Ticket to Work and Work Incentives Advisory Panel
Quarterly Meeting Minutes
Embassy Suites at Chevy Chase Pavilion
Washington, DC
November 13-15, 2000

Day 1: Monday, November 13, 2000

The meeting was called to order by Deborah Morrison, Designated Federal Officer, at 9 AM. Ms. Sarah Wiggins Mitchell, Advisor Panel Chair, extended a welcome to Panel members and the public, reviewed the calendar, and asked the members to introduce themselves. Members present at this meeting were: Richard Burkhauser, Kris Flaten, Frances Gracechild, Larry Henderson, Jerome Kleckley, Stephanie Smith Lee, Bryon MacDonald, Stephen Start, and Susan Webb.

J. Kenneth McGill, Associate Commissioner, Office of Employment Support Programs (OESP), Social Security Administration (SSA), opened the meeting by presenting an update on implementation of the Ticket to Work and Work Incentives Improvement Act (TWWIIA). Mr. McGill distributed advance copies of the Notice of Proposed Rulemaking (NPRM) to implement TWWIIA. Following publication in the Federal Register, there will be a 60-day public comment period. Mr. McGill quickly reviewed Subparts A-J:

• Subpart A contains introductory material.
• Subpart B on Ticket eligibility excludes beneficiaries under the age of 18 and those categorized as "medical improvement expected."
• Subpart C on suspension of Continuing Disability Reviews (CDRs) defines use of the Ticket as "making progress toward the goal of reducing or eliminating dependence on disability benefits within reasonable timeframes."
• Subpart D outlines responsibilities and duties of the Program Manager (PM).
• Subpart E describes the constitution and role of Employment Networks (ENs).
• Subpart F delineates participation by state vocational rehabilitation agencies.
• Subpart G describes individual work plans (IWPs).
• Subpart H outlines EN payment systems, both in terms of outcomes and outcome-milestones.
• Subpart I covers dispute resolution.
• Subpart J describes inclusion of Alternate Participants.

Mr. McGill added that SSA is also seeking public comment on:
1) a national model for periodic reports by ENs;
2) performance measures for EN quality assurance; and
3) the possibility of issuing Tickets to beneficiaries aged 16-18.

Ms. Mitchell then opened the meeting to public testimony on the definition of a Ticket.

Ms. Sue Augustus of the SSI Coalition said her organization serves low-income senior adults and people with disabilities. It focuses on identifying systemic barriers and making proposals to correct them. She recognized that TWWIIA represents more voluntary choices for beneficiaries and a long-term approach to "return to work." The challenge, according to Ms. Augustus, is the "creaming" issue, particularly related to persons with developmental and cyclical (largely psychiatric) disabilities. Her concern is that ENs will concentrate on those who are easy to place. Another concern is that a significant number of beneficiaries will not access the system. She also noted the need to bring in creative approaches by non-traditional ENs. In addition, she had a concern about SSA providing notice to beneficiaries and wondered who would pay for needed assistive technology under the new system. Responding to a question from Ms. Webb, Ms. Augustus said her organization would make specific recommendations in response to the NPRM. Asked by Ms. Mitchell about notices to beneficiaries, she stated that the Ticket notice should be simple to understand, short, accessible, and available on the Web.

Mr. Andrew Sperling, Director of Public Policy, National Association for the Mentally Ill (NAMI), questioned the restriction on eligibility for those beneficiaries listed as "medical improvement expected" (MIE). This population represented a large share of beneficiaries with mental illness. MIE status should not be a limitation on obtaining the Ticket, in his view. He also advocated an unlimited number of Tickets to benefit those people with episodic illnesses and cyclical, intermittent work histories. Responding to a question from Dr. Burkhauser, Mr. Sperling said there was always a potential for "creaming."

Mr. Dan O'Brien, Oklahoma Department of Rehabilitation Services, said that he directs the SSA-funded State Partnership Initiative (SPI) project in his state. The Oklahoma SPI program has piloted a Ticket-like voucher system and milestone payments. He warned that, if Ticket payments are not adequate, there will be no choice of vendors. In his view, SSA had to be careful to learn from payment lessons of the Alternate Participant (AP) program. He also stressed the need to include transition-age youth. Responding to a question from Mr. MacDonald, Mr. O'Brien stated that 16-18 year olds were used to structure, getting dressed, and going to school, and they had no sense of entitlement to benefits. These individuals were psychologically prepared for the work environment. Ms. Lee brought up the issue of "creaming" and stated that milestone payments are designed to assist small providers and address needs of beneficiaries with the most significant disabilities.

Ms. Marty Ford, Director of Government Affairs, ARC of the United States, said that the Ticket should go to all beneficiaries who want to participate. In her opinion, using the MIE designation to exclude beneficiaries ignores legislative intent. Further rulemaking may be necessary if the MIE standard is applied, she added. She emphasized that there should be no limit on the number of Tickets in order to accommodate people with severe disabilities, including those with sporadic, episodic, or life-long conditions. Dr. Burkhauser asked about the risk of "buying the base," i.e., paying ENs for what they would have done naturally. Ms. Ford did not see that as a concern. She noted that there is a need to break open the system and reach people as soon as possible.

Mr. Alan Bergman, President and CEO of the Brain Injury Association, observed that the legislation is not the result of Congressional benevolence, but rather fiscal cost containment. He added that SSA needs to help those beneficiaries under 18 years old. Under IDEA, he said, transition planning begins at 14 years old or earlier. Since the neurological recovery process is unknown, categorizing someone with a neurological condition as MIE may be unfair. He also supported the principle of more than one Ticket per lifetime. Ms. Webb asked about the potential for school systems to serve as ENs. Mr. Bergman supported the idea and emphasized the importance of cooperation between the school system and the vocational rehabilitation (VR) agency. Mr. Start asked about programs for people with developmental disabilities and mental illness. Mr. Bergman said that the ENs and the PM needed to make linkages to long-term supports. Ms. Lee stressed the need for self-determination among these populations.

Addressing the transition issue, Mr. Mike O'Brien, Oklahoma Department of Rehabilitation Services, stated that opportunities need to be created for youth while they are still in school. A Ticket for 16-18 year olds is necessary. His agency is working with 2000 young persons in 19 pilot projects. He also expressed concern about people potentially left behind, i.e., those with traumatic brain injury, mental illness, developmental disabilities, and visual impairments. The right environment has to be created in order to position all people to be successful. Dr. Burkhauser asked about the advisability of integrating 16 year olds in the workforce. Mr. O'Brien said they need an education option in their IWP. Ms. Webb asked about the transition from school to sheltered work. Mr. O'Brien said it is now necessary to go beyond sheltered employment. Supported employment should be viable.

Ms. Jenny Kaufmann of the National Senior Citizens Law Center said that, with respect to MIEs, the processing of continuing disability reviews (CDRs) is dependent on Disability Determination Services. There is a large backlog of CDRs. Most beneficiaries categorized as MIE want to return to work, she said, and they should receive Tickets.

Ms. Catherine Mario of New York Vocational and Educational Services for Individuals with Disabilities (VESID) expressed a concern about maintaining a high level of professionalism among ENs. She also wondered about recruitment of ENs in rural areas and among tribal nations. She added that VR agency coordination with ENs has to be in compliance with the Rehabilitation Act and the Workforce Investment Act. Ms. Mario also expressed support for streamlining the administrative process behind the Ticket. Ms. Webb asked about her point on professionalism to ensure quality. Ms. Mario replied that she is concerned about making job placements without taking into account counter-indications (i.e., consumer health issues).

Ms. Mitchell then called for a 30-minute break. Upon returning, she opened the meeting to public comments on qualifications of TWWIIA employment networks.

Mr. Charles Harles, Executive Director, International Association of Business, Industry and Rehabilitation (IABIR), said he represents a diverse group of service providers, primarily Projects With Industry. He stressed that alternatives need to be available. Good providers should have easy access to EN status. There is a need to break down bureaucratic barriers among Department of Labor, Department of Education, and SSA. Milestones have to be flexible, especially for smaller providers.

Mr. Dan O'Brien said that, in order for the customer to win through choice, the system needs a well-defined product, a well-informed consumer, and easy entry for the supplier (the EN). Capital requirements for ENs are in inverse relation to milestone payments. Under the milestone system in the NPRM, SSA will not achieve more EN participation than in the Alternate Participant program. There will, in fact, be less competition for the VR agency and other state agencies. Ms. Lee said that the program should be as inclusive as possible and asked how to attract non-traditional providers. Mr. O'Brien replied that this is a difficult problem, but SSA needs to pay out more and bigger milestones (as was the case in Oklahoma's SPI program). Dr. Burkhauser asked about qualifications restrictions reducing entry for potential ENs. Mr. O'Brien did not foresee a major problem, but acknowledged the need for a gatekeeper.

Ms. Marty Ford advocated that the new program move away from the VR system and any arbitrary barriers for ENs. The criteria, in her view, should be whether the EN can provide services successfully, especially in the initial rollout period. Ms. Mitchell asked about the possibility of a single individual serving as an EN. Ms. Ford saw no problem with this. Mr. MacDonald suggested employers serving as ENs, and Mr. Start suggested families as ENs. Ms. Gracechild recommended grants for on-the-job training and career opportunity development to employers.

Mr. Alan Bergman stressed that there has to be a real choice, with a focus on outcomes rather than quality assurance and outputs. Under the RSA Choice Demonstration projects run by United Cerebral Palsy, there were very few entry criteria for providers. He added that providers could be relatives or neighbors under this program. There also needs to be an informed consumer. Ms. Lee stated that the regulations focus on input rather than outcomes. Ms. Webb suggested a consumer training curriculum. Mr. Bergman endorsed the idea of consumer education, rather than simply handing out information. He pointed to distrust of SSA by beneficiaries and the need to change this perception.

Ms. Susan Prokop of the Paralyzed Veterans of America (PVA) said that half of her organization's members receive disability benefits. She found the MIE distinction to be unfair. Also, beneficiaries need more than one Ticket in a lifetime. She also endorsed broad coverage by ENs.

Mr. Mike O'Brien questioned the negative perception of state VR agencies, adding that these agencies cannot serve everyone in the system. Cost-sharing partnerships between the VR agency and other ENs should be considered, in his view. He cautioned that quality control is essential and cited "fly-by-night" agencies that exploited workers' compensation cases. Mr. O'Brien described the optimal outcome as "cool jobs with benefits," including potential for career advancement. This outcome should pay at least the average state wage for the occupation, plus health insurance, vacation, sick leave, etc. Mr. MacDonald asked about licensing credentials. Mr. O'Brien replied that there is a licenser law in Oklahoma that requires professional credentials for this sort of counseling. Ms. Flaten said there should be allowances for people not working full-time. Mr. O'Brien acknowledged that the Ticket system does not cover this eventuality.

Ms. Mitchell then declared a break for lunch. The meeting reconvened at 1:30 pm. Ms. Mitchell opened the floor to public comment on design of outcome and milestone payment methods.

Ms. Susan Prokop stated that providers may shun the program, given the proposed level of milestone payments in the NPRM. Moreover, self-employment should not be discouraged by the milestone system.

Mr. Andrew Sperling pointed to the fact that there is no pre-employment milestone payment in the NPRM. There is also the question of how to deal with SSI consumers. A gradation system may be needed for EN payments, even when substantial gainful activity (SGA) level has not been reached. Ms. Flaten remarked that most first jobs for beneficiaries are not at livable wages. Mr. MacDonald agreed that most are working under the SGA level. Ms. Webb noted better access to health care under TWWIIA. Mr. Start pointed to the attitude of the mental health community that "work is a bad thing." It was time to change this thinking. Mr. Sperling replied that NAMI is pushing a new outlook emphasizing benefits of employment, including opportunity for socialization.

Ms. Marty Ford noted that, to limit costs of the program, milestones payments are less than outcome payments. However, it was expected that milestones would pay out 38-39% of the benefit, yet the NPRM proposal only offers 34%. She added that this will be a disincentive to serve the severely disabled and suggested a system of customized milestones with the approval of the PM. Dr. Burkhauser asked if she was willing to accept greater regulation to balance off more flexible milestones. Ms. Ford said that flexible milestone proposals should go through the PM oversight structure. Ms. Lee asked how the Ticket could move people out of sheltered workshops. Ms. Ford replied that this depends on individual circumstances. Ms. Ford agreed with Mr. Start that funding under Title XIX, Title XX, and special education programs should be linked.

Mr. Dan O'Brien outlined the Oklahoma milestone payments designed to reward significant steps toward a larger goal (e.g., milestone payments at 3 days, 4 weeks, 8 weeks, and 12 weeks after employment). Persons with mental or developmental disabilities or head injuries are mostly placed in supported employment, whose services cost $5000-$10,000. He added that SSA proposed milestone payments would not cover these supports. Mr. O'Brien calculated the break-even point for providers at between 2 and 4 years and concluded this was not realistic. He advocated: 1) increasing the number of milestones (3 to 9); 2) phasing in a threshold for earnings; 3) stipulating that milestone payments should not be recouped in the first 12 months of outcome payments (but spread out over 60 months); and 4) creating a two-tier system for the more severely disabled. Responding to Panel questions, Mr. O'Brien suggested applying percentage quotas for placements by providers to remain in the system.

Mr. Alan Bergman asked: What are the correct milestones? How many are needed? Should they be individualized? He pointed to the example of persons with cognitive disabilities who often need individualized programs of "work first, training later." He also cited the 1998 ADA tax credit as a means of covering costs of long-term supports. Mr. Bergman noted research from the University of California at San Diego that demonstrates how functional needs should be taken into account when designing a differential payment system. He suggested moving toward a differential payment system based on intensity of need and looking at lessons learned in the healthcare risk-adjustment system in the SSA equity study. Responding to a question from Mr. MacDonald, he said the Federal government and Congress here are not engaged in risk-sharing, but risk-shifting onto the provider community in the private sector.

Ms. Mary Kelly of the National Association of Developmental Disabilities Councils emphasized that people with severe disabilities are at risk of being left out. For this reason, SSA should begin on the equity study as soon as possible. She added that milestones have to be individualized to meet the person's needs. Ms. Gracechild asked which obstacle was most significant and deserving of a milestone. Ms. Kelly replied it was meeting accommodation needs, especially assistive technology. Ms. Lee asked if individualization would be part of the work plan. Ms. Kelly responded that it could be part of the negotiation with the EN. Ms. Mitchell asked about priorities in the equity study. Ms. Kelly said the study should look at who is having trouble with the Ticket process and what strategies are successful.

Ms. Celane McWhorter of the Association for Persons in Supported Employment stated that, without milestones, supported employment organizations could not participate in the Ticket program. She suggested interim regulations for a three-year period with a milestone system based on a two-tier system. The second tier would be for people who need significant supports. Ms. Lee asked her to elaborate on the second tier. Ms. McWhorter replied that the second tier could be individualized, perhaps based on the PASS model. Dr. Burkhauser asked about the criteria separating the two tiers. Mr. MacDonald suggested the IWP as a way to move forward to develop milestones (with the consumer in control). Ms. McWhorter noted that milestones should not be set indefinitely. Mr. Start recommended looking at the people who do not get picked up by ENs and then revisit the milestone/outcome system. Ms. McWhorter warned that consumers cannot wait for three years for the approach to be changed. The SSA formula disenfranchises everybody, she added.

Ms. Mitchell then called for a 30-minute break. Upon returning, Ms. Mitchell opened the floor to public comment on TWWIIA implementation.

Ms. Susan Prokop stated that the "2 for 1" demonstration pilot project was very important to PVA, as many of its members confront the SSDI "income cliff." She said the Panel should press SSA on this project. She rejected the notion of induced entry of working persons with disability returning to the Social Security roles and expressed a hope that the "2 for 1" demonstration would focus on incomes above SGA. Ms. Prokop advocated Panel meetings outside of Washington. Building on this comment, Ms. Lee stated that the Panel could work with the Consortium of Citizens with Disabilities, use the Internet to pose questions to the public regarding the NPRM, and hold hearings across the country. Other disability organizations could put the Panel questionnaire on their websites. Mr. MacDonald noted that a briefing on the "2 for 1" demonstration was scheduled for November 15 and that the issue highlighted how complex the work of the Panel was. He also called for greater public input.

Mr. Andrew Sperling emphasized that the original Jeffords bill had provisions for immediate implementation of the "2 for 1" demonstration. He added that most of the Benefits Planning, Advocacy & Outreach (BPA&O) grantees had little experience serving adults with severe mental illness. He said that SSA needs to overcome consumer suspicions and that the potential for induced entry was a "red herring." Ms. Gracechild noted that the RSA has issued new standards for independent living centers on their cross-disability responsibilities (including serving people with mental illness). Mr. MacDonald agreed, adding that collaborative partnerships incorporating non-traditional organizations won BPA&O grants in California. Dr. Burkhauser expressed the need for more information on the "2 for 1" demonstration and the induced entry phenomenon.

Mr. Dan O'Brien stated that, under the Joint Training Partnership Act, there was a two-tier system for helping emotionally disturbed adolescents. He added that, in assessing the "creaming" issue, SSA should track those Ticket holders rejected by ENs. The Oklahoma SPI program has had to teach consumers how to advocate for themselves. He also calculated that the "2 for 1" demonstration would raise the level of outcome payments to $2200 a month. Ms. Webb asked about partnerships between the VR agency and the ENs. Mr. O'Brien replied that the Oklahoma VR agency under the SPI program already subcontracts with eight private providers. Ms. Webb noted that Arizona had initiated a program where families of persons with developmental disabilities (DD) made employment decisions, but the state DD agency did not approve the program. Mr. O'Brien stressed the need for competition, but added that sufficient capitalization is the problem for ENs.

Ms. Marty Ford focused on the status of 700,000 disabled adult children (DACs) who, upon re-entering the system after working, would lose DAC status and would return based on their own work history. She emphasized that their status needs to be assured. The "2 for 1" demonstration is strongly supported by ARC. However, SSA's proposal to reduce benefits beginning below the SGA level should be voluntary. Ms. Ford also noted the issue of overpayments, which should be addressed through an SSA tracking system. She also brought up CDR protections for beneficiaries outside the Ticket system. Finally, she advocated holding Panel field hearings at conferences of large disability organizations. Responding to Panel questions on the DACs, Ms. Ford stated that these are disabled dependents who have a severe impairment prior to the age of 22. They receive benefits through the Title II system based on their parents' work history. In her view, SSA has to make it clear that a disabled adult child using the Ticket would be able to go back onto the system and retain DAC status.

Mr. Mitch Jessirich of the World Institute on Disability supported the Panel decision to reach out to the community. He suggested working with local agencies, especially those assisting ethnic minorities, and organizing focus groups of employers and consumers.

Mr. Michael Van Essen of the AIDS Assistance Organization of Palm Springs, California, emphasized that the consumer needs to be assured that no harm will come to him/her through participation in the program. Too many consumers, he added, have a perceived adversarial relationship with SSA. SSA regional offices need to be less formidable and more accessible. He also endorsed the idea of a more vigorous outreach program and encouraged consideration of self-employment options.

Ms. Kara Freeburg of the American Network of Community Options and Resources (ANCOR) said her organization represents providers who serve people with mental retardation and other disabilities. ANCOR members have been encouraged to become ENs, but are reticent due to the costs involved. She stated that more flexibility and larger payments for milestones are required.

The Panel then adjourned at 5 pm.

Day 2: Tuesday, November 14, 2000

Ms. Mitchell reconvened the Advisory Panel at 1:35 pm. The morning sessions had been devoted to panel work group deliberations on the Ticket and employment networks, payment systems, and dispute resolution/protection and advocacy, respectively. Ms. Mitchell emphasized the process of responding to the NPRM. The Panel is seeking input from the public through roundtables and hearings during the 60-day period of public comment following NPRM publication.

Ms. Mitchell then provided the summary report from the dispute resolution/protection and advocacy (P&A) work group. These issues had been discussed in the Panel teleconference November 8th. Her group went through the relevant provisions of the NPRM (Section 411.600) and made a series of recommendations. First, the P&A grant program needs to be rolled out as soon as possible. The sections concerning information and referral, education and training, outreach, and legal representation and advocacy are not tied to the Ticket rollout schedule. She emphasized that this assistance is available to all beneficiaries, not only Ticket holders. The work group recommended that specific timelines be inserted into this process involving state P&A agencies and particularly concerning grievance procedures [Section 411.605(a)]. The work group also recommended changing Section 411.605(d) to read: "The EN must inform each beneficiary seeking services from the EN of the availability of assistance from the State P&A system." For Section 411.615, there was concern that only the EN is contacted and that due process rights of beneficiaries are not addressed; recommended language is as follows: "The PM will contact the EN and beneficiary to submit all relevant information within 10 working days." Also, revised language was recommended for Section 411.615(d), to wit: "The information should include a description of any solutions proposed by the EN when the beneficiary sought resolution through the EN's grievance procedures, including the reasons the beneficiary or the EN rejected each proposed solution."

Ms. Mitchell stated that mediation had been discussed in the November 8th teleconference. There was Panel consensus that mediation makes sense (in that it saves time and money), but that it must be voluntary. P&A agencies cannot act as mediators, since they are advocates. The work group recommended using independent mediators external to SSA, but could not resolve the payment issue for these mediators. The inquiry regarding mediation can be made by the PM. The dispute resolution procedures should be analogous to appeals in the judicial arena, in that each side should prepare its case and provide it to the other party. At this point, notice should be given to the P&A agency, with the beneficiary's approval. Alternatively, the P&A agency might take a more active position by sending a letter to the beneficiary outlining his/her rights and responsibilities and asking if the beneficiary wants the P&A agency's assistance. Any such letter must be written in the beneficiary's primary language.

The work group found that Section 411.620's provision of 20 working days for the PM to provide a written recommendation is sufficient. With respect to Section 411.625, Ms. Mitchell asked at what point the 15 days begin for request of SSA review. Regarding Section 411.630, she inquired if the SSA decision would be considered the result of the external review. She also asked if the beneficiary will have a right to participate and have representation. The work group also found that 60 work days is sufficient for the mediation process, once the PM has received notice. But Ms. Mitchell questioned whether the open and flexible language of Section 411.630 provides sufficient guidance to beneficiaries about what their rights are.

Ms. Webb asked if the work group anticipated that the P&A agency would use TWWIIA funding to provide this service. Ms. Mitchell replied affirmatively. Ms. Flaten suggested that, when a beneficiary receives notice of this process, a second person (possibly a case manager or a family member) could receive a duplicate of the correspondence. She added that guidelines are needed for what can come out of a dispute. Ms. Mitchell noted that it is difficult to list all the possible outcomes. Ms. Lee asked if a beneficiary wants to separate from an EN, do they need to go through dispute resolution? Ms. Alaine Perry of the SSA staff responded that the law provides the beneficiary the right to reassign or withdraw the Ticket at any time.

Ms. Mitchell asked if there are any language standards for SSA. Ms. Marie Strahan, Acting Executive Director of the Panel, replied that there are some standards for field offices in certain geographic areas. Mr. Start agreed with Ms. Flaten that a second party be designated to receive documentation from an EN, particularly in cases of people with developmental disabilities. Ms. Flaten said that this should occur at the initial sign-up stage with the EN. Ms. Mitchell wondered what would happen if the two parties do not agree to mediation. Ms. Strahan responded that it would go to the PM for judgment. Ms. Flaten endorsed the idea that the timelines for the internal grievance processes should be consistent. All ENs should adhere to the same guidelines. Ms. Mitchell observed that the P&A process should be separate from the regulatory process. Ms. Strahan asked how the mediators would be selected. Ms. Mitchell replied that each state has its independent mediation panels.

Ms. Lee suggested that the Panel collect key questions to pose to the public on the web site and possibly publish in the Federal Register. Ms. Mitchell opened the discussion for public comment. Mr. Michael Van Essen suggested using a registered letter or some form of return receipt to indicate that SSA information had been received. Ms. Marty Ford noted that 30 working days is too long for the internal grievance procedures and asked what relation the grievance process would have to use of the Ticket, particularly regarding CDR protection. Ms. Mitchell emphasized the importance of expediting the P&A grantmaking process and assuring that it is separate from the Ticket process.

Mr. MacDonald then presented the report of the Ticket and employment networks work group. He noted that the group addressed four basic questions: Who gets the Ticket? What constitutes use of the Ticket? What are the qualifications for an EN? Will there be only one Ticket per beneficiary?

Regarding Ticket eligibility, the work group expressed concern that the age cutoff for 16-18-year-olds would send a negative message to younger persons on benefits. Some 70 % of these 18-year-olds pass through redetermination and go on SSI. Mr. MacDonald listed other youth employment initiatives: the youth councils under the Workforce Investment Act, vocational outcome counseling under IDEA, and youth initiatives by the Presidential Task Force. Yet, he said, participation by younger persons in the Ticket program is limited. He added that the opportunity for young people to avail themselves of the Ticket at age 16, tied into blended funding, could be part of a long-term planning process. He also noted the pending preparation of an SSA report on transitioning youth.

The work group also raised questions about exclusion of the MIE category from Ticket participation. Mr. MacDonald noted the paradox of sponsoring a demonstration project on early intervention strategies, while telling people they do not qualify for the Ticket during the MIE interim right after they qualify for benefits. He also pointed to the requirement that beneficiaries be in current pay status and observed that an individual in 1619-B with sufficient earnings not to receive an SSI check would not be eligible for the Ticket.

Mr. MacDonald asked what would happen to a Ticket holder who works for two or three years, with the EN receiving payments. If the individual needs to go back on benefits, would he/she eventually be eligible for a second Ticket? Mr. Start responded that, from discussions with Mr. McGill, it was his understanding that the individual would be eligible for a second Ticket. Mr. MacDonald said that the relevant parts of Section 411.125 were unclear on this point. He gave the example of a Ticket holder in his/her fifth year of employment who has a medical relapse and returns to the rolls for two years. The person then wants to return to work. Would such a person start from scratch with a new Ticket, or would he/she have only the fraction of payments on the old Ticket? Providing services to this individual would not be attractive to any EN. He asked for clarification from SSA.

Mr. MacDonald then turned to the issue of use of the Ticket. He pointed to the chart on page 85 of the distributed NPRM. He noted that SSA wants a clear way of tracking work progress and that the system is being driven by the provision of CDR protections. He stated that the IWP is already a mechanism for tracking the beneficiary's progress in this respect and asked how a beneficiary could pursue full-time education and still fulfill SSA's work requirements on use of the Ticket. The work group thought that the EN reporting mechanism on satisfactory IWP progress would constitute a sufficient tracking system. Mr. MacDonald noted that CDRs are an important part of program integrity, and Ticket use would provide exemption from CDRs for a substantial period of time.

Ms. Webb asked how, in the outcome payment period, the EN could prove that the individual is still working. She suggested that the EN reporting system to the PM and the consumer reporting system on the IWP be combined. Dr. Burkhauser observed that very few ENs would agree to an IWP that required no work during the first three years. Mr. Start added that the SSA tracking schedule does not necessarily preclude four years of college, since so many students are on work-study programs. Ms. Flaten suggested that the tracking system operate in terms of qualifying quarters (based on FICA statements).

Mr. MacDonald then turned to qualifications for ENs outlined in Section 411.315 of the NPRM. He had reservations about Subsection 411.315(a)(3) since provider specializations may entail some degree of discrimination, for example, a specialized provider only serving people with vision impairments. Ms. Webb observed that the ADA allows these specialized programs, so long as they are screening people in (who otherwise would not be served). Mr. MacDonald also questioned selection criteria in Subsections 411.315(b)(1)(i-ii) that entail specific training or credentials. He proposed alternative, less restrictive language requiring "an educational background or other direct experience commensurate with providing employment services, vocational rehabilitation, or other supports." Ms. Flaten added that the work group did not want to exclude consumer groups from serving as ENs. Ms. Webb requested clarification of language in Subsection 411.315(b)(2). Mr. MacDonald also questioned language in Subsection 411.315(c) that an entity provide credentials "required by State law." Some, but not all, of the services needed by consumers are licensed by the state. He felt that this wording is too restrictive and might discourage a non-traditional provider (like an employer) from participating. Ms. Strahan offered to provide clarification on this point. Ms. Lee raised the issue in Subsection 411.315(d)(3) that the language might preclude participation by an organization not big enough to meet all of the standards to be involved in government contracting or procurement. Ms. Mitchell requested staff clarification on this point. Mr. Start warned that language in Subsection 411.315(c) could result in state VR agencies or other state entities asserting their right under state law to define whether an EN is certified or not. Ms. Webb noted that centers for independent living have tried to do vocational counseling for state agencies, but have been told they need a CRC. Ms. Lee added that the Choice projects have had successes using nontraditional providers for serving people with the most significant disabilities. Ms. Mitchell said that this area requires more public input.

Following a brief recess, Ms. Mitchell asked for public comment on these issues. Addressing the issues of multiple Tickets, Ms. Marty Ford made the distinction between a consumer who has used the entire Ticket and goes back on the rolls and a consumer who returns to the rolls during the 60-month period of eligibility. She asked if, in both these cases, the consumer was entitled to a new Ticket. The point requires clarification from SSA, she added.

Ms. Mitchell then asked for the report of the payment systems work group. Ms. Webb stated that she had requested a briefing on the NPRM payment structure from Mr. McGill's staff. Specifically, she asked the staff to detail how the payment calculation base (PCB) was figured. She emphasized that the PCB is the basis on which all of the milestone and outcome payments are derived. Ms. Webb added that calculation of the outcome payments is straightforward at 40% of the PCB over 60 months (with COLA increases).

The proposed milestone payment structure is more difficult to understand, she stated. For SSDI recipients, the first milestone would be paid after three months of employment (not necessarily consecutive, but within a 12 month period); that milestone payment would amount to 68% of PCB, or $470. The second milestone comes at the seventh month of employment within a 12 month period, not necessarily consecutive. It would pay out 68% of two months of PCB, or $940. When the individual zeros out on cash benefits, then the outcome payments start following completion of the trial work period. However, during the first 12 months of outcome payments, SSA will recover the milestone payment costs by proportionally reducing the outcome payments. Ms. Webb stated that an EN will only receive $90 a month for those 12 months for an SSDI recipient, and only $57 a month for an SSI recipient. Past the twelfth month, ENs are paid milestones on a graduated scale, amounting to 85 percent of total "outcome only" payments.

Ms. Webb reported that the work group concurred unanimously that this system was not workable. No one thought that an EN could operate under the proposed milestone payment structure. Mr. Start stressed that this view was unqualified. He added that, "instead of the milestone system being what it was intended to be, which was a method by which small providers could participate, and a method by which providers could serve severely disabled people who are expensive and difficult to serve people, to front-end load a little bit of the risk, has done the absolute opposite. It is actually a punishment." He stated that the calculations are so severe as to go directly against legislative intent, driving out small providers and making it prohibitive and impossible to serve difficult-to-serve populations.

Ms. Mitchell asked if there is an alternative model. Mr. Start pointed to milestone calculations by Mr. Dan O'Brien in a paper submitted to the Panel. In addition, Mr. Start said that the aggregate percentage should be increased to 40% of PCB in order to provide services to people with more severe disabilities. He also pointed to the three-tier milestone payment structure in Oklahoma as a potential model for serving people with more significant disabilities. According to Ms. Webb, the work group also discussed the possibility of outcome payments before the consumer zeroed out cash benefits. If the "2 for 1" feature is adopted, there would be even less incentive to zero out benefits. Ms. Webb reported Mr. Harles' suggestions of milestones at initial evaluation and on gaining employment. She also relayed Ms. McWhorter's recommendations that the milestones be individualized based on the IWP and that SSA view TWWIIA as an ADA accommodation. Mr. Start said that equitable milestone models had been developed that were cost-beneficial to SSA, but that the proposed system of milestones was shifting all the risk onto the providers. He also questioned the graduated outcome payments, since most of the provider costs are incurred on the front end.

In addition, Mr. Start characterized the 40% rate as too low. Ms. Strahan noted that the 40% fixed percentage is stipulated in the law. Dr. Burkhauser agreed and added that the equity study represents the means to raise the level above 40%. Ms. Lee added that the milestone-outcome rate was much less than 40%. Dr. Burkhauser said he would like to see a demonstration of how the base numbers were calculated with respect to the PCB. Mr. Start noted that individualized milestones are supported by many in the advocacy community, but a gatekeeper is then required to provide guidelines and procedures. Perhaps there can be multiple levels of milestones, he said, but then people are being categorized and labeled. Ms. Lee pointed to the Robert Wood Johnson Foundation project on self-determination that uses individualized person-centered planning, primarily in housing, but also in employment.

Ms. Webb reported on the presentation to the work group by Mr. Michael Morris of Community Options in Princeton, NJ. Mr. Morris recommended that the equity study be part of a competitive bidding process, with the Advisory Panel playing a major role. He also supported exploring a range of milestone options and educating consumers about Ticket options. In addition, he pointed to the need to provide services to the Ticket holder who is not picked up by any EN. Ms. Lee added that the equity report should look at different reimbursement rates for the people who are identified as harder to serve, and should also consider self-employment options.

Ms. Mitchell emphasized the need to communicate this information to consumers and the general public. Ms. Flaten added that it is unfair to pay ENs less for helping harder-to-serve SSI recipients. Mr. Start said that P&A agencies could make a major contribution in educating and training consumers. Ms. Mitchell noted that this was the conclusion of the P&A working group. Mr. MacDonald suggested that the Panel Advice Report recommend that the NPRM be considered a three-year interim final rule pending the outcome of the equity report. Mr. Harles noted that an interim rule for three years would constitute a serious problem. Ms. Lee said it was suggested that an interim rule be adopted solely on the payment system.

Ms. Mitchell raised the question of disseminating information and gaining input from the public. She mentioned focus groups, meetings, roundtables, and teleconferences as means to achieve this. She added that the Panel needed to develop questions that it could pose to the public and disseminate via the Internet and advocacy networks. She suggested members holding focus groups or roundtables in their own regions of the country. Mr. Start asked whether the objective of this exercise is to publish an Advice Report making recommendations on the NPRM to SSA. Ms. Mitchell said that is the intent, but the Panel needs to act within the 60-day public comment period. Ms. Lee suggested that the Panel come up with ten key issues on which it is seeking public input. Ms. Flaten proposed the model of the suicide prevention meetings across the country, sponsored by the Office of the Surgeon General. Mr. MacDonald suggested producing a draft Advice report before the Panel's next meeting. Ms. Mitchell asked Panel members to reflect overnight on these options and adjourned the meeting at 5:14 pm.

Day 3: Wednesday, November 15, 2000

Ms. Mitchell opened the meeting at 9:05 am. She introduced Mr. Ken McGill, who gave the Panel an update on TWWIIA implementation.

Mr. McGill reaffirmed his commitment to work with the Panel and acknowledged receipt of the memorandum from Ms. Strahan on work processes and developing a productive relationship with the Panel. One area of consultation is on the TWWIIA grants, contracts, and cooperative agreements. SSA is moving forward with the BPAO re-announcement in FY 2001 for uncovered areas. One problem is that SSA does not yet have an FY 2001 budget. There is no need for re-application if a valid proposal has been submitted. Mr. Start asked about applications from non-traditional and for-profit providers. Mr. McGill emphasized there was no bias in the independent review panels ranking these applicants. Ms. Flaten asked for some notice to be sent to applicants explaining the delay. Mr. MacDonald noted complaints about the onerous level of detail required in the BPAO application. Mr. McGill said it is necessary to review the uncovered areas, whether they are small-population states with no coverage or large-population states with insufficient coverage. Mr. Start stated that issues of serving people with more significant disabilities, use of the Ticket, and the payment system need to be addressed in the equity study. He stressed the central role for the Panel in this study. Mr. McGill replied that the SSA Office of Policy has the lead on the equity study. He added that Ms. Morrison of his staff will act as liaison to the Panel and that channels for information dissemination will be established. Ms. Strahan expressed the concern that benefits assistance be available not just at the beginning of the program but as an ongoing service. Mr. McGill reassured the Panel that his office is planning for the long term. Ms. Webb asked about collaborative pooling of resources among BPAO grantees. Mr. McGill said he would encourage such cooperation. Ms. Lee asked if there is an evaluation mechanism to measure the success of consumer choice, particularly among people with the most significant disabilities. Mr. McGill replied that grantees such as centers for independent living will certainly have this concern as a priority. Ms. Flaten warned about consumers receiving benefits counseling and subsequently being reclassified as medically improved when this is not the case. Ms. Lee expressed skepticism about providers teaching consumers how to advocate. Mr. McGill responded that there are different incentives for different players. Some ENs may provide this type of counseling to consumers. He noted the initiation of the SSA Employment Support Representatives (ESR) program, designed to promote work incentives and provide assistance to interested beneficiaries. Ms. Mitchell expressed concern that the ESR not be isolated as the only person dealing with work incentives in an SSA office. Mr. McGill agreed to provide the Panel with a description of how the ESR program is operating.

He added that another area of SSA focus is on the CDR protections for SSDI beneficiaries, to be implemented in January 2002. Ms. Mitchell reiterated her work group recommendations that the P&A grant program be expedited and that P&A agencies be funded to represent all beneficiaries. She added that P&A agencies should engage in information and referral, education and training, outreach, and system advocacy.

Mr. McGill announced the 13 Ticket states for the initial 2001 rollout: Arizona, Colorado, Delaware, Florida, Illinois, Iowa, Massachusetts, New York, Oklahoma, Oregon, South Carolina, Vermont and Wisconsin. Responding to a question from Ms. Webb, he said that the RFP for ENs will appear shortly and that the first Ticket could be mailed out in February instead of January. Mr. Start emphasized that all people testifying believe the NPRM milestones system is unworkable. He added that it looks like another Alternative Participant program. He warned that SSA will lose credibility if it rolls out the program under this payment system. He asked if SSA intended to implement these regulations as interim. Mr. McGill noted that these are proposed rules, and he asked for Panel and public input for the final rules. Mr. Start requested a dialogue between the Panel work group and SSA officials on the implications of the NPRM. He added that, "because we are so far off target now, this program is dead on arrival." Mr. McGill asked the Panel for a list of areas to be addressed in such a dialogue.

Ms. Webb agreed with Mr. Start that the program as proposed is unworkable and asked what lessons had been learned from the RSVP/AP Program. She added that consumers want new options, and the proposed rule discourages new providers from participating. Ms. Lee warned that the proposed system cuts out creative non-traditional approaches, particular for those who are harder to serve. Under the proposed milestone system, she said, people with the most significant disabilities would not find any EN to take their Tickets. She asked if SSA could go back to Congress for a technical amendment for a month's extension.

Mr. McGill replied that, while there was no January 1 deadline in this particular area, SSA was moving ahead in implementing the program structures. Ms. Strahan asked about timelines for implementation. Mr. McGill said he would get back to the Panel on that shortly. Ms. Lee said that the Panel is planning creative ways to obtain public outreach on these issues and asked for SSA cooperation in this matter. Ms. Mitchell asked if there was any public comment, but no one came forward. She then said the Panel would move to SSA staff briefings.

Ms. Strahan introduced Mr. Paul Van de Water, the Associate Commissioner for Research, Evaluation and Statistics and Mr. Mark Nadel, the Associate Commissioner for Disability and Income Assistance Policy, both in the Office of Policy. Also present was Mr. Paul O'Leary of the Division of Program Evaluation. Ms. Strahan added that these speakers and the offices they represent are responsible for much of the evaluation and demonstration projects.

Mr. Van de Water said he would discuss plans for evaluating the Ticket program and for setting up the benefit offset demonstrations required under Section 302 of the law. He added that Mr. Nadel will address possible demonstration projects on youth transition options under Section 301. Mr. Van de Water cautioned that these plans are at the very early conceptual stage and that nothing is set in stone. He noted that, in terms of the program evaluation, his office will examine criteria such as program cost, services provided, and employment outcomes. But the overall goal, he added, is to identify whether the Ticket program is succeeding in terms of returning beneficiaries to work, reducing reliance on benefits, and reducing program costs. SSA will use both in-house and contractor resources in this effort. The contractor to design the evaluation will probably be selected in December. The design phase will last 18 months. Mr. Van de Water asked for Panel input in this process. The second stage will be to select an implementation contractor to operate through 2007. He added that the evaluation will look at net outcomes, but will also do a process evaluation to see how the Ticket system is actually working on the ground. The design contractor will also structure comparative designs (to contrast rollout states with other states, for example). The net impact evaluation will assess what difference the Ticket is making in terms of the law's criteria.

Mr. Van de Water then turned to the preparation of the report on adequacy of incentives, required by law 36 months after enactment. The legislation envisions that there might be some sort of ongoing adjustments to the payment process as a result of this. He asked if the law envisioned adjustments applied to the payment system generally or to certain distinct groups. First, it is necessary to identify shortfalls in the incentives, including unmet demand for services. Second, if the nontraditional providers are not providing services to these enumerated groups, are there resources freed up from the more traditional providers because other beneficiaries will be shifting their source of services? The third question is, to what extent there is an overlap between four groups of participants: those with a need for ongoing support and services; those with a need for high-cost accommodations; those who earn a sub-minimum wage; and those who are working and receiving partial benefits. The objective here is to determine how employment networks will be assessing the costs of providing services to these various groups and the risks they'll face in considering whether people in these categories are actually likely to leave the benefit rolls and, therefore, trigger payments under the Act. Another question will be to what extent ENs provide support resources for these groups. Mr. Van de Water asked for Panel assistance in identifying the four groups laid out in the Act and in designing the survey instrument.

Mr. Start asked if it were possible, upon implementation, to test two or three milestone systems in various states. Mr. Van de Water replied that he had not ruled out this option, but that it would be almost impossible to apply in terms of meeting the December 2002 deadline for the study. Mr. Start then inquired if the demonstration projects will be separate from the rollouts. Mr. Van de Water responded that they are separate, but that he is not inclined to complicate the rollout. Ms. Webb asked if three years of data are necessary before drawing conclusions. Mr. Van de Water noted that, if significant results are apparent early, conclusions can be drawn immediately. Ms. Lee noted that the original amendment would have started immediately to pay different rates for people who are harder to serve. She added that the contractor doing the equity study needs to be familiar with the beneficiary population, including people who require ongoing supports or who are more expensive to serve. She also expressed concern that the 40% cap would apply to the equity study because, in her view, this would be contrary to legislative intent. Mr. Van de Water stressed that, given the short timelines, it is essential to figure out ways of teasing out the most useful information simply by observing what will be going on in the initial rollout of the Ticket itself.

Mr. Start suggested approaching the study from a design perspective as sequential studies within a larger framework in order to obtain shorter-term results, particularly on equity issues. Mr. Van de Water said he appreciated the suggestion. Mr. MacDonald cautioned that the intersection between employment, healthcare and public programs, and people with disabilities is not strict science. There are a number of critical variables involved in the study, and it is important to be inclusive, rather than exclusive in putting together a credible evaluation. Mr. Van de Water agreed with this assessment, adding that it is hard to design a research instrument that produces clear results when simultaneously the program is being rolled out nationwide.

Mr. Van de Water then addressed the "2 for 1" demonstration project. He noted that the law required SSA to examine specific criteria: the estimated savings to Social Security and other federal programs, the relationship between a benefit offset scheme and the Ticket, the effects of possible induced entry or reduced exit from the program, the terms of return to work, and employment outcomes. In terms of design, he foresaw mandatory participation through random treatment and control groups located in the same area, along with a blind control group. There will be competing objectives of observing a range of behaviors, balanced against project management limitations. Program features to be considered are: 1) what is the level of earnings disregard; 2) whether a trial work period is necessary; 3) whether the benefit offset should apply permanently or over a fixed period of time; 4) whether there needs to be a cap on earnings while participating; and 5) how the demonstration project relates to the payment system under the Ticket. Under Section 302, there is no authority to change the payment mechanism. The assessment of induced entry will be a key concern from the cost viewpoint.

Ms. Mitchell called for a short break. Upon returning, she asked Mr. Nadel to make his presentation. Mr. Nadel acknowledged the need for a youth transition strategy covering pre-SSI redetermination young persons. These individuals have a high dropout rate, are much less likely to have earned income, and have a low employment rate, partially due to fear of losing benefits. The SSA research effort will, first, seek to design a policy and then test it. The problem with the Ticket program is that it is premised on returning people to work. However, the best outcome for many of these children would be continued education. But this outcome provides no payment incentive to the EN. Mr. Nadel outlined three criteria for this effort: 1) that it have measurable results; 2) that incentives exist for providers; and 3) that there be flexibility to serve diverse populations. He postulated a hypothetical "Ticket to Education" for post-redetermination 18-year-olds. Providers would offer services to assist the beneficiary in meeting educational objectives. There could be milestone payments during the course of education. Once the individual is employed, there could be outcome payments. Potential problems include: covering additional expenses and determining a reimbursement mechanism. He also mentioned the possibility of an outcome-based transition assistance system for younger children. As a next step, he wants to focus on developing program models (with input from the Panel).

Mr. MacDonald asked about the potential impact of the "2 for 1" demonstration project on the number of persons with dual eligibility for SSI and SSDI. Mr. Van de Water said he would appreciate any ideas on the subject. Subsequently, Ms. Mitchell called for a short break.

Upon returning, she introduced Mr. Charles Howton from the General Services Administration (GSA) to provide an overview about the Federal Advisory Committee Act (FACA). Mr. Howton briefly discussed the origins and history of FACA. He pointed to two objectives of FACA when it was passed in 1972: 1) to set in place the GSA management system; and 2) to assure that advisory committee meetings will be open to the public unless they can be closed under the Sunshine Act. The FACA is, if nothing else, a contemporaneous sunshine or access statute that allows the public to observe this particular process of government, which is the use of extramural advisors for the executive branch to provide advice and recommendations for the government to carry out certain programs. The Advisory Panel is one of the few in the Federal Government that reports to the President, Congress, and the sponsoring agency. Under FACA, it is assumed that meetings where the Panel deliberates on its mission will be open. However, administrative meetings do not necessarily have to be open. Those meetings for fact-finding or preparatory work are not subject to FACA.

Mr. MacDonald asked if Panel members "brainstorming" with staff is covered under FACA. Mr. Howton replied that it would not be covered so long as Panel members do not provide recommendations to SSA. However, consultation with agency counsel might be advisable, because, in those cases, Panel members may be providing guidance or advice to SSA. The results of any such preparatory work have to be taken to the full Panel. Mr. Start asked about drawing the line on providing input and not advice. Ms. Mitchell insisted that any fact-finding be brought to the Panel's attention. Mr. Howton described preparatory work as gathering information, conducting research or analyzing relevant issues and facts in preparation for a meeting of the Advisory Panel or drafting position papers for Advisory Panel deliberations. Administrative work is defined as discussing administrative matters or receiving administrative information from a Federal officer.

Ms. Mitchell asked about the requirement to publish notices of meetings in the Federal Register. Mr. Howton replied that open meetings have to be announced in the Federal Register 15 calendar days in advance with a summary of the agenda. The agency must make the legal decision in advance if a FACA meeting is to be closed. Prior notice giving reason for closure is required. If notice of a meeting is late, it is advisable to explain why it is late. Unless Congress so authorizes, the agency is responsible for compliance with FACA. The work group meetings established by the Advisory Panel are not covered by FACA. Outreach sessions to solicit public input do not constitute a FACA meeting.

Ms. Mitchell thanked Mr. Howton and adjourned the meeting until 1:30 pm. Upon returning, she introduced the next speaker, Mr. Thomas Hamilton of the Health Care Financing Administration (HCFA). Mr. Hamilton introduced the HCFA team working on TWWIIA health care benefits and explained the handouts distributed to the Panel. He emphasized three principal objectives: make work possible, make it pay, and make it productive. With respect to making work possible, he noted three areas of focus: health coverage, vocational rehabilitation, and comprehensive coordination of services. Health coverage needs to be available and adequate for people returning to work. HCFA is sending out notices to SSDI beneficiaries outlining the extended Medicare coverage and is helping states develop the Medicaid buy-in opportunities or improve the adequacy of the supports and services that are available to people with Medicaid/Medicare coverage. HCFA has awarded Medicaid infrastructure grants to 24 states and the District of Columbia, and the second round of solicitations is scheduled for the spring. States are using the grant funds to design or implement Medicaid buy-in plans, to improve their personal assistance services, and to develop the demonstration to maintain independence. HCFA is also encouraging states to adopt the TWWIIA option to continue Medicaid coverage even after an individual may have medically improved such that he/she no longer meets the disability definition. There are eight states that have implemented the Medicaid buy-in, and the goal is to increase that number to 20 by the end of 2001. HCFA is committed to coordinating its "return to work" services with those of other Federal agencies and expanding its role in habilitation, i.e., enhancement of an individual's skills and capabilities. Employment is not possible unless pieces of programs run by different agencies can work together.

With respect to making work pay, Mr. Hamilton observed that many people with substantial disabilities are dependent on a number of different sources for income and support (SSI, HUD Section 8 rent subsidies, etc.). These subsidies are reduced as earnings increase, so that it is possible for an individual, by going to work, to achieve a reduction in net income. SSA is working to address the SSDI "income cliff" and other areas, and it would be advantageous to bring in HUD to address access to rent subsidies while working.

Finally, Mr. Hamilton discussed making work productive. The President has established an inter-agency task force on assistive devices, looking in particular at what Medicare and Medicaid cover and how assistive devices can contribute to employment. It is also necessary to examine issues of on-the-job supports and career development. The overall goal is to assist people with disabilities to act on their initiatives to experience valued social and economic roles in the community.

Mr. MacDonald asked about the possibility of personal assistance services expanding into the area of job coaching. Mr. Hamilton replied that personal assistance services can be available during the work day to help with activities of daily living, but not to instruct people on job tasks. Ms. Flaten inquired about raising the low Medicaid reimbursement rates for providers. Mr. Hamilton noted that this is primarily a state function, and the main barrier is the availability of state funds. What is also needed is better training and a more supportive environment around personal assistance service workers. He added that one positive development is the introduction of legislation on Choice System Change grants by Senator Harkin. Ms. Gracechild noted that, in California, personal assistance service workers' wages are being raised to $11.50/hour within five years (with health care benefits).

Ms. Mitchell then opened the floor to public comments. Ms. Susan Prokop asked if states could "piggy-back" the TWWIIA Medicaid buy-in on top of the Balanced Budget Act buy-in. Mr. Hamilton said this was largely a matter of state design. Some states give the executive broad authority in this area. Ms. Emily Kaufmann asked if HCFA plans to encourage states that have been reluctant to expand the Medicaid program. Mr. Hamilton responded that there is a need to inform states about these options, particularly on how to design a buy-in. People have to understand the trade-offs, to see that, while there may be more Medicaid spending, there are tremendous benefits to the state's economy. Mr. MacDonald inquired about investigating the more equitable balancing of the cost between employer health care and Medicaid as more people with disabilities qualify for private benefits. Mr. Hamilton pointed to the Minnesota program that designed the buy-in to make it attractive for people to convert from medically needy as a Medicaid eligibility status to the Medicaid buy-in. He added that, in designing their buy-ins, most states have built-in procedures whereby the buy-ins will pay the premiums for private insurance policies if the Medicaid agency makes the determination that it would cost less. Mr. Start asked about the issue of induced enrollment. Mr. Hamilton responded that, if it is concerned about this, a state could make it financially unattractive for individuals to quit work, for example, by enacting an entry premium to Medicaid. Dr. Burkhauser asked what happens to people moving in and out of the labor force or who lose work due to layoffs in a recession. Mr. Hamilton replied that the entry premium could be designed, so that it is zero at low incomes. States have a tremendous amount of discretion in the matter. Ms. Mitchell then thanked Mr. Hamilton and announced a short break.

[Note: The rapporteur does not have a copy of the Policies and Procedures document.]

Upon returning, Ms. Mitchell opened the Panel business meeting. Submitted minutes of the September 11, 2000 teleconference were approved unanimously. She opened the discussion of the Policies and Procedures document. Ms. Gracechild noted that, under Section B, all materials should be available in alternative formats, and sign interpreters should be provided, if needed. Ms. Mitchell agreed that there should be a general statement about accessibility of meetings in terms of communication and materials. Ms. Webb suggested changing language under "Representing the Panel" to read: "Individual Panel members are not authorized to speak on behalf of the Panel to outside public or private entities." Ms. Flaten asked if the section on accordance with FACA was necessary, given Mr. Howton's briefing earlier. Ms. Mitchell suggested adding a statement about FACA compliance by the full Panel at the front of the document. She stated that the Panel should look over the document, make necessary changes, and plan to approve it at the November 27th teleconference. Mr. MacDonald questioned the provision in the Charter (p. 2) that: "the Panel shall be available for consultation [by the Commissioner] upon request." He added that this language might send the wrong message that Panel consultation with the Commissioner is optional and discretionary. He emphasized that this is not the intent of the legislation. Ms. Mitchell asked the staff to make this language more consistent with the legislation.

Turning to meeting schedules, Ms. Mitchell said that she assumed there would be no face-to-face Panel meeting in December. She added that the next possible date for a meeting would be in the second week in January. She also put forward a proposal to schedule quarterly meetings the first full week (Tuesday-Wednesday-Thursday) of the second month of each Federal quarter. She recommended the following dates: February 6-7-8, May 8-9-10, August 7-8-9. There being no objection, she asked that these dates be published in the Federal Register.

Ms. Webb asked about the timeline for the Advice Report to the Commissioner during the 60-day public comment period. Ms. Strahan stated that the Advisory Panel members are treated by SSA as special employees. She added that, for this reason, it is not necessary for the Panel Advice Report to be issued during the public comment period. She noted that the Panel has the option to publish a preliminary report during the comment period and a final report after the comment period. She suggested doing a guidance report to the community during the comment period, assess the public comments, and then do a final Advice Report to the Commissioner on the regulations.

Mr. Start asked how long the Panel had to have an impact on the final rule. Mr. McGill said he could not predict this, but added that the final rule has to go through agency and OMB clearance. Ms. Strahan made an official request of Mr. McGill to let the Panel know how much time it has after the end of the comment period to get an Advice Report to the Commissioner. Mr. MacDonald suggested periodic distributions of public comments during the comment period (along with staff summaries on subject matter).

Ms. Mitchell stated that a teleconference is scheduled for November 27^th. She suggested one or two additional teleconferences in December as a way of circumventing a December meeting. Ms. Mitchell noted that the payments work group has the most difficult task facing it in terms of recommendations. She said that hopefully the three work groups could have their recommendations ready for Panel approval by the first December teleconference. Ms. Lee said that the Panel could prepare questions for the public at the November 27^th teleconference. Ms. Mitchell asked the work groups to bring recommended questions on November 27^th. Mr. MacDonald suggested that the questions be distributed before the 27^th. There being no objections, Ms. Mitchell asked for questions by November 22^nd.

Ms. Mitchell suggested December 12^th (1:30-4 pm EDT) for a teleconference, and it was approved. She added that the Panel might need to bring on additional staff. Ms. Web asked if the payments work group is authorized to have teleconferences without prior public notice. Ms. Mitchell replied this is preparatory work. She added that, to the extent possible, the Panel would want to give the public notice of work group meetings where the public could participate. However, in these cases, she stated, the Panel is not restricted by the FACA requirements of 15 days' notice.

Mr. Start asked the payments work group members to schedule their teleconference. They agreed on November 21^st. Ms. Strahan asked if it was appropriate for the work group to invite certain outside experts without providing any public notice. Ms. Webb asked for data from the Gallup survey of potential ENs in order to invite non-traditional providers to participate. She suggested that the teleconference be taped as a public record. Ms. Mitchell added that notice could also be put on the SSA web site. Mr. MacDonald asked how long it takes to post such a notice on the SSA web site. Ms. Strahan replied it takes three days (expedited). Ms. Lee asked if someone would have phone charges to join the teleconference. Ms. Strahan said there is a cost. Ms. Mitchell stated that the Panel could assume the cost. Ms. Flaten suggested December 19^th, 1:30-4 pm EDT for the second December teleconference, and it was approved. There being no objection, Ms. Mitchell then set the dates for the January meeting as January 9-10. She also recommended holding two of the quarterly meetings outside of Washington. Ms. Lee suggested holding the January meeting in the Washington area because of the NPRM. Mr. MacDonald asked that there be a public comment period during the January meeting. After Panel discussion, Ms. Mitchell set the public comment period for January 9, 8:30-9:30 am.

Ms. Mitchell then suggested regional public teleconferences with Panel members. Ms. Strahan noted that there is a cost associated ($6000-$8000) with any such meeting for transcription services, interpreters, and other needs. The present contract would also have to be modified. There will also be additional staff time required. After Panel discussion, Ms. Mitchell requested preparations for four regional teleconferences.

Ms. Strahan then turned to administrative issues. Ms. Tamara Allen has pulled together an outline for the required annual report to the Congress, the President, and the Commissioner of Social Security. Ms. Strahan suggested that the first annual report be issued in December. The report will cover establishment of the Panel, organization, appointments, work on the NPRM, and perhaps minutes of meetings. There could also be a summary report of the meetings and other activities like the work groups. She asked for any feedback from the Panel. If the Panel produced any documents (like the preliminary Advice Report), she added, these could be included. Mr. MacDonald suggested that the Advice Report be referenced as scheduled to be submitted in January. Ms. Lee asked that the annual report be put on the agenda of one of the December teleconferences. Ms. Strahan said that Ms. Allen will move forward with preparation of the annual report.

Ms. Strahan then introduced Ms. Susan Mitchell of Pricewaterhousecoopers, who is designing the web site. Ms. Strahan said that a questionnaire on design and content of the web site has been distributed to the Panel. Ms. Susan Mitchell stated that her firm is now in the requirements gathering stage on questions like audience, users, and content. She requested feedback on this from the Panel. Dr. Burkhauser asked about the possibility of designing an interactive part of the web site for public input. He inquired if staff has the time necessary to keep up with the interactive part. Ms. Strahan said she couldn't answer that today, but that OESP is carrying the cost of the web site. Ms. Susan Mitchell said the OESP web site is updated as much as four times a week. Dr. Burkhauser asked if the site will be Bobby-approved. Ms. Susan Mitchell replied that the OESP site is 100% Bobby accessible.

Mr. MacDonald asked if the Panel could receive regular summaries of mail received. Ms. Strahan stated that each Panel member will receive a laptop computer with a separate e-mail account for Panel business. She also announced that, in terms of staff, she has advertised for a budget management specialist and will soon advertise for three policy analysts. She expects announcements will be posted in January. She also suggested training courses for those Panel members less familiar with SSI, SSDI, and return to work. In addition, she announced that the Panel has obtained office space at 400 Maryland Avenue SW (7^th floor) in Washington, DC.

Ms. Mitchell then summarized the three-day meeting. Day 1 was spent receiving public input. On Day 2, the work groups met in the morning. In the afternoon, the Panel had deliberations on the work group reports. On Day 3, the Panel had reports from OESP, SSA Office of Policy, GSA (on FACA), and HCFA. The Panel then concluded with a business meeting. Ms. Mitchell then entertained a motion for adjournment. As Designated Federal Officer, Ms. Morrison declared the meeting adjourned at 4:43 pm.