien and presents an alternative payment schedule. Several other people have proposed alternatives to the regulation.

In response to a question from Ms. Flaten, Mr. Seifert said that the payment calculation base included some recipients who work and thus receive lower benefits. He pointed out that the more people who work, the lower the payment calculation base and the lower the payments to providers. Success breeds lower payments. Ms. Webb asked if there was a way to calculate the payment base differently than SSA had calculated it. He said that the law uses the term "average", but it depends upon how SSA defines average. He felt the average payment should be the federal monthly SSI amount. Ms. Webb asked if the payment could be calculated based upon only those participants who were eligible for a ticket and Seifert said this might be possible. In response to another question from Ms. Webb, Mr. Seifert said he did not have a solution for the problem that blind people have a higher level of earnings and providers who serve them would not be eligible for an outcome payment until the blind person achieves a higher SGA. Ms. Lee suggested that the SGA for all beneficiaries should be raised to the blind level and Mr. Seifert agreed, but stated that this would not solve the above problem.

Andrea Harles, International Association of Business, Industry and Rehabilitation: Milestone Payments and Provider Protection when a Beneficiary Moves Their Ticket.
Ms. Harles supported Seifert's comments. She said that she had just attended a conference of 50 people from INABOR, whose members place people with disabilities into competitive employment. INABOR members serve many SSI and SSDI beneficiaries who leave the rolls to go to work. These providers felt concerned about the high degree of risk they would experience. These providers were supportive of the concept of choice but were concerned about providing time consuming and expensive services up front, then having the participant take their ticket elsewhere. They wanted some protection for the financial investment in the up-front services. This could be handled through a more remunerative milestone payment or a sharing of the outcome payment with the second provider. Ms. Lee asked if the providers were aware of the provisions that enable appeals to the PM and Ms. Harles said that the providers were not convinced of the viability of this option. Ms. Webb asked about payback of milestones within the first year of outcome payments. If the beneficiary moves the ticket before the first year of outcome payments has been completed, does the second EN pay the milestones back? Ms. Harles stated that some beneficiaries change providers because they are not happy with services, but other times, it is a lack of commitment to the goal that was set between the beneficiary and the provider. Ms. Harles felt that the regulations should contain more specific requirements for the PM in dispute resolution.

Andrew Sperling, NAMI: MIE Exclusion and low outcome payments
Mr. Sperling expressed concern about the exclusion of people with medical improvement expected (MIE) from receiving a ticket. This is not an exclusion that is mandated by the legislation, but this category is determined largely by state eligibility determination agencies. Most of these people remain on the rolls after their first CDR. NAMI feels it is arbitrary to use the MIE classification as a standard for receipt of a ticket. Mr. Sperling also expressed concern about the outcome payments and advised SSA to make them uniform across the period of outcome payments, rather than raising them during Years Four and Five. Ms. Mitchell asked if he would support a beneficiary appeal of the MIE classification. He agreed, stating that eligibility technicians view mental illness with a jaundiced eye and this would shift the burden of proof to make them show why the classification was given. He recommended that if such an appeal was established, a quick timeline for decisions should be included. Mr. Golden said that there were some demonstrations projects where the appeal process was being modified to eliminate certain steps and where SSA representatives meet with consumers during the initial eligibility process. Mr. Golden suggested that the panel look at MIE data in these demonstrations. Ms. Webb asked why the MIE population was not originally excluded from the Ticket and Mr. Sperling said that SSA believed that the beneficiary is likely to leave the rolls irrespective of the ticket. He felt that, based upon data that supports early intervention, the ticket should be put in the hands of beneficiaries as soon as possible. Ms. Mitchell pointed out that an appeals process was a very expensive way to address this issue. Ms. Flaten stated that 83 percent of MIE's stay on the rolls after their first CDR.

The panel took a break at 10:30.

Chris Griffin and Larry Henderson joined the meeting.

Ticket Implementation: Ms. Mitchell directed the panel's attention to the issue of timeline for ticket implementation. She suggested that the panel send a letter to the Commissioner outlining provisions and issues that should be tabled until further deliberation takes place. Staff has drafted a list of these issues, including 16-18 year old and MIE eligibility for a ticket, the milestone payment system, notice requirements for dispute resolution, reporting requirements for ENs and wage reporting for beneficiaries. The panel tabled a motion at the last meeting about whether to release the RFP for providers. Ms. Lee asked if the panel wanted to recommend that the RFPs not go out until these issues are resolved. Ms. Mitchell stated that the consensus of the panel was against this position because it would hold up the whole ticket implementation. Ms. Lee said that the panel should hear presentations from Mr. McGill and from the Congressional staff before deciding on these issues. Ms. Flaten asked that more time be spent discussing Seifert's proposal on SSI milestone payments. Ms. Lee also suggested that The ARC's recommendations be reviewed, specifically, those related to disabled adult children and the timely progress issue. Ms. Mitchell felt that the panel should focus its letter on two or three issues.

MIE Issue: Mr. Golden stated that the MIE designation has a disproportionate impact on the psychiatric population. He added that a small proportion is found ineligible for benefits at the first CDR, so this rule disproportionately withholds tickets from people with psychiatric disabilities. Ms. Webb asked about the cost of providing tickets to this group. She suggested that the panel answer this question before making the recommendation to include MIEs. She wondered what SSA's rationale for exclusion of this population. Mr. Golden asked what percentage of the MIE's had psychiatric disabilities. Ms. Strahan stated that the rationale stated in the preamble to the regulations was that people would leave the rolls irrespective of the ticket.

Milestone Payments: Ms. Lee said that the panel's comments should present this issue from the consumers' perspective; e.g., individuals who are harder to serve will be less likely to find a provider who will take the ticket if the milestone payments are too low. Mr. Golden also said that State VR agencies are concerned that if there are no providers available to take tickets, state VR agencies will become overwhelmed with the number of requests. Lower milestones also undermine the consumers' choice.

Reporting Requirements: Ms. Mitchell stated that burdensome reporting requirements might not be an issue that stops the roll out, but is of such concern that it should be addressed. With regard to reporting, Ms. Lee felt that the RFP should not be sent out until the credential requirements are reduced. The panel agreed to address the credentialing issue under another item in the letter. Mr. Golden recommended that the letter state that the panel received public comment in support of its position on all of the above issues.

Adequate notice to beneficiaries: The panel felt that beneficiaries should be notified of the P and As when they receive their ticket and at critical junctures thereafter. Ms. Griffin asked that relevant public comments be included in this section.

Age Limitation: Mr. Golden wondered if transition age students were eligible for reimbursement from SSA through the VR agency. He further stated that the letter to the SSA Commissioner should not be held up waiting for answers to the above questions. Ms. Mitchell stated that the panel had voted to support this issue. Mr. Golden also suggested that the panel use information from one of the Presidential Task Force reports that recommends including this population in public programs.

Ms. Lee pointed out that there are a number of remaining issues that must be resolved before ticket implementation, including the Disabled Adult Child and "timely progress" issues, but added that she did not want to hold up the letter until these issues are resolved. Ms. Flaten asked when the draft advice report was to be issued and Ms. Strahan stated that both the letter and the advice report would be ready by the beginning of next week. Ms. Flaten suggested that doing a letter and a report were duplicative and Ms. Strahan stated that the advice report was based upon the NPRM and would not address the implementation schedule. The panel agreed that Ms. Lee's issues would be discussed in the preliminary advice report. A draft of the letter will be sent to all panel members for comment.

Ms. Mitchell asked the panel to consider whether to have a March meeting in Phoenix. She stated that there were uncertainties around the budget situation. Another problem is that a number of people have conflicts with scheduling in March. Ms. Webb stated that she would prefer a Phoenix meeting for medical reasons. Ms. Strahan stated that funding was a major issue and that the panel could not continue to have face-to-face meetings in addition to the four quarterly meetings. As an alternative, Ms. Mitchell wondered if the report could be finalized at the May meeting. Other panel members felt the report should not be delayed. Ms. Lee suggested that the report could be finalized by email and teleconference. Ms. Mitchell said she favored a face-to-face meeting. Ms. Strahan stated that the expense rose significantly for staff if the location was outside DC, but that meeting accommodation costs were significant wherever meetings were held. Ms. Mitchell will check the availability and preference of panel members and make a final decision tomorrow. The May quarterly meeting will be held May 8-10 in St. Louis and the following meeting will be held August 7-9.

Quarterly Update Briefings From SSA Officials: The afternoon session began with a presentation by Ken McGill, Associate Commissioner for OESP. Mr. McGill stated that the regulations on SGA, work exclusions, and student income have not been rescinded. The regulations went into effect on January 29th. He added that there is no time change on the proposed TWWIIA regulations. The Benefits Planning, Outreach and Assistance grants process is well underway. 42 states and 2 territories have been funded. The RFA for the remaining eight states will be out until April 1. The P and A Requests For Application have been sent out. The National Association of Protection and Advocacy Agencies is working with its members to complete the applications. Expedited reinstatement for benefits is in effect and detailed instructions to the field offices will be sent out later this week. Mr. Golden asked if beneficiaries would be notified of the expedited review and Mr. McGill said there were no plans to do this so far. He would take this suggestion under advisement. Mr. MacDonald asked for more information about this new provision to go to the panel and Mr. McGill agreed to email additional information to the panel.

Mr. McGill said that there have been some conference calls within the 13 roll-out states with VR agencies. SSA will be sending a letter very shortly asking the VR agencies under which system they want to be paid. When the final rule comes out, the VR agencies will have the opportunity to change their payment option.

Mr. McGill mentioned Bush's New Freedom Initiative, which recommends swift and immediate action to implement the TWWIIA. Mr. McGill stated that the RFP for ENs was almost ready. The issuance of tickets will follow in late March. The schedule calls for a four-month roll out in the 13 states. There will be a monthly release for all new beneficiaries after that time.

Staff will begin working on the regulations after the comment period, which ends February 26. After the final rules are written, they must be cleared through several levels of SSA. Next, the regulations are reviewed and cleared by OMB, with input from other federal agencies.

Ms. Lee asked for SSA's rationale for releasing the RFP before the regulations are final. Mr. McGill said that the legislation requires SSA to start the implementation in 2001. It makes no sense to release tickets before ENs so SSA must first release the RFP to establish the networks. In response to a question from Mr. MacDonald, Mr. McGill stated that the EN applications could be turned around within 30 days. The RFP is a rolling process, so that providers can apply whenever they are interested.

Mr. McGill distributed the Statement of Work for the EN RFP. It includes a cover sheet, twelve sections, and a signature sheet. The first three pages provide basic information about the provider. The 12 sections follow, with a signature page for each section. With regard to EN qualifications, Ms. Griffin expressed concern that employers may draw the conclusion that they cannot be ENs. She felt that employers should be encouraged to provide services under an EN, even if they have never hired someone with a disability. Mr. Golden said that the statement is very "voc rehabbey". Employers may not understand the meaning of the requirements and might be afraid to get involved. Mr. MacDonald felt that the credentialing went beyond the Statute, which does not require employers to provide vocational rehabilitation, and education. Mr. McGill stated that ENs need to provide a variety of services. Ms. Flaten asked how the proposed regulations would allow a person to become their own employment provider. Ms. Lee felt that the credentialing issue was significant enough that the RFP should be delayed until it was resolved. Ms. Webb expressed concern that providers will not contract with other providers until they enroll consumers and conduct assessments. Mr. MacDonald stated that the Panel has already voted on its related recommendations, through the work group report.

Mr. McGill continued to review the document. The next topic of discussion related to informing consumers about the Benefits Planning and Assistance Organizations. Ms. Mitchell wondered if information about the BP and As could be included in the information to beneficiaries about the ticket and Mr. McGill said he would check into this. Mr. McGill also pointed out that beneficiaries do not have to use a ticket to use the Benefits Planners.

With regard to provider payments, Ms. Webb asked what the rationale was for the EN to request payment on a monthly or bi-monthly basis. This relates to how beneficiaries report their earnings after they become employed. Mr. McGill stated that the purpose was to prevent delays in the reporting process, but he would clarify this matter after consultation with other SSA staff. Ms. Webb raised a question about the requirement to submit the percentage of budget spent upon services to ticket holders. Mr. McGill traced this requirement back to the legislation and Ms. Webb contested his explanation. Ms. Griffin felt that the reporting requirement should focus upon outcomes. McDonald stated that the legislative requirement is financial reporting with no specification.

Mr. McGill continued his presentation with the training section of the document. He said that ENs must accept the materials and training that SSA makes available. ENs can, however, start providing services before the training is offered. Mr. MacDonald expressed concern that ENs should be allowed to take web-based training or get training in some other way. Mr. McGill said that a variety of training would be conducted. Section Ten is the dispute resolution section and describes how this process will be implemented. Ms. Lee expressed concern that there is no requirement that ENs tell beneficiaries about how to change providers if they are dissatisfied. She asked that language around this issue be strengthened. Mr. MacDonald pointed out that there is no mechanism for consumer participation in disputes between ENs.

Ms. Mitchell asked how the issues raised by the panel will be addressed. Mr. McGill stated that he would follow up with staff on the various items and get back to the panel shortly. Mr. MacDonald again pointed out that the panel had already voted on some of the issues and had made recommendations to SSA.

Ms. Webb asked if there was an assumption that One Stop Centers automatically met the requirements to become an EN and Mr. McGill said One Stops must meet all relevant requirements to become an EN. Mr. McGill stated that he found the panel's input valuable to the SSA staff in constructing the NPRM and other documents.

Ms. Mitchell introduced the next presenter, Paul Van de Water, Associate Deputy Commissioner, Office of Policy. He discussed the ticket evaluation and the one-for-two benefit offset demonstration. The Lewin Group has been hired to develop the evaluation design and a second contractor will be hired to conduct the evaluation. A notice has been published in the Commerce Business Daily for the implementation contract and several dozen organizations have responded. Lewin has established a technical support group, which consists of its contractors and consultants and several other experts. Lewin staff will be available to brief the panel on a regular basis.

Mr. Van de Water continued by explaining that there are two studies required by the legislation. The first is an equity study, which determines if the most severely disabled people are being served by the ticket program. The other is the adequacy of incentives study. Mr. MacDonald expressed concern about two independent studies being conducted at the same time and Mr. Van de Water said they would be closely coordinated. There will also be a survey to measure the unmet demand for ticket services. This study also looks at the incentives that are necessary to encourage people to work using the ticket. Ms. Lee stated that the purpose of the equity study was to focus on people with the most severe disabilities and what providers need to serve them. Ms. Lee expressed concern that the study seems to be focused upon who is not being served; e.g., waiting lists. It was suggested that a committee meeting be scheduled with Mr. Van de Water to provide input into the evaluation. Mr. McDonald stated that the panel be a significant component of both of the evaluations as required in the legislation. Ms. Lee said that she would be pleased to identify experts and Ms. Mitchell said she felt the whole panel should be involved in this matter.

Mr. Van de Water went on to discuss the SSDI demonstration project. He explained that $6 million had been appropriated to initiate the demonstration, but that SSA was requesting a permanent appropriation. The legislation states that SSA focus upon the "induced demand" related to changes in the work incentives. This is an extremely complex study to carry out. Mr. Golden asked if any of SSA's State Partners Programs have any data on induced demand and Mr. McGill stated that these programs worked with SSI, not DI, beneficiaries and that these programs were in the first stages of implementation.

The panel took a break and reconvened at approximately 4:10.

House of Representatives Perspectives: Ms. Mitchell introduced Jeff McLynch, Democratic staff of the House * Committee. Mr. McLynch reviewed the purpose of the TWWIIA legislation and the Advisory Panel. He said it is clear that the Advisory Panel has an important role in implementation of the legislation. The panel's mandate goes beyond the ticket program to other work issues, such as Medicare and Medicaid, and other actions necessary for beneficiaries to go to work. Congress wished to give the panel a significant amount of independence, and to represent beneficiaries with disabilities. Half of the panel must represent people with disabilities, or be people with disabilities.

Ms. Mitchell introduced Kim Hildred, Staff Director of the House Social Security Subcommittee: Ms. Hildred stated that return-to-work is a new mission for SSA, so there needs to be an independent advisory panel to assist SSA in achieving this goal. The panel's role is critical as SSA develops the final regulations for the TWWIIA. She noted that the Administration is moving forward on implementation of the regulations, even though consumers and providers have raised concerns.

Ms. Lee asked about the EN RFP release before the regulations are finalized. Ms. Lee said that SSA's reason for moving forward is Congressional intent that the ticket program be implemented, beginning in 2001. Ms. Hildred said that while agencies try to adhere to Congressional deadlines, implementation is sometimes slower than desired. SSA must strike a balance between meeting Congressional intent and responding to consumer concerns and it is important for the panel to provide input. Ms. Hildred stated that moving forward is important, but not at the expense of a program that will work. Ms. Lee also asked about the credentialing of service providers and stated that the draft regulations contained requirements that were burdensome to providers and did not foster choice. Ms. Lee also mentioned concerns with the outcome payments and how they are being calculated. Ms. Hildred stated that concerns about how the base is calculated should be taken up with SSA because the legislation is not that specific. Mr. MacDonald commended the House and Senate staff for their commitment to passage of the legislation and for inclusion of a strong panel. Ms. Hildred commented that the ticket program was created to get people back to work. The program tries to promote creativity and foster non-traditional approaches. The milestone payments were controversial, but Congress felt milestones were essential to encourage non-traditional providers. She stated her hope for a rich and varied service provider network with maximum flexibility.

Ms. Webb asked for Ms. Hildred's comments on whether Congress intended outcome payments to be made at zero or at reduced SSI benefits. Ms. Hildred said that SSA has the authority to interpret the law, but that when zero benefits was meant, it was so stated in legislation. Ms. Webb explained that the SSI calculation base for outcome payments is lower than the maximum benefit because of workers receiving partial benefits and those who had been on benefits for a partial year. Ms. Hildred responded that SSA could interpret the law as it saw fit where the legislation was not specific.

Mr. MacDonald commented that the Ticket program is more than just TWWIIA and that beneficiaries are not getting that message. He described a common misperception that beneficiaries will get extended health care if they get a ticket. There is no synchronized strategy for roll out of the various pieces of the legislation. Ms. Hildred said that the service delivery system is very fragmented, and one of the panel's purposes is to make recommendations on service coordination. She hoped that the panel would have a role to play in advising Congress and the President on these issues. Ms. Lee expressed concern that the current ticket program would not adequately serve people with more significant disabilities and how the equity study would address this issue. There was some discussion as to whether the outcome payment rate should go over the forty percent maximum for these beneficiaries. Ms. Hildred stated that research and demonstration projects and studies are usually quite flexible. Ms. Flaten asked if saving General Fund dollars is as important as saving Trust Fund dollars. After Ms. Hildred said yes, she continued that providers have more incentive to work with people on SSDI because they have a higher benefit calculation. Mr. McLynch continued that cost savings in both programs, along with return of beneficiaries to work, was equally important. Ms. Hildred stated that the Congressional committees were taking a close look at the disability benefit programs, policies of other countries, and how disability has changed in the years since SSI and SSDI were developed. Ms. Mitchell stated that the panel was having difficulty obtaining the data to demonstrate that early intervention produced cost savings.

Ms. Webb questioned the five-year break-even point in the legislation. She supported a more holistic view of cost savings; for example that savings to the trust fund should include beneficiary payments who are working, even part time. Ms. Hildred encouraged the panel to recommend technical amendments that would make the program work more smoothly. Mr. MacDonald mentioned the cash cliff for SSDI beneficiaries and how the demonstration projects should be designed. Ms. Hildred said that a technical amendment might be required to make this demonstration operational.

Ms. Mitchell thanked the Congressional staff for their presentations.The meeting was adjourned at 5:05 p.m.

Wednesday, February 7, 2001

Ms. Mitchell opened the meeting at approximately 9:05 a.m.

Public Comment: Ms. Mitchell announced that one member of the general public had transportation problems yesterday and was not able to attend the meeting to testify. She opened the meeting for public comment and called upon Dan O'Brien, of the vocational rehabilitation agency in Oklahoma.

Dan O'Brien, State VR Agency in Oklahoma; Aggressive roll out of the ticket program. Mr. O'Brien discussed the VR agency's track record of providing services to SSI and SSDI beneficiaries in Oklahoma. He questioned the assumption that private agencies would provide a better and more comprehensive array of services than the State VR agencies. He also questioned the aggressive roll out of the tickets, saying that agencies are not ready to serve ticket holders. Ms. Webb asked if there was an agreement between the State VR agency and the One Stop Centers in Oklahoma. Mr. O'Brien stated that memoranda of understanding were being developed with the different One Stops in the state. He expressed concern over the level of access and disability services that people receive through the One Stops. He stressed that 150,000 people have severe disabilities are not awarded SSA benefits that are referred to the State VR agency. The SSA does not track what happens to these individuals. This group of people will not get a ticket and there will be no referrals to VR as of March 1. Mr. MacDonald wondered how agencies would handle the deluge of contacts when the tickets are rolled out at the end of March. He suggested that this distribution be spread out over six to eight months. He also expressed concern that the rules were not finalized and EN training needs to be provided. The system is not prepared to handle the influx of calls.

Ms. Flaten expressed concern that training has been provided to the thirteen states without the panel's knowledge. Ms. Strahan stated that training for the roll-out states has been mentioned at panel meetings. Ms. Mitchell expressed concern that the ENs will not be in place before the tickets are rolled out. Ms. Strahan agreed to provide the panel with the numbers of SSI/DI beneficiaries that will receive a ticket and the number of ENs in the Gallop Poll that said they would be interested in being ticket takers. Mr. O'Brien estimated that there were approximately 86 venders who might be ENs, for the 100,000 potential beneficiaries eligible for a ticket.

Ms. Webb requested that the panel consider the motion from the last meeting to delay the issuance of the tickets for 90 days. Mr. O'Brien stated his commitment to making the ticket work.

Summary of Regional Meetings: Ms. Webb stated that most participants came to the public hearings to listen and learn and did not have prepared public comments. The questions were used to elicit their comments, giving participants a way to look at the NPRM and focus upon the pertinent issues. She also stated that beneficiaries did not come to the hearings in significant percentages, nor is the panel hearing from new potential providers. The consumer groups said they wanted more flexibility in who should become an EN, while traditional providers wanted certification and specifically the CRC. There was consensus that the IWP should be considered a substitute for the IPE, and that a second or a continued ticket should be provided. There was also a great deal of confusion about whether beneficiaries needed to use the ticket to get the Medicaid and other benefits.

Ms. Webb stated that there were about 40 people in Phoenix, including the teleconference and on-site participants. One person testified that the rules were too complicated and the system should not be over regulated. One person stated that milestones should be $3500, but Ms. Webb pointed out that this significantly reduces the outcome payments. One person expressed concern about the dispute resolution process and asked why a parallel system was being established. This person expressed concern that Maximus had no experience with dispute resolution for people with disabilities. People felt that information about dispute resolution should be sent to consumers early and often.

Ms. Webb stated that the mental health community was interested in the ticket renewal, easy back on and eligibility for MIE. Many people felt that the system encourages creaming and there is little incentive for providers to be involved. A private provider recommended a milestone payment of $300 at development of the IWP. They felt that "timely progress" should be based upon the IWP. A representative of UCP encouraged involvement of employers as part of the EN. There was also support of the easy back on provision. One CIL representative opposed credentialing, saying that credentialing did not necessarily produce outcomes. Another person felt that the ticket should be ongoing, because employment was not permanent for anyone, including people with disabilities.

Ms. Webb said that people representing people with developmental disabilities were concerned about the potential of losing long-term funding if they use a ticket. People with DD may not be well served under this program. One person advocated for individualized milestones and expressed concern about the PM evaluating programs. There was unanimous support for people between 16 and 18 years old receiving a ticket.

Ms. Webb continued by presenting the results of the Atlanta hearing. A representative of the agency for the blind was concerned about the loss of existing work incentives with the introduction of the ticket. There were a number of questions about whether a certain entity would qualify as an EN. For example, one person promoted self-employment as part of the Home of Your Own Program. A P and A expressed concern that the PM would determine "timely progress" and felt that this was more appropriately negotiated between the EN and the individual. A service provider felt that $1400 was too low a milestone payment for people with psychiatric disabilities.

Ms. Flaten summarized the hearing in Minnesota. She said that one provider testified that it cost $2800 to place an individual in employment under a welfare reform program. One person said that the system actually discriminates against people with DD because of the low milestone payments. She stated that an issue is missing from the summary about using more than one source of funding while using a ticket. ENs would like this said more explicitly in the NPRM. Comments were also received about lack of notice for the hearing and the over reliance on email for communication. Ms. Flaten commended the State VR agency for assisting with hearing logistics. People who needed accessible transportation could not get there because of lack of advance notice.

Bryon MacDonald summarized the California teleconference and said that another teleconference was scheduled for February 15. The input is validating the panel's deliberations on certain issues. He said that consumers and providers are not familiar with the nuances of the NPRM, but they are still raising the same issues as the panel. VR agencies, potential ENs, P and As and other agencies attended the conference call, but few consumers were present. There is a misperception that beneficiaries must use a ticket to keep their health insurance. Some people said that the ticket program will not address people with high rehabilitation costs. One provider questioned limiting the milestone payments to 85 percent of the outcome payments. This person felt that the whole ticket process is irrelevant to agencies that serve severely disabled people, because most expenses are incurred at the beginning of the process. Providers are paid their first milestone after the IWP is developed. The regulations are a continuation of current complex systems and SSA needs to develop more plain English information.

Ms. Strahan stated that it is very important to be in the community as often as possible, but the panel should not take on a public affairs role for SSA. The SSA has a large publication staff, which has about sixty times the budget of the panel to do this work. The panel should educate this office and let them educate the public. Ms. Webb wondered if the panel could use other SSA resources to conduct PR activities. Ms. Strahan suggested that this would be a significant expansion of the panel's role. Ms. Webb questioned whether the public affairs office had the expertise to do this work. Ms. Flaten asked if the Office could consult with the panel in development of materials. Perhaps SSA could contract with individual members of the panel to conduct these activities.

Mr. Golden reviewed the plans for the New York meeting and stated that 3200 invitations had been sent. He is actively trying to recruit students, people from the education system, employers, and family members. There has been a great deal of interest and he is concerned about how to give everyone the opportunity to be heard.

Preliminary Advice Report: Theda Zawaiza (SSA Staff) drew the panel's attention to the work group reports contained in the packet and said there were 21 issues raised. The document contains background on the issue, a public input summary, and a list of preliminary recommendations. Not all of the recommendations are included in the draft advice report, because the panel needs additional information and further deliberation.

The panel divided into two working groups. One group considered the Dispute Resolution recommendations and the other considered the milestone payments and eligibility. These discussions are summarized below.

Milestone and Eligibility Work Group:

Panel members in attendance were Mr. MacDonald, Ms. Flaten, Ms. Webb and Mr. Golden. Paul Seifert and Dan O'Brien were present from the general public. Marie Strahan and several other SSA staff were also present.

Mr. MacDonald turned to issue three of the Work Group report, concerning the issuance of more than one ticket or extending the ticket. The work group report does not contain a firm recommendation on this issue. Mr. MacDonald pointed out that the Statute limits the ticket to 60 months. The Statute also says that the Commissioner MAY issue a ticket. There may be additional savings to the General Fund in issuing more than one ticket, because beneficiaries will obtain more support and remain employed longer. Mr. Seifert explained that if the outcome payment is limited to 40 percent of the benefit, the other 60 percent is still a cost savings.

There was discussion around what the current statute provided regarding whether a person can get a second ticket during the same period of disability eligibility. Does the person go through a new period of eligibility when they use the "easy back on" provisions of TWWIIA? SSA staff clarified that the expedited re-entry is similar to Section 1619. The outcome payments will have already started when a person is in this status. The person would not be eligible for a second ticket because they are in the same period of eligibility. Ms. Strahan stated that there is guidance out to the field offices to this effect. Seifert mentioned another problem; when a person returns to benefits, he or she must deposit the ticket with the State VR agency and previously will have exhausted the ticket value. He recommended that a person get a new ticket when the payment under the old ticket has been exhausted. Mr. MacDonald stated that there might still be cost savings with issuance of a second ticket. Ms. Flaten suggested that people be able to have more than one ticket, but that it should not be a continuous ticket. Ms. Strahan raised a question about cost and suggested that the work group should pose this question to the actuary; e.g., is there a cost implication to increasing the number of months of outcome payment under the ticket? Ms. Webb wondered if this issue should be discussed now, since there will be additional rulemaking later. Mr. Seifert and Mr. MacDonald felt that the statement in the regulations that a second ticket will not be issued should be struck.

Mr. Seifert asked what happens to the payment on the first ticket if the person stops working and the agency then has no incentive to provide services if the payment runs out. Ms. Strahan stated that a question around period of entitlement has been sent to General Counsel. Mr. Golden stated that it was difficult to make a recommendation without more data. He recommended that this issue be flagged as an important issue for future discussion.

The question about an unused portion of a ticket is another issue that should be raised separately. Ms. Zawaiza will tease the recommendations out into two recommendations; the first is what is already written and the other relating to the unused portion of the ticket. Mr. Seifert stated that if a person gets a second ticket before the first ticket has expired, the first ticket should be nullified. The second question is whether you can get a second ticket after the first one has expired during the same period of eligibility. He pointed out that a beneficiary could be in the same period of eligibility for seven years and need another ticket to retain their employment. Ms. Flaten suggested, "Are there any circumstances under which a person should be entitled to more than one ticket or have their ticket value reset?" Ilene Zeitzer (SSA staff) suggested that if a second ticket is issued, it could be of a lower value than the first, and whatever value is left on the first ticket could be a down payment on the second. The panel decided to remove the following sentences from the recommendation. "The work group has not reached a firm recommendation on this issue. It requires further research, discussion, and deliberation." The work group also deleted "A second recommendation. ticket implementation period." The summary of input could be enhanced with additional examples. Ms. Flaten will send ideas to Ms. Zawaiza.

Mr. MacDonald turned to Issue Six, the Timely Progress Issue. He said that the panel has recommended three months of employment at any time during the 60 months as an indication of timely progress. Ms. Strahan asked how this recommendation would impact transition age students, or those in an education program. Ms. Webb felt that timely progress should be based upon the IWP. Ms. Strahan stated that the rationale for the timely progress requirement is to keep people from receiving related benefits (delayed CDR) when a person isn't really progressing toward employment. Ms. Webb felt that the PM should not be making decisions about timely progress; these decisions should be made between the beneficiary and the provider. The panel recommended that "The PM use the annual reports EN to the PM required by statute and by Section 411.325e of the proposed rules to provide proof of timely progress as outlined in the goals and objectives of the IWP.

The group broke for lunch at about 12:30

The work group held a lengthy discussion about the paradox between credentialing and flexibility of ENs. Mr. MacDonald suggested language that required the PM to include a provider that did not meet the current credentialing requirements as an EN, if the provider was recommended by a beneficiary. Mr. Golden expressed concern that any entity, irrespective of qualifications, could become an EN. Mr. Golden felt that the panel had already recommended including non-traditional providers as ENs.

Mr. Seifert expressed concern about the regulation that agencies had to meet state credentialing requirements. He said there are many licensing requirements that do not conform to state law, but still assure quality. The work group recommended excluding the licensing requirement from the regulations. Ms. Webb stated her feeling that the certification system protects the system, not consumers. It is not the TWWIIA regulations mission to determine timely progress.

A heated discussion followed about the appropriateness of credentialing for ENs. The consensus was that the existing work group recommendation should stand and that the certification by state law requirement should be deleted.

Should a beneficiary be allowed to be his or her own EN? Ms. Webb expressed concern that this would enable beneficiaries to receive 40 percent of their benefits for 60 months. She felt this was not the intent of Congress. The work group dropped this issue.

The payment for partial benefits issue was considered by the work group. Ms. Webb suggested that the information Seifert had provided be included as one alternative to the current regulation. The work group felt it could not endorse Seifert's plan because Ms. Lee and others were absent and no one had time to review it thoroughly. Ms. Flaten suggested that milestone payments be different under the SSI and SSDI program. Ms. Webb stressed repeated requests for information from SSA actuaries that had not been provided. The work group recommended outcome payments for partial benefit reduction, but felt they could not go forward with a specific plan due to lack of cost information.

Dispute Resolution Work Group:

Information about protection and advocacy services and how to access them should be available at any time to all beneficiaries seeking or using work incentives, including the ticket. Specifically, an SSI beneficiary should receive a formal notice of the availability of protection and advocacy service,

1. he or she is issued a ticket,

2. he or she applies to the EN for services,

3. when he or she signs the individual work plan.

4. in the event his or her services are decreased, suspended or terminated; and.

5. when he or she filed a complaint against the network.

A 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 and the subsequent inquiry by the protection and advocacy agency as to the beneficiary's wish for PNA protection, protection and advocacy assistance.

Notices from the EN and the protection and advocacy agency: The beneficiary's IPE, IWP and any other documents should be in the beneficiary's primary or accessible communication language.

Should there be time limits imposed on all parties involved in the dispute resolution process?

Background: Proposed regulations either do not reflect timelines for a dispute resolution or, where they do, they are inadequate or inconsistent. For example, there are no timelines for the Ens' internal grievance process or the Social Security Administration's review process. See also sections 411.435, 411.615, 144.625, and 411.630.

Input summary: Commentors were concerned about the impact on a beneficiary once a dispute arises. One aspect of that concern is the length of time it will take to resolve a complaint and what happens to the beneficiary's training and employment status during the complaint review process.

It was suggested that there should be strict timelines to minimize the adverse impact on all parties when the complaint is filed.

For complaints filed by beneficiaries with The EN, the EN should have fifteen working days to resolve a complaint.

If not resolved satisfactorily, the EN or the beneficiary can request a review by the project manager. The request for review with the submission of all supporting documentation by both parties must be submitted within ten working days of receipt of the EN's dispute resolution decision.

The project 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 working days after the program manager receives the party's request for mediation and should be completed within twenty working days after it is scheduled. Mediation does not foreclose a further appeal to the SSA.

The SSA should have no more than twenty working days to resolve appeals. All disputes involving ENs vocational rehabilitation agencies and the project manager must be resolved within 60 working days, including SSA review.

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 EN without the beneficiary's consent.

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

Deliberation on Preliminary Advice Report: Ms. Mitchell convened the full panel meeting at approximately 3:00. She thanked Ms. Zawaiza for compilation of the workgroup reports. Mr. MacDonald presented the report from Workgroup One. Mr. MacDonald suggested that the recommendations go in the front of the document and the summaries and background be in the back. Ms. Griffin stated that the discussion piece should be eliminated, leaving the background, issue, and recommendation sections. Mr. MacDonald recommended an executive summary, which contains the recommendations. The panel agreed.

Issue One: Mr. MacDonald read the recommendations from his report. The panel made minor edits to Issue One, such as removing "at least" and "should".

Issue Two, MIE eligibility: The panel agreed that the recommendation will be the first sentence. MIE status appeal will be placed in the discussion. Mr. MacDonald stated that the panel had voted last summer to recommend that all beneficiaries get a ticket, but SSA has not chosen to follow this recommendation.

Issue Three: The work group recommends that SSA should conduct a cost-benefit analysis on the feasibility of a beneficiary receiving more than one ticket. The discussion will contain some parameters under which beneficiaries might receive a second ticket. The sentence, "A second recommendation for further panel discussion. implementation period." Was deleted.

Recommendations Four and Five stand as they are, with the exception that the text of Section 411.325 should be quoted for clarity.

The panel moved to discussion of the milestone payments recommendations. Under Issue Two, Recommendation 2, the panel eliminated the phrase, "from the view of the beneficiary and from society as a whole."

Timely Progress: The workgroup recommendation was adopted. This recommendation stated, "The PM use the annual reports EN to the PM required by statute and by Section 411.325e of the proposed rules to provide proof of timely progress as outlined in the goals and objectives of the IWP."

Panel members raised concerns about the clarity of this recommendation. Evaluating timely progress is independent of payments to the ENs. Timely progress is being redefined from a specific outcome to adherence to the IWP, which is based upon an agreement between the EN and the beneficiary. Ms. Webb stated that the work group's intent is that progress on the goals and objectives of the IWP be reported annually. Timely progress should be defined as compliance with terms and conditions outlined in the IWP. The EN is responsible for developing annual reports delineating this progress. Staff should rewrite the recommendation to read, "We recommend that timely progress be defined as.and that the reporting mechanism be."

Additionally, "the panel received significant public comment supporting a change in this rule," should be added.

The recommendation allowing ENs substitute other plans for the IWP remains as stated.

The next recommendation states that a beneficiary should retain their eligibility with VR while depositing their ticket with another EN. This speaks to the recommendation that VR clients must deposit their ticket with VR if eligible for those services. Ms. Strahan said that if the beneficiary deposits the ticket with another provider, VR is prohibited from receiving cost reimbursement through SSA for any services provided, because the regulations say that SSA will pay the ticket holder. Mr. MacDonald stated that this provision results in lack of choice for the consumer. Ms. Strahan said that VR would have no incentive to serve an SSA beneficiary if they deposit the ticket with another agency. The regulations would also mean that any services paid for before the ticket is issued would not be reimbursed. There seems to be a conflict in the regulations regarding assignment of a ticket to the VR agency with a beneficiary who is eligible for VR services. Ms. Webb pointed out that people are eligible for VR services irrespective of the ticket and they could save their ticket and deposit it somewhere else after receiving rehabilitation services. They are only reimbursed after the person has worked for nine months. So if a person deposits a ticket with someone else after receiving services, VR does not get reimbursed.

Mr. Hickman said that once an individual applies for VR services, the ticket is considered assigned to the VR agency (Section 385). The panel felt there should be a recommendation to rewrite Section A to include consumer choice. The beneficiary should have a clear understanding that when they sign the IPE, they are assigning their ticket to the VR agency. Staff will develop appropriate language and the recommendation.

The meeting was adjourned at 5:00 p.m.

Thursday, February 8, 2001

Update on PM Implementation: Ms. Mitchell opened the meeting and introduced Ilene Baylinson from Maximus. Ms. Baylinson stated that the PM plays a pivotal role in the success of the program and stressed her commitment to open communication with the panel. She also introduced Mary Saterfield and Drew Hoffman. She explained that Maximus was founded in 1975 and has 25 years of experience with human services programs. Maximus has 4000 employees and over 100 offices that deal with medicaid and other programs. They have revenue of about $400 million. SSA is Maximus' oldest client. Maximus has designed the DDS system, so they have a strong understanding of the SSA system. This understanding is also based upon the management of the national program to refer people with substance abuse into treatment. Maximus established a national network of providers and linked beneficiaries with them.They looked at outcomes and paid providers.They also are conducting a pilot project to move youth into employment initiatives.

Ms. Baylinson described her and the agency's experience in employment programs. She stated that Maximus also operates an education and information line that serves SSI/Medicaid populations.

Ms. Baylinson stressed the importance of flexibility and change in program implementation. Maximus' first contract responsibility is recruitment of ENs. They have a team of marketing coordinators to establish the EN base. They will begin by focusing upon current Alternate Providers (APs) and agencies that have expressed interest through the Gallop survey. Maximus will be contacting these organizations before the RFP is released to get them ready to apply to be ENs. Marketing will take place over the entire five years of the contract. Maximus will review the applications before sending them to SSA.

Training will include in-person meetings, web based training, and written materials. The mode of training will depend upon the geographic concentration of interested providers. Maximus will also hire about 50 specialists that will staff a toll-free number. Staff will be organized by geographic area so they will become familiar with the states and the services available in that state. The toll free number will also serve as a centralized resource.

Maximus will also assist SSA in reviewing EN requests for payment, for accuracy and completeness. Program data will also be collected on recruitment, outcomes, etc. Overall management support services will be provided.

All of the management and supervisory staff are now on board and have been fully trained. Other staff will be trained in March. The data collection system will be operational by the end of the month, as will the toll free number.

The EN training materials are being finalized. Staff will be on board by March 1 to begin to answer consumer and EN questions. Ms. Baylinson closed by expressing her commitment to the success of the program.

Ms. Webb asked where Maximus offices are located. Ms Baylinson stated that they have only one office currently, which is in Alexandria. They are considering another office on the west coast. Ms. Webb also asked about training of ENs on reporting requirements. She pointed out that if the reporting requirements are not spelled out from the beginning, providers will assume significant costs if they need to retool later. Maximus responded that the basic requirements are known, but they are still working with SSA to clarify other requirements. Ms. Webb asked what criteria were used in terms of disability experience in hiring and how Maximus' experience allows them to handle the dispute resolution processes. Ms. Baylinson stressed that it takes a special kind of person to work with people who have disabilities and that Maximus tries to recruit such people. Mr. MacDonald asked if she felt that the PM's job is to track consumer outcomes or evaluate progress as outlined in the IWP. She stressed that Maximus role will not be to evaluate the types of services that ENs provide to beneficiaries, or to make judgments about the IWP. Maximus will look at whether the EN is progressing in terms of serving beneficiaries; e.g., how many beneficiaries are being served.

In response to a question from Mr. Golden, Ms. Baylinson stated that there will be a total of 90 marketing coordinators when all states have been rolled out in Year Three. The staff are experienced in employment, disability services, and community development. They also have experience in working with beneficiaries. The staff will be cross-trained so that the staff can supplement each other where needed. Mr. Golden further asked about training and who is conducting IWP development, work incentives, and other training. Ms. Baylinson responded that some organizations applying to be ENs will be selected to assist with the training based upon their areas of expertise. Maximus will develop formats and models that will simplify the documentation process. Benefits planning and work incentives training will be provided by other entities with more experience.

Ms. Strahan asked if Maximus had any plans to hire people with disabilities who are SSI/SSDI beneficiaries and Ms. Baylinson responded that Maximus has a track record of hiring beneficiaries for their program. In response to a question from Ms. Webb, she said that the ticket web site is under development and will be available soon. Mr. Golden asked what goals have been set for hiring individuals with disabilities and how many of the people hired so far are people with disabilities. Ms. Baylinson responded that Maximus had not set specific goals and did not know how many people with disabilities have been hired. Mr. MacDonald wondered how Maximus would deal with changes in the reporting requirements as the regulations are finalized. Ms. Baylinson expressed concern about this issue and said that it would be unlikely that there would be significant reporting changes. However, it is Maximus responsibility to educate and assist the field in making required changes.

Mr. MacDonald asked for clarification on how the payment structure for ENs will work. Ms. Baylinson explained that Maximus will review each payment request and follow up with the EN to make sure that documentation is correct. Maximus will move employment specialists to staff up this task as needed. The purpose of Maximus' review is to facilitate the payment process by identifying problems, rather than have SSA staff contact the EN if there are problems. Ms. Griffin asked about Maximus' experience under other contracts with dispute resolution and how the DR process will be set up. Ms. Baylinson stated that Maximus' most relevant experience was with SSI/SSDI beneficiary referral to substance abuse programs, where the Legislation required that a person lose benefits if they did not go into treatment. The approach Maximus will take will depend upon the parties involved and the situation. Ms. Mitchell asked what relationship Maximus would have with individual beneficiaries, since most of the interactions seem to be directed toward the ENs. Ms. Baylinson stated that Maximus role is to facilitate the interactions between beneficiaries and ENs. Communication with the beneficiaries would facilitate this process. For example, beneficiaries will probably contact Maximus when the tickets go out and Maximus can link the beneficiaries with potential ENs in their locality.

Ms. Flaten asked how many beneficiaries each staff person will handle and Ms. Baylinson said this will vary by EN. Larger organizations will require less staff attention. Maximus will put a quality assurance team in place to do internal and external reviews of program activities.

The panel broke at 10:20 and reconvened at 10:40.

Deliberations on Implementation of TWWIIA: This session began with a presentation from Ken Mr. McGill. He stated that the updated Redbook is on the SSA website and will be mailed out on February 14th. Mr. McGill stated that the comments made at the panel meeting were extremely helpful and SSA staff made some changes in the RFP yesterday, based upon those comments. Specific areas of change included the reporting requirements and the qualifications sections. Ms. Webb suggested that a form be developed on which potential ENs could state their qualifications and Mr. McGill said he would consider developing such a form, although he expressed concern about being too prescriptive. Mr. MacDonald expressed his appreciation for re-examination of the qualifications section of the RFP and expressed the hope that the changes would enable more non-traditional providers to apply.

Ms. Webb asked how SSA would handle outcome payments in the event that an individual moves the ticket to another provider after the initial milestones are paid. Specifically, how will the milestone payments already made to the first provider be recovered? Mr. McGill stated that the Statute allows more than one simultaneous payment for a beneficiary.

Mr. McGill reviewed a document that outlined ticket release during the first year of operation. There will be one release at the beginning of the process of about 236,000. Ms. Mitchell expressed concern about the ambitious roll-out schedule and Mr. McGill said he was aware of these concerns. Ms. Mitchell expressed concern that the panel had not reviewed the draft pamphlet that will be distributed to ticket users. Mr. McGill stated that the document was a draft and was not meant for public distribution. Ms. Griffin said that this draft was being widely distributed on the Internet. Ms. Mitchell expressed her desire for panel input into documents for distribution to the public related to the ticket and Mr. McGill stated that he would take comments on the draft immediately. Ms. Mitchell asked if there was a specific reason that this booklet had not been sent to the panel for review and Mr. McGill said it was an oversight, resulting from multiple projects with simultaneous deadlines.

Ms. Flaten asked for a copy of an implementation timeline to follow SSA's activities more closely. Mr. McGill referred the panel to the website for a broad overview and said that he would identify such a document for distribution. Ms. Flaten expressed concern that non-traditional providers were not listed in the draft pamphlet as potential ENs.

Deliberations on Preliminary Advice Report: Ms. Mitchell turned to the last section of Mr. MacDonald's report. Ms. Strahan presented the staff draft of the panel's recommendation dealing with ticket assignment to the State VR agency when a beneficiary applies for VR services. The recommendation states that SSA should rewrite Section 411.385 to make it clear that an SSA beneficiary with a Ticket who applies for State VR services has choice in deciding whether to assign (or deposit) that Ticket to the State VR agency, to assign it to another EN, or not to assign it at all. Ms. Mitchell and other panel members felt that the staff draft and the proposed language expressed the panel's wishes. Ms. Flaten also recommended that additional language be added to Section 390 to clarify that beneficiaries currently receiving VR services have a choice in depositing their ticket.

Dispute Resolution (DR) Work Group: Ms. Griffin stated that the group spent significant time yesterday changing the structure but not the substance of the group work report. The group collapsed the original ten issues into five. Ms. Griffin stated that timelines for the appeals process need to be reasonable and that there should be an external review. She said that beneficiaries should be notified several times throughout the process of their rights to DR. The work group proposed recommended times for notification; at ticket issuance, at filing, when the IWP is signed, when SGA is achieved, and when a dispute arises. The work group recommended that timelines for DR should be more clearly stated in the regulations. Ms. Webb noted the absence of time frames throughout the regulations, not just pertinent to DR. The workgroup recommended that ENs have 15 working days to resolve a beneficiary complaint. The EN or the beneficiary should go to the PM within ten working days of the decision. If the parties agree to mediation, the request should be acted upon within ten days and scheduled within 20 days. The next level of appeal should be SSA, with a deadline of 20 days. Ms. Strahan stated that sometimes an appeal to SSA takes about 18 months and that 20 days may be unrealistic, even though the appeal is much less complex. Mr. Golden asked for clarification from Mr. McGill as to which department at SSA would handle the dispute resolutions. He also asked who would be handling this within Maximus. The work group's final point was that services to the beneficiary should be continued at the same level, if the beneficiary desires, while the appeal is in process. All notices should be in alternative formats or appropriate languages. Mr. Golden wondered if the IWP is as legally binding as the IEP. Ms. Griffin stated that the workgroup used protections under the IEP as the basis for the recommendations. Ms. Griffin recommended keeping the language about service continuation broad, stating clearly and simply that services should be continued. Examples of why services should be continued should be in the rule preamble.

Ms. Mitchell stated that the payment group report would be discussed after lunch.

Update on HCFA Implementation: Ms. Mitchell reconvened the meeting at approximately 1:35 p.m. She introduced Joe Razes, from the Health Care Financing Administration (HCFA), to talk about HCFA implementation of TWWIIA. He stated that there are two grants under HCFA's responsibility: the first is the demonstration grants, which enable people who are not disabled under Title II of the Social Security Act, but still have disabilities which require medical coverage. The second is the infrastructure grants of $500,000 given to states. There have been two rounds of infrastructure grants so far. In response to a question from Ms. Webb, Mr. Razes stated that the infrastructure grant funds could be used in four categories; designing a buy-in program, restructuring Medicaid services in the state, preparing to apply for the demonstration grant, and to set up infrastructure training partnerships. The only major requirement to receive the infrastructure grant is that the State must operate a personal assistance services program (PAS). These grants cannot be used for services and there is no requirement for matching funds. The demonstration grants and the infrastructure grants will probably be awarded in August or September. These grant applications are available at WWW.HCFA.GOV/DHHS/HCFA/initiatives/TWWIIA.

Two demonstration grants have been awarded so far; one in Mississippi and one in Rhode Island. Twenty-five infrastructure grants have been awarded. Mr. Razes described the technical assistance partnerships. He said that HCFA does not have the knowledge base to give technical assistance (TA) on establishing Medicaid buy-ins. The partnership funds will be given to states that have experience under the Balanced Budget Act to work with other less experienced states. These partnerships will be established by the end of March, as the first step toward establishing a TA network. These partnerships will conduct research and provide technical assistance, assist with cost modeling, develop premium structures, and facilitate information exchanges among the states. Ms. Flaten asked what criteria are used to award the Medicaid buy-in programs. Mr. Razes said that there is a great deal of flexibility under the TWWIIA program regarding Medicaid buy-ins.

Mr. Razes stated that HCFA is working with the George Washington Center for Health Policy and Research, which compiles information on Medicaid buy-in states. They are convening two technical assistance meetings later this year and have put together a website containing Medicaid buy-in information. They will be developing policy papers and making recommendations on future policy and research. HCFA will also issue a competitive contract to continue this research at the end of the GW contract.

Mr. Razes explained that a work incentives conference is being held in Georgetown on February 12 and 13. It will focus on effective ways for Medicaid agencies to partner with others to create a comprehensive approach to employment. The American Public Human Services Association is funding the conference. Mr. Razes pointed out that one of the drawbacks to an 1115 waiver is that it must be budget neutral. States must be extremely creative in developing these waivers. HCFA wants to structure the 1115 waivers so states could apply for a demonstration grant at the same time, because the demonstration grants are not subject to budget neutrality. This means that some 1115 recipients could be funded under demonstration dollars.

Mr. MacDonald mentioned that $5 million had been reserved for an evaluation report to Congress about whether to extend the buy-in and other work incentives after the Law's expiration. Mr. Razes explained that a series of meetings is being held with SSA to discuss and resolve inter-agency issues. The meetings are also used to develop a research strategy, share information and develop work groups. He suggested that the panel bring forth any items of concern that impact both agencies. HCFA also conducts telephone training with its field offices to insure that SSA and HCFA field offices are in contact and have positive relationships with SSA.

Ms. Flaten asked what efforts are being made to include Medicaid beneficiaries in grant activities. Mr. Razes said he was not aware of any requirements, but other panel members said consumer involvement was required for the Infrastructure grants. Ms. Flaten said that consumer involvement was not occurring in Minnesota and she strongly recommended that HCFA encourage such involvement. Mr. MacDonald also heightened the importance of consumer involvement at all levels.

Deliberations on Advice Report: Milestone Payment Workgroup Report: Ms. Webb stated that her group would like to have made stronger recommendations than the report contained, but couldn't due to missing information from the SSA actuaries. The actuaries have been asked to make presentations, but have not been available. Dr. Burkhauser, who is a member of the work group, has been in contact with the actuaries, but he is currently unavailable due to other commitments. She stated that some of the recommendations do not sound as strong as they might without this information. The recommendations include four milestone payments and individualized milestones for beneficiaries who need significant or expensive supports. Information about what occurs if the beneficiary changes their ticket when some milestones have already been paid could impact this recommendation.

Ms. Webb presented Stephanie Lee's recommendation to use the individualized planning process to determine if and when additional milestones are necessary. Ms. Lee supports a flexible approach for beneficiaries for whom the proposed milestones will not work. She is recommending a maximum $5000 milestone up front. Mr. Golden pointed out that the panel did not yet take a position on whether work should be integrated or not. Ms. Flaten said that perhaps the ticket is not the most effective way for people to get their long-term support services met. Perhaps other programs are better able to meet this need.

Ms. Lee was contacted by telephone to participate in this discussion. Marty Ford of the ARC commented that it was not helpful to confuse sub-minimum wages with sheltered work. She also said that references to "hard to serve" categories are sprinkled throughout the law. The panel should not think about this group only in terms of future services. Ms. Lee stated that she wanted to add a couple of sentences in the discussion that explained what a "flexible" milestone meant. The panel decided to move Ms. Lee's language to the discussion section.

Ms. Webb stated that the only other significant item for discussion was Mr. Seifert's Tuesday handout related to outcome payments when the beneficiary is in partial benefit status. The panel decided to include Mr. Seifert and Mr. O'Brien's handouts as attachments to a separate recommendation as examples of payment schemes for partial benefits. Additional discussion will be included in the final report.

The next recommendations were read. The discussion moved to Recommendation Four, which addressed meeting with IRS personnel to discuss wage reporting. Ms. Webb said that she had met with IRS and SSA to find out if there was a way to get wage reports from the IRS rather than the consumer and the employer, as the regulations now propose. The IRS reports all employer income to SSA on an annual basis and SSA sections out the people who are on DI and SSI. Getting this information monthly would require IRS to do this task, which they probably would not be willing to do. Mr. MacDonald asked why SSA couldn't submit the names to IRS for them to send SSA earnings information. SSA staff will obtain information to answer this question. Ms. Webb said that some states get the reports quarterly by tapping into the child support or unemployment data, but there is also a significant delay in this process. After verification, only 94 percent of wages are reported correctly. The other problem is that SSI sheltered work earnings are not subject to FICA withholding. Ms. Webb said it was probably not practical to look at the SSA internal process for wage reporting. The panel will delete the reference to the meeting with IRS in the draft advice report and will recommend that SSA, in conjunction with the panel, will develop a mechanism to facilitate accurate payments.

Mr. Golden asked why the cost reimbursement option is only available to VR and not to private ENs. Ms. Webb responded that this is a statutory provision. Ms. Webb stated that Section 390 is in direct conflict with Section 411.510. It deals with what happens when a beneficiary has a VR IPE in process when they get a ticket. Section 390 says that VR agency may only seek cost reimbursement in this situation; in the next section, it provides the VR agency the option of cost reimbursement or outcome payments. The panel recommended that the Agency resolve the conflict.

The panel took a break at about 3:45.

Business Meeting: Ms. Mitchell reopened the meeting at about 4:10. The minutes of the January 9-10 meeting and January 23 teleconference were approved. Ms. Strahan reported that the hiring and contracting freeze ordered by President Bush is in place at SSA until a Commissioner is appointed. She announced that Ilene Zeitzer, who has worked for many years at SSA in international disability policy, has joined her staff. Mildred Owens has also been detailed to assist with budget and contracting work. The move to the new office space is taking place and staff should be relocated by next week. The budget for the panel is in dispute and Ms. Strahan is appealing a proposed budget cut. The web site should be up and running before the next quarterly meeting.

Ms. Mitchell stated that the next meeting is May 8-10 in St. Louis. There will be a March meeting on March 26-28 in Phoenix. This will be a full public meeting. Panel members moved and seconded a motion to approve the preliminary advice report and the motion was adopted unanimously.

Ms. Mitchell explained that a motion from Steve Start had been tabled at the last meeting. The motion stated, "Mr. Start moved that the panel advise that SSA release the RFQ with the proviso that it is based upon draft regulations and that SSA release the tickets 90 days after release of the RFQ." This motion was later amended to include, "subject to review of the RFQ by the panel". Panel members moved and seconded a motion to put the motion back on the table for discussion. The motion was withdrawn, leaving the original motion still tabled. Ms. Lee moved that the panel recommend that SSA not release the RFP for the ENs and the tickets for beneficiaries until the TWWIIA regulations are final. Ms. Flaten said she was extremely concerned about the tickets being released to participants. Ms. Lee said there are significant issues that need to be resolved in the regulations and the RFP should not be released until the regulations are final. She further stated that there should not be a ticket release until the ENs are in place. Ms. Mitchell stated her preference that the RFP go forward but the tickets be withheld. Ms. Mitchell felt that the tickets should not be released close upon the heels of the RFP. Ms. Griffin stated her concern that the RFP not be released until the regulations are finalized because the regulations are currently still in flux. Mr. MacDonald emphasized that the PM had explained that system changes are expensive if they are made after program design. He asked what the hurry was in implementing the program when it could be dramatically changed. In response to a question from the panel, Mr. McGill stated that he wanted to move forward with the RFP and ticket release so the agency could stay as close as possible to the time frames in the Statute. He also mentioned the "swift implementation of TWWIIA" mentioned in the Bush New Freedom initiative.

Ms. Mitchell asked what would happen if the RFP was delayed until after the end of the comment period. Mr. McGill stated that this would not be problematic. The comment period ends on February 26, so this delay would not make much difference. Ms. Lee felt that if the RFP was issued as is, the chance of changing the regulations based upon consumer and panel input would be much less. Ms. Griffin asked when final regulations would be expected and Mr. McGill stated that his most optimistic guess would be three to four months, or around June. Ms. Flaten expressed concern that the regulations may not get adopted as quickly as June and wondered if a time limit could be established, whereby SSA would be advised to wait until the regulations were finalized, but if they were not finalized by a certain date, the RFP would be issued. Ms. Webb stated that the RFP has language that enables the ENs to modify their applications based upon any changes in the regulations. She felt that having ENs in place might be a better incentive for the Administration to approve the rule quickly. She felt that the longer we wait to finalize the rule, the harder it will be to get it finalized. Mr. MacDonald amended the motion and read his amendment. "Sec: 411-105 What is the purpose of the Ticket to Work program? The stated purpose of the Ticket to Work program is to expand the universe of service providers available to individuals who are entitled to Social Security benefits based on disability. The Panel is making substantive recommendations to change the proposed rule. Based on a review of the RFP, the Panel believes that the RFP, as an application of a proposed rule, may jeopardize the early success of a new model program. Distribution of the RFP and tickets should wait until possible revisions are made based on a final rule. The motion is based on the information presented about the recruitment of Ens by the PM in an integrated process with wide distribution of tickets". He later withdrew his amendment.

Ms. Mitchell stated that the panel's Operating Procedures say that a member who is absent from a meeting can vote on a motion within five days of the meeting by registering his or her vote with the Chairperson. She stated that Mr. Henderson had left the meeting and had registered his vote with her. Ms. Lee's motion was read. Ms. Webb asked for a roll call vote. Mr. MacDonald, Ms. Griffin, Ms. Flaten, and Ms. Lee voted Yes, and Ms. Webb, Ms. Mitchell and Mr. Henderson voted No. The motion passed, pending the absentee ballots. Ms. Mitchell noted that the majority of the panel was not present.

Ms. Flaten moved that the distribution of the tickets be delayed until the final rules are issued. Mr. MacDonald seconded the motion. Mr. MacDonald, Ms. Griffin, Ms. Flaten, Ms. Mitchell, Mr. Henderson and Ms. Lee voted Yes, and Ms. Webb voted No. Ms. Griffin moved that the RFP for the ENs not be released until two months after the comment period closes, which would be April 27, to give the panel the chance to look at the comments and suggest any changes to the RFP. Ms. Flaten seconded the motion. Mr. MacDonald, Ms. Flaten, Ms. Griffin, Ms. Mitchell, Mr. Henderson and Ms. Lee voted Yes and Ms. Webb voted No. Ms. Mitchell stated that the last two motions are alternatives to Ms. Lee's motion if that motion does not pass when the absentee votes are considered.

Ms. Webb stated that Justin Dart has been taken to the hospital and is expected to have surgery in the morning. She asked for the panel's prayers and thoughts. Ms. Strahan asked if staff could draft the letter to the Commissioner regarding NPRM provisions and send it to the panel for review. There was informal agreement from the panel.

The meeting was adjourned at 5:25 by Deborah Morrison.