Ticket to Work and

Work Incentives Advisory Panel

2004 Annual Report to the President and Congress

Year Five

Social Security Administration

Ticket to Work Incentives Advisory Panel

Submitted December 2005

SSA Pub. No. 63-011

Ticket to Work and

Work Incentives Advisory Panel

2004 Annual Report to the President and Congress

(Year Five of the Panel)

*Submitted*

*December 2005*

Table of Contents

A Message from the Chair ii

Executive Summary 1

Background 3

Annual Interim Report to the President and Congress -- Year Five 6

Emerging Issues 13

References 14

Appendices 15

> A. The Panel 15
>
> B. Panel Correspondences and Policy Letters 18
>
> C. Testimony before Congress 22
>
> D. Advisory Panel Priorities August 2004 to August 2005 38

A Message from the Chair

On behalf of the Ticket to Work and Work Incentives Advisory Panel, it
is my privilege to issue our fifth Annual Interim Report to the
President and Congress. The year was one of transition for the Panel,
with changes in staff and membership. This report covers calendar year
2004, during which the Panel continued to focus attention on
recommendations made in 2003 for improvements to the Ticket Program, and
positioned itself to respond to proposed regulatory changes in the
following year. In September 2005, notice of proposed revisions to the
Ticket to Work program was published in the Federal Register. The
proposed changes include many of the specific recommendations made by
the Panel during the past two years and will be discussed in the
subsequent Year Six Annual Report to the President and Congress.

The Panel had an active year with quarterly meetings that included the
participation of the Social Security Administration (SSA) and other
federal agencies on program implementation, emerging challenges, and
opportunities to improve participation by beneficiaries. Presentations
and public comment were also offered by other interested parties
including beneficiaries, service providers, advocates, agencies
participating as Employment Networks, employers, state policy experts
and researchers. The Panel solicited input from all presenters about
progress made to date and suggestions for specific improvements.

In 2004, the final phase of roll out of the Ticket to Work Program was
completed with over 10 million tickets having been mailed to
beneficiaries in all 50 states and the US territories. The first one
million dollars in payments has been made by SSA to Employment Networks
as a result of required employment outcomes having been achieved by
ticket users with disabilities. An increasing number of states have
designed and begun implementation of a Medicaid Buy-In program and the
Benefits Planning Assistance and Outreach (BPAO) and Protection and
Advocacy for Beneficiaries of Social Security (PABSS) projects
nationwide continue to advise and support beneficiaries to seek
employment, use work incentives to retain earnings and needed public
benefits, and improve financial independence.

This report highlights the Panel's findings, issues, conclusions and
recommendations on the implementation of the programs of the Ticket to
Work and Work Incentives Improvement Act of 1999. The specific
recommendations and the identification of emerging issues to the
President, Congress and the Commissioner of Social Security are made to
contribute to continued improvements in program implementation and to
help set a larger vision of coordinated action across federal and state
government that recognizes the benefits to society of improved
employment for Americans with disabilities. It is my privilege to share
with you this Year Five Annual Report.

Respectfully Submitted,

Berthy De La Rosa-Aponte, Chair

Executive Summary

Calendar year 2004 marked the fifth year of implementation of Public Law
106-170, the Ticket to Work and Work Incentives Improvement Act of 1999
(the Act). The final phase of roll out of the Ticket to Work Program was
completed with over 10 million tickets having been mailed to
beneficiaries in all 50 states and the US territories. During the fifth
year, thousands of individuals with disabilities seeking employment
assigned their tickets with Employment Networks (ENs) or State
vocational rehabilitation agencies (SVRA), and thousands of others went
to work using new State Medicaid Buy-In Programs and other work
incentives now available under the Act.

The Ticket to Work and Work Incentives Advisory Panel (see appendix A
for a list of members) continues to monitor the progress of critical
implementation issues and take a broad look at the relationships among
major federal programs that play an important role in the lives of
working persons with disabilities. The Panel believes several areas
deserve the attention of the Social Security Administration. These key
areas, specifically those vital to the success of the Ticket to Work
Program as well as those important to the efficient and effective
operations of SSA's overall employment support programs, are discussed
in this report. The Panel believes that if its concerns are addressed by
the Commissioner of SSA, the President, and Congress, they will help to
ensure that work incentives and employment supports created under the
Act continue to benefit and support the employment needs of Americans
with disabilities. As will be discussed in the Year Six Annual Report,
regulatory changes proposed in 2005 respond to many of the
recommendations made by the Panel in 2003 and 2004 regarding
improvements in the EN payment system, increased cooperation between
state VR agencies and ENs, and increased choice for beneficiaries.

Panel Recommendations---Year Five

Marketing and Public Education--The Panel urged SSA to move forward
rapidly as the research findings of randomly selected beneficiaries are
translated to new marketing materials and rolled out as a multilevel
campaign.

EN Payment System--The Panel urged Congress to clarify that the Ticket
to Work Program should be used as a supplemental rather than a
substitute funding source and that SSA should implement the program as a
complement to the traditional SSA/VR reimbursement program, paying SVRAs
for up front services and paying ENs for long-term employment outcomes.

The Panel specifically endorsed Recommendation Three of the Adequacy of
Incentives (AOI) Advisory Group's recommendations to implement
Partnership Plus -- the state vocational cost reimbursement in
combination with an EN as an outcome payment option. Under a Partnership
Plus option, an eligible Ticket holder could receive VR services from
SVRAs, including supported employment and other time-limited
employment-related services and supports, and then receive ongoing
supports and services from an EN. The result would be increased choices
for beneficiaries and increased cooperation among SVRAs and ENs.

BPAO and PABSS Programs--The Panel continued to urge Congress to
increase funding levels for both the Benefits Planning Assistance and
Outreach and Protection and Advocacy for Beneficiaries of Social
Security (PABSS) programs. Public comment and presentations before the
Panel document that current funding levels are not adequate since many
of the programs cannot meet the increasing demand for services or
sufficiently cover the assigned geographic area.

Medicaid Buy-In--The Panel discussed the need for the Centers for
Medicaid and Medicare Services (CMS) to evaluate whether program
features such as asset and income limits and fee structure selected by a
state are inhibiting the intent of the Act to increase employment and
earnings. They also discussed the need for CMS to provide additional
guidance to states about continued coverage under a Medicaid buy-in when
a person shows medical\
improvement.

Capitalization and Expansion Through Blended Funding--The Panel
recommended expanding communication among federal partners to improve
interactions between the Ticket to Work Program and other public funding
including Department of Labor (DOL) programs and Medicaid to address
capitalization issues of ENs and expand supports for beneficiaries. The
Panel also discussed the need for DOL to develop a management
information system to collect data on beneficiaries to determine
services and supports received and outcomes.

Background

Summary of the Ticket To Work and Work Incentives Improvement\
Act of 1999

The Ticket to Work and Work Incentives Improvement Act (the Act), which
was enacted on December 17, 1999, is administered by the Social Security
Administration (SSA) and the Department of Health and Human Services
(HHS). It increases beneficiaries' choices for rehabilitation and
vocational services, removes barriers that require people with
disabilities to choose between health care coverage and work, and
ensures that more Americans with disabilities have opportunities to work
and lessen their dependence on public benefits. Different provisions of
the law became effective at various times, generally beginning one year
after enactment.

*Summary of Title I---Ticket to Work and\
Self-Sufficiency and Related Programs*

*Subtitle A---Ticket to Work and Self-Sufficiency and Related Programs*

Subtitle A establishes the Ticket to Work Program, under which most
beneficiaries will receive a "ticket" that they can use to obtain
vocational rehabilitation, employment, or other support services from an
approved provider of their choice. This voluntary program has a 3 year
national phase in. It establishes a program manager, Employment Networks
(ENs), and payment systems; calls for a report on the adequacy of
incentives and the establishment of a dispute resolution mechanism;
provides for suspension of continuing disability reviews (CDRs) for
persons using the ticket; and establishes the Ticket to Work and Work
Incentives Advisory Panel to advise the Commissioner of SSA, the
President, and Congress on the Ticket to Work Program and other work
incentives and employment supports.

*Subtitle B---Elimination of Disincentives to Work*

Subtitle B eliminates the work activity standard as a basis for
reviewing an individual's disability status and provides for expedited
reinstatement of benefits if the person does not continue working.

*Subtitle C---Work Incentives Planning and*

*Outreach*

Subtitle C sets up the Work Incentives Outreach Program, including
external Benefits Planning, Assistance, and Outreach programs and the
internal corps of Social Security experts on work incentives and
employment. It establishes a grant program for a protection and advocacy
(P&A) agency in each State to assist beneficiaries.

*Summary of Title II---Expanded Availability of Health Care Services*

Title II expands State options under Medicaid for workers with
disabilities. It calls for a Government Accountability Office (GAO)
study on extending Medicare coverage for Social Security recipients, and
establishes State infrastructure grant authority and demonstration
projects. It calls for a demonstration of coverage under Medicaid of
workers with potentially severe disabilities and allows disabled
beneficiaries to suspend Medigap coverage.

*Summary of Title III---Demonstration*

*Projects and Studies*

Title III extends the disability insurance program demonstration
authority and calls for specific studies and reports, including a
demonstration study of a \$1 reduction in benefits for every \$2 earned.

Strategic Partners---Public\
and Private

The Act contains numerous references to other agencies at the Federal,
State, and local levels and to private sector service providers, all of
whom are key partners in its implementation. Other Federal and State
programs and systems may not be mentioned, but they represent obvious
partners for SSA in employment services and supports. Effective
collaboration among a wide array of partners will be critical to the
success of the Ticket to Work Program.

*Under Title I---Ticket to Work and\
Self-Sufficiency and Related Programs*

SSA's Office of Employment Support Programs (OESP), which is under the
Deputy Commissioner for Disability and Income Security Programs, is
critical in the implementation and operation of employment support
initiatives. The OESP administers employment supports, including the
Ticket to Work Program, and selected Maximus, Inc., as the contract
program manager to recruit rehabilitation providers as ENs. SSA's Office
of the Deputy Commissioner for Operations manages SSA's 10 Regional
Offices, over 50 Area Offices, and 1,300 Field Offices and is
responsible for Area Work

Incentive Coordinators (AWICs) in the Area Offices and Work Incentive
Liaisons (WILs) in the Field Offices work within SSA to implement the
Ticket to Work Program, work incentives, earnings reporting, and other
employment support programs and provisions. The Ticket to Work and Work
Incentives Advisory Panel advises the Commissioner of SSA, the
President, and Congress on the implementation of the Act and on an array
of work incentive programs across a number of Federal agencies.

P&A systems in the States are funded by SSA to help beneficiaries obtain
information and advocacy support related to employment services and
dispute resolution. BPAO programs are funded by SSA and provide benefits
counseling to beneficiaries. State vocational rehabilitation agencies,
funded by the Rehabilitation Services Administration in the Department
of Education (ED), provide rehabilitation and a broad range of
return-to-work services for SSA beneficiaries. Special education at the
State level is funded through the Office of Special Education Programs
in ED and serves beneficiaries between the ages of 14 and 22 in
school-to-work transition programs. One-Stop Career Centers at the local
level, funded through the Employment and Training Administration of the
Department of Labor, are specifically mentioned in the law as potential
ENs and may include State VR agencies as One-Stop partners. Other parts
of DOL, such as the Office of Disability Employment Policy, are involved
in public policy decisions at the national level that potentially affect
beneficiaries returning to work.

*Under Title II---Expanded Availability of Health Care Services*

The Centers for Medicaid and Medicare Services of HHS at the national
level and State Medicaid agencies are partners in providing increased
medical coverage for beneficiaries. Other Federal agencies -- the
Administration on Developmental Disabilities, the Maternal and Child
Health Bureau, and the Center for Mental Health Services (also in HHS)
fund programs to provide advocacy, residential, and employment support
services to low-income SSA beneficiaries from specific beneficiary
populations.

*Under Title III---Demonstration Projects\
and Studies*

SSA's Office of Program Development and Research, within the Office of
Disability and Income Security Programs, conducts or commissions the
mandated projects and studies. The National Institute on Disability and
Rehabilitation Research and the Interagency Committee on Disability
Research in ED, as well as the Assistant Secretary for Planning and
Evaluation in HHS, also undertake or coordinate research on Ticket
participants and other persons with disabilities.

Other Partners for Titles I, II and III

Other partners include the Section 8 Housing program in the Department
of Housing and Urban Development and the Transit Subsidy Program in the
Department of Transportation, which provide housing and transportation
benefits for SSA beneficiaries.

Annual Interim Report to the President and Congress---Year Five

*The Ticket to Work came in my life at a time when I had exhausted every
avenue.... After receiving my Ticket, I spoke with four vendors and
settled on Integrated Disabilities Resources (IDR). Understand, not
every ticket holder agency is equipped to meet my needs...so IDR was the
right choice for me. After working with IDR, I took on new challenges
and capitalized on what I had already had under my belt....The Ticket to
Work Program provides an entry back to a productive life. It supplies
one with direction, hope and guidance granting a solid home base to rise
from.*

> Terri Hancock, Ticket User
>
> Newman, Georgia
>
> Testimony before the Subcommittee on Social Security, House Ways and
> Means Committee
>
> March 18, 2004

Introduction

The fifth annual report of the Ticket to Work and Work Incentives
Advisory Panel continues to monitor the progress of critical
implementation issues and takes a broad look at the relationships among
major federal programs that play an important role in the lives of
working persons with disabilities. Since the passage of the Americans
with Disabilities Act in 1990, expectations continue to grow among
individuals with disabilities and families that public policy will shift
and align services and supports to encourage work and advance
self-sufficiency.

In the Ticket to Work and Work Incentives Improvement Act of 1999,
Congress affirmed that "the policy of the United States \[is\] to
provide assistance to individuals with disabilities to lead productive
work lives." (42USC1320b) In the Act, Congress cited innovations in
assistive technology, medical treatment and rehabilitation as well as
advancements in public understanding of disability and the desire of
millions of beneficiaries to work as critical reasons to reduce and
eliminate existing barriers to employment.

The promise of the Act is enormous. Equally as large in scope is the
potential to reduce the fear of loss of health coverage; expand choices
in obtaining services and supports needed to find, enter and maintain
employment; and the creation of financial incentives to encourage work.
Currently, there is no blueprint to guide the building of a better
economic future for Americans with disabilities. The Act offers the
opportunity to test new strategies and relationships that can respond to
both real and perceived barriers to employment and economic advancement.
Despite enduring poverty and unemployment for a majority of working age
adults with significant disabilities, the Act offers a new framework to
advance work participation, reduce dependence on government, and improve
short and long term financial independence and personal well-being. As
beneficiaries, service providers, public agencies, employers, and other
stakeholders struggle with implementation challenges, we must not lose
sight of the promise and potential of the Act to favorably impact
millions of Americans with disabilities. As will be discussed in the
Year Six Annual Report, regulatory changes proposed in 2005 respond to
many of the recommendations made by the Panel in 2003 and 2004 regarding
improvements in the EN payment system, increased cooperation between
state VR agencies and ENs, and increased choice for beneficiaries.

Ticket to Work Program

Calendar year 2004 completed the third and final phase of roll out of
the Ticket to Work Program. The Social Security Administration mailed
more than 10 million tickets to beneficiaries in all 50 states and the
US territories. Although over 78,000 beneficiaries have assigned their
tickets with Employment Networks, over 90 percent of the assignments
have been to State vocational rehabilitation agencies and less than 10
percent have been made to private ENs. At the end of the calendar year
2004, SSA certified over 1,000 ENs to offer beneficiaries more choices
in their selection of service providers to help design and implement
plans to achieve preferred employment outcomes. However, less than one
third of the ENs enrolled in the Ticket to Work Program actually
accepted tickets. At each quarterly meeting, the Panel heard
presentations and public testimony from beneficiaries who are ticket
holders as well as other interested stakeholders including SVRAs,
service providers who have become ENs, employers, and other disability
related organizations with first hand knowledge of program
implementation. The Panel also heard updates on the Ticket to Work
Program from Deputy Commissioner Martin H. Gerry, SSA Office of
Disability and Income Security Programs and other lead staff from SSA's
Office on Program Development and Research and Office of\
Employment Support Programs.

In February 2004, in response to an agency briefing, stakeholder
presentations and public comments, the Panel issued an Advice Report to
Congress and the SSA Commissioner, Jo Anne B. Barnhart, entitled "The
Crisis in EN Participation -- A Blueprint For Action." In March 2004,
several Panel members testified before the Subcommittee on Social
Security of the House Committee on Ways and Means on program
implementation issues. In April and May 2004, Panel members made several
written requests to the SSA Commissioner to provide specific
recommendations. In July 2004, Panel members met with the SSA
Commissioner to discuss proposed changes to the Ticket to Work Program
and the timeline for publication in the Federal Register.

Marketing and Public Education

The Panel believes several areas deserve the attention of SSA. A
coordinated marketing and public education campaign nationwide is needed
to increase awareness of and interest in the Ticket to Work Program. In
addition to sending out the initial letter about the Ticket to Work
Program, there should be multiple strategies to increase understanding
about the benefits of the ticket and also the relationship of the ticket
to other work incentives and the Act provisions. A strategic marketing
campaign should be complemented by major public education and training
activities that would explain that the Ticket to Work Program is a new
and voluntary approach to return to work that may be used separately or
with traditional vocational rehabilitation (VR) services. Beneficiaries
must be educated about the array of public and private supports and
services including benefits specialists, disability program navigators,
One-Stop Career Centers (One-Stops) and the workforce development
system, and state Medicaid Waiver and Buy-In programs. Through public
education and training, beneficiaries can gain a clearer understanding
that they can choose among EN providers as well as the relationship
between a ticket and other public benefits such as health care or
housing.

In response to Panel recommendations, SSA began mailing follow-up
letters to beneficiaries who received a ticket but have not used it. The
follow-up letters to ticket holders included a variety of messages with
different methods of evaluation being employed to help determine how to
frame the most effective notices in the future. SSA also has contracted
with Fleishman-Hillard to develop a strategic marketing plan with
multiple objectives to: educate and raise public awareness about the
Ticket to Work Program, especially among people with disabilities, and
the social and employment services that support them; simplify the
messages and materials and make them more relevant to encourage
participation; and create strategic partnerships to disseminate the
campaign message and materials. By the end of 2004, the contractor had
performed an audit of existing materials and communications on the
Ticket to Work Program and conducted interviews and focus groups with
key stakeholders including beneficiaries, service providers and
employers.

SSA sponsored research based on interviews of randomly selected
beneficiaries nationwide revealed that 67 percent of unemployed
disability beneficiaries would prefer to be working. Employment is a
critical ingredient for a meaningful life and would help them to develop
new friendships, social relationships and financial independence.
Research findings also revealed that only 22 percent of the
beneficiaries interviewed were aware of the Ticket to Work Program and
only one percent had ever used it. Almost 80 percent of the interviewees
were unaware of information sources and supports available to assist
them, including how the Ticket to Work Program might benefit them.

> The Panel urged SSA to move forward rapidly as the research findings
> of randomly selected beneficiaries are translated to new marketing
> materials and rolled out as a multilevel campaign.

EN Participation

Recruiting and retaining a large number of ENs is a critical factor in
accomplishing the primary goal of the Ticket to Work Program -- giving
people with disabilities a real choice in rehabilitation and employment
services. The majority of providers enrolled as ENs continue to not
accept tickets. ENs are uncertain about whether and how they can use
funds from other public sources to serve ticket holders and continue to
fear loss of other stable funding sources.

The Panel urged Congress to clarify that the Ticket to Work Program
should be used as a supplemental rather than a substitute funding source
and that SSA should implement the program as a complement to the
traditional SSA/VR reimbursement program, paying SVRAs for up front
services and paying ENs for long-term employment outcomes.

Adequacy of Incentives

The Panel continues its strong support of needed changes to the EN
payment system and the administration of claims for payment. In
September 2004, the Final Report of the Adequacy of Incentives Advisory
Group was issued by the Disability Research Institute from the
University of Illinois at Urbana-Champaign. The AOI Advisory Group was
established at the request of SSA to address the adequacy of incentives
for individuals with significant disabilities to participate in the
Ticket to Work Program. Section 101 of the Act identified four target
groups as individuals: a) with a need for ongoing supports and services,
b) with a need for high cost accommodations, c) who earn a sub-minimum
wage, and d) who work and receive partial cash benefits. The AOI
Advisory Group was comprised of individuals having diverse backgrounds
with research and/or experiential expertise in the successful employment
of individuals with disabilities. Membership in the AOI Advisory Group
included four members of the Ticket to Work and Work Incentives Advisory
Panel.

The final report summarizes and integrates the findings and
recommendations contained in four interim reports produced over a
15-month period. The AOI Advisory Group proposed a set of 10
recommendations to improve the adequacy of incentives for individuals
with disabilities in the four targeted groups. Additional
recommendations were included to the extent they related to improving
the adequacy of incentives for all beneficiaries. Guiding principles
that shaped the recommendations of the AOI Advisory Group were:

> • The Ticket to Work Program should recognize and respond to the
> heterogeneity of the population of persons with disabilities receiving
> cash assistance under Supplemental Security Income (SSI) and Social
> Security Disability Insurance (SSDI).
>
> • To judge the success of the Ticket to Work Program, it is important
> there be a critical mass of program participants.
>
> • Reform efforts should be designed to increase EN participation and
> the number of people using the ticket.

Consistent with these guiding principles, the AOI Advisory Group agreed
that the ticket payment system should share the risk between SSA and ENs
by providing adequate upfront\
payments to ENs to generate interest and to recognize the
appropriateness of a policy of partial self-sufficiency. The program
should reward ENs that are able to reduce beneficiaries' dependence on
cash assistance programs as well as those that are able to eliminate
beneficiaries' dependence on those programs.

The Panel specifically endorsed Recommendation Three of the AOI Advisory
Group's recommendations to implement Partnership Plus -- the state
vocational cost reimbursement in combination with an EN as an outcome
payment option. Under a Partnership Plus option, an eligible Ticket
holder could receive VR services from SVRAs, including supported
employment and other limited related services and supports, and then
receive ongoing supports and services from an EN. The result would be
increased choices for beneficiaries and increased cooperation among
SVRAs and ENs.

While the Panel eagerly waited for the Notice of Proposed Rulemaking
(NPRM) from SSA to be published in the Federal Register to respond to
the Panel and other interested parties' recommendations for changes,
Maximus, the program manager, continued to market the program
nationwide. EN Capitalization conferences were conducted in Dallas,
Texas; Detroit, Michigan; and Providence, Rhode Island. Additional EN
Capitalization conferences were planned in at least three additional
cities in 2005 to help identify sources of public and private funding
that can help capitalize the upfront costs for EN participation prior to
receipt of outcome-based payments under the Ticket to Work Program. A
website on the Ticket to Work Program continued to receive heavy traffic
and SSA staff continued to participate in national, regional, state and
local conferences to expand awareness and outreach to beneficiaries and
service providers. At the suggestion of Panel members, SSA's Office of
Communications revised brochures and fact sheets on the Ticket to Work
Program and work incentives using a question and answer format.

Several members of the Panel also participated in a teleconference with
the SSA Associate Commissioner for Employment Support Programs, Sue
Suter, to provide advice on planning town hall meetings expected to
occur after publication of proposed changes to the Ticket to Work
Program in the Federal Register.

Benefits Planning, Assistance and Outreach and Protection and\
Advocacy for Beneficiaries of Social Security

The Social Security Protection Act of 2004 extended authorization of
Benefits Planning, Assistance and Outreach programs from fiscal year
2005 to fiscal year 2009. In the first four years of implementation, 114
BPAO programs assisted over 140,000 beneficiaries with benefits planning
services to help negotiate the complex rules and procedures of Social
Security work incentives and other federal and state public benefits.
The first of two BPAO\
customer satisfaction surveys released findings in 2004 that revealed
consistent, high quality ratings for the services received and important
increased work outcomes. Almost one-third (31 percent) of beneficiaries
surveyed (1764) reported they had started working, either full (5
percent) or part-time (26 percent) after speaking to the benefits
specialist. In December 2004, a new five-year cycle of funding became in
effect for all 57 Protection and Advocacy for beneficiaries of Social
Security (PABSS) grantees. The PABSS program, authorized under the Act,
has received high ratings of satisfaction from beneficiaries.

The Panel continued to urge Congress to increase funding levels for both
the BPAO and PABSS programs. Public comment and presentations before the
Panel document that current funding levels are not adequate since many
of the programs cannot meet the increasing demand for services or
sufficiently cover the assigned geographic area.

Medicaid Buy-In

The Medicaid Buy-In authority under the Act expands state authority to
provide Medicaid coverage to working people with disabilities who,
because of income and assets, would not otherwise qualify for Medicaid
coverage. Participants "buy in" to the program by paying a premium in
the form of a co-payment and receive full Medicaid benefits in return.
The Act offers states the flexibility to customize their Buy-In programs
according to their unique needs and objectives.

In July 2004, the Cornell University Institute for Policy Research
presented its findings from Panel funded research on the effectiveness
of Medicaid Buy-In programs in promoting the employment of people with
disabilities. At the end of 2004, 31 states have implemented Medicaid
Buy-In programs, with a total enrollment of over 65,000 participants.
Early indications\
suggest that the Centers for Medicare Medicaid Services funded Medicaid
Infrastructure Grants (MIG) have been instrumental in helping states to
develop Medicaid Buy-In programs. Since a majority of states are
recipients of MIG funding, they are moving forward to design and
implement comprehensive systems of support to advance work and improved
financial independence. MIG funding is also helping states to develop
new levels of cross-agency collaboration that align policy and systems
to more consistently respond to beneficiary needs and preferences to
work and advance self-sufficiency without fear of loss of health
coverage.

Findings presented to the Panel reveal that there is considerable
variation across states in the eligibility criteria used by Medicaid
Buy-In programs relative to gross income and asset limits. The premiums
charged by states for enrollment in the Medicaid Buy-In program also
vary substantially with states using different methods to calculate
premiums. As a result of eligibility criteria and premium amount
differences, there is considerable variation in enrollment among
participating states. Anecdotal evidence from consumer surveys,
interviews and focus groups indicate that enrollees view the Medicaid
Buy-in program as critical to their own ability to work or sustain
earnings. The Panel will continue to monitor state activities to design
and implement Medicaid Buy-In programs as part of comprehensive work
incentive strategies.

The Panel discussed the need for CMS to evaluate whether program
features such as asset and income limits and fee structure selected by a
state are inhibiting the intent of the Act to increase employment and
earnings. The Panel also discussed the need for CMS to provide
additional guidance to states about continued coverage under a Medicaid
buy-in when a person shows medical improvement.

Capitalization and Expansion Through Blended Funding

In November 2004, the Urban Institute presented its findings from Panel
funded research on employment assistance to people with disabilities
through the Workforce Investment Act's One-Stop Career Centers. The
Workforce Investment Act (WIA) of 1998 is designed to provide a
coordinated and streamlined system of supports and services that
integrate seventeen previously separate employment and training programs
through a One-Stop delivery system. There are currently over 3,000
One-Stop Career Centers operating nationwide that offer assistance to
job seekers, including individuals with disabilities. In 2003, SSA and
the U.S. Department of Labor's Employment and Training Administration
jointly created a program to fund Disability Program Navigators to serve
selected workforce investment areas and One-Stop Career Centers in
seventeen states. The Disability Program Navigator is responsible for
improving access and support in One-Stop Career Centers and improving
collaboration with other service delivery and funding systems that
impact people with disabilities including BPAO programs, Social Security
field offices, Medicaid, VR, Transportation, and Mental Health and
Developmental Disability service agencies. At the present time, DOL does
not track enrollment for services in One-Stop Career Centers by
beneficiary status. The Panel's Program, Design, Implementation and
Evaluation Committee has set as a priority to examine more closely the
interactions between the Ticket to Work Program and other federal and
state programs, to identify opportunities to improve coordination and
expand resources to serve individuals with the most significant
disabilities. A better understanding of the extent to which One-Stop
Career Centers currently provide services to beneficiaries is hindered
by data limitations associated with the current WIA reporting system. As
changes are made to the Ticket to Work Program payment system, the
One-Stop Career Centers may offer new targets for participation as ENs.

The Panel recommended expanding communication among federal partners to
improve interactions between the Ticket to Work Program and other public
funding including DOL programs and Medicaid to address capitalization
issues of ENs and expand supports for beneficiaries. The Panel also
discussed the need for DOL to develop a management information system to
collect data on beneficiaries to determine services and supports
received and outcomes.

Emerging Issues

The Panel continues to gather information and conduct reviews of
programs and projects stemming from the Act, the Ticket to Work Program,
and related Federal agency operations and initiatives. This information
comes from many sources, including consultants; public testimony;
reports from Social Security Administration, Centers for Medicare and
Medicaid Services, and other Federal agencies; data analysis; research
findings; Federal investigations; public and private analysis and
conference presentations; hearings; testimony from beneficiaries,
providers, and grantees; and feedback from the Panel's e-mail discussion
list and website. Here are some of the emerging issues the Panel is
analyzing and following closely.

*Return People with Psychiatric Disabilities to Employment:* Given the
significant growth in the numbers of persons with mental illness on the
Social Security Disability Insurance and Supplemental Security Income
rolls, the Panel should focus on the challenges faced by this group of
beneficiaries. Employment is an important route to recovery, economic
empowerment and enhanced self-sufficiency. The Panel wants to learn more
about successful strategies in working with people with psychiatric
disabilities, the appropriateness of available work incentives, and
challenges with current rules governing continuing eligibility for
benefits and rapid reinstatement if working does not prove viable.

*Access to Health Care:* The fear of loss of public health coverage
remains a primary disincentive to employment. In addition to the
Medicaid Buy-In program, the Panel wants to learn about other options to
increase health care access for beneficiaries. Emerging approaches have
developed in a number of states to use Medicaid and Medicare with
private health care as the primary payer. The exploration of access to
health care and innovations in coverage that balance public and private
responsibility for costs could benefit employers and individuals with
disabilities and deserves the attention of this Panel.

*Access to Transportation:* Senior officials from the Department of
Transportation (DOT) addressed the Panel on the critical relationship
between access to transportation and employment. Across federal and
state agencies, new strategies are being designed and tested to improve
the availability of accessible transportation utilizing public and
private systems to reduce and eliminate transportation as a significant
barrier to employment. The Panel will collaborate with DOT to explore
opportunities and to develop and market innovative strategies to
beneficiaries.

*Elevate and Incorporate the Beneficiary Voice:* The Panel discussed the
importance of a beneficiary voice and perspectives being heard,
communicated and integrated into recommendations made by the Panel. The
Panel discussed conducting a beneficiary summit with clear outcome goals
and follow-up strategy. The Panel will continue to monitor, research,
and analyze these and numerous other issues in the coming months.

References

Ticket to Work and Work Incentives Advisory Panel (2004). *Advice report
to Congress and the Commissioner of the Social Security Administration:
The crisis in EN participation---a blueprint for action.*\
Washington, DC: Author.

*Final Technical Report: Adequacy of Incentives*

*Advisory Group Project.* (September 2004). Champaign, IL: Disability
Research Institute.

Social Security Administration's Office of Employment Support Programs
(2004). *Benefits Planning, Assistance and Outreach (BPAO) 2004 Customer
Satisfaction Survey Results.* Washington, DC: Author.

Goodman, N., & Livermore, G. (2004).The effectiveness of Medicaid Buy-In
programs in promoting the employment of people with disabilities:
Briefing paper prepared for the: Ticket to Work and Work Incentives
Advisory Panel. Washington, DC: Cornell University\
Institute for Policy Research.

Holcomb, P., & Barnow, B. (2004). Serving People with Disabilities
Through the Workforce Investment Act's One-Stop Career Centers. Briefing
paper prepared for the Ticket to Work and Work Incentives Advisory
Panel. Washington, DC: Urban Institute and John Hopkins University.

Appendix A: The Panel

Members of the Panel

Twelve individuals serve on the Panel: four appointed by the President,
four by the Senate and four by the House of Representatives. The
appointees represent a cross-section of experience and expert knowledge
as recipients, providers, veterans, employers and employees in the
fields of employment services, vocational rehabilitation and other
disability-related support services. Most are individuals with
disabilities or their representatives. Several have personal experience
as beneficiaries of Social Security.

Cheryl Bates-Harris is a Senior Disability Advocacy Specialist for the
Training and Advocacy Support Center (TASC) of NAPAS where she has over
20 years experience and expertise working with people with disabilities.
She currently co-chairs the CCD Work Incentives Implementation task
force and CCD Employment and Training task force and is an active member
of the CCD Social Security Task Force. She was an invited participant in
the Ticket to Work & Work Incentive advisory Panel 2003 EN Summit. The
President appointed her to serve a 4-year term ending in 2008.

Katie Beckett is a college student in Iowa and has been an advocate all
her life. She has often traveled to Washington, DC, to speak before
policymakers about children with special health care needs. She is the
co-founder of Kids as Self-Advocates (KASA) and former co-chair of the
KASA Board. The Senate appointed her for a 4-year term ending in 2006.

Libby Child was the Manager of Integrated Disability Management Services
for Steelcase, Inc., for 25 years before resigning in December 2002 to
pursue consulting, teaching, and writing. She was responsible for
Steelcase, Inc.'s integrated claims system under which workers'
compensation, short- and long-term disability, permanent and total
disability, and compliance with the Family Medical Leave Act are fully
coordinated and managed. Since 1990, she has lectured extensively
throughout the United States on workers' compensation and integrated
disability management and continues to serve on many disability-related
boards, commissions, and councils nationally and in Michigan. The
President appointed her to a 4-year term ending in 2006.

Berthy De La Rosa-Aponte, M.A., is the State Project Director for the
Florida Family Support Project. She has a daughter with developmental
disabilities and has been advocating for people with disabilities for
more than 20 years. She has served on numerous boards and committees as
an advocate for the rights of people with disabilities and has received
several awards for her contributions. The House appointed her to serve a
4-year term ending in 2007. In October 2004, Berthy De La Rosa-Aponte
was appointed Chair of the Panel.

Thomas P. Golden is a member of the faculty of the Program on Employment
and Disability in the School of Industrial and Labor Relations at
Cornell University. Since joining the faculty in 1991, he has directed
several national initiatives focusing on training, technical assistance,
and organizational development related to work incentives, transition
systems change, and employment for people with disabilities. He recently
became a member of the National Academy on Social Insurance. The
President originally appointed him for a 2-year term. The Senate has
reappointed him to serve a 4-year term ending in 2008.

Frances Gracechild is the Executive Director of the Resources for
Independent Living, Inc., in Sacramento, CA. She also serves as an
instructor at California State University at Sacramento and as the
president of Health Access of California. The House reappointed her to a
4-year term ending in 2006.

Andrew J. Imparato, J.D., is a member of the Massachusetts bar and is
President and CEO of the American Association of People with
Disabilities (AAPD). He has extensive experience in public policy work
on behalf of people with disabilities and has served as General Counsel
and Director of Policy for the National Council on Disability, as
attorney--advisor to Commissioner Paul Steven Miller at the Equal
Employment Opportunity Commission, and as Counsel to the Senate
Subcommittee on Disability Policy. He is well known for his public
speaking to dispel myths about people with mental illness. The Senate
reappointed him to serve a 4-year term ending in 2008.

Jerome Kleckley, M.S.W., C.S.W., is the Director of Hospital Services
for the Eastern Paralyzed Veterans Association in Jackson Heights, NY.
As a Navy veteran, he has been actively involved in veterans\' issues
and has served as an advocate for veterans with disabilities. The House
appointed him to a 4-year term ending in 2004.

Bryon R. MacDonald is Project and Policy Development Manager at the
California Work Incentives Initiative (CWII), World Institute on
Disability, in Oakland, CA. CWII combines community-based public policy
development with health and benefits training, technical assistance, and
website applications. He provides State and national consulting,
training, and leadership on employment support, health care, and
benefits planning programs for persons with disabilities. The President
appointed him to a 4-year term ending in 2004.

David Miller is responsible for the overall strategic planning and
policy development for human service programs at Communication Services
for the Deaf in Sioux Falls, SD. He was formerly the South Dakota State
Director of Rehabilitation Services and was responsible for the
administration of vocational rehabilitation, independent living,
personal attendant, and disability determination services throughout the
State. He has a master's degree in rehabilitation counseling and more
than 29 years of leadership experience in the development and management
of large public and private disability programs. The Senate appointed
him to a 4-year term ending in 2006.

Sarah Wiggins Mitchell, R.N., M.S.W., J.D., chaired the Panel through
October 2004 and is President and Executive Director of New Jersey
Protection and Advocacy, Inc. She is a member of the bar in New Jersey
and Pennsylvania and has a background in nursing and social work. The
President appointed her to chair the Panel for a 4-year term ending in
2004.

Stephen L. Start is CEO of Steve Start Inc., a Spokane, WA, company that
provides professional management, rehabilitation, and residential
services for people with disabilities, seniors, and people who are
economically disadvantaged. The House appointed him to serve a 4-year
term ending in 2004.

Dorothy Watson an independent consultant, is known for her in-depth
knowledge and understanding of Social Security disability programs. She
has worked on numerous disability reform proposals in both the Executive
and Legislative branches of the US Government. She retired in 2001 from
the Senior Executive Services in the Social Security Administration
(SSA) after a long career that included more than a decade in
legislative affairs as well as a stint on Capitol Hill as a Professional
Staff Member of the Senate Special Committee on Aging. Recently, she was
on staff of Concentra Medical Centers, a company that serves injured
workers and their employers and was also a member of the Adequacy of
Incentives Advisory Group that provided recommendations for improvements
in the Ticket to Work Program. The President appointed her to serve a
4-year term ending in 2008.

Torrey Westrom, J.D., lost his eyesight at age 14 in a farm-related car
accident in 1987. He graduated from Bemidji State University in 1995 and
was elected to the Minnesota House of Representatives in 1996, becoming
Minnesota's first blind elected State representative. He was re-elected
to his fourth term in November 2002 and continues to work on policy
issues ranging from training/employment opportunities for people with
disabilities to transportation and agriculture. He graduated from law
school in 2003 and became a member of the Minnesota bar. The President
appointed him to a 4-year term ending in 2006.

Responsibilities of the Panel

The Ticket to Work and Work Incentives Improvement Act of 1999, Public
Law 106-170 (the Act) established the Ticket to Work and Work Incentives
Advisory Panel within the Social Security Administration (SSA) on
December 17, 1999. The Panel is governed by the provisions of the Act;
Public Law 92-463, as amended, which sets forth standards for the
formation and use of advisory committees; and the General Services
Administration (GSA) regulations on the Federal Advisory Committee Act.
The original charter establishing the Panel was submitted to the GSA and
filed with the Committee on Ways and Means of the House of
Representatives and the Committee on Finance of the Senate on March 21,
2000; the charter was renewed in March 2002. The Commissioner of the
Social Security Administration swore in the original members of the
Panel on July 24, 2000.

Panel duties include advising the President, the Congress and the
Commissioner of Social Security on issues related to work incentives
programs, planning and assistance for individuals with disabilities and
the Ticket to Work and Self-Sufficiency Program. Operating procedures
governing the activities of the Panel have been developed and approved.
The Panel meets quarterly alternating locations between Washington, DC
and Ticket Program roll - out states to hear regional testimony. The
Panel transmits an Annual Interim Report on the implementation of the
Act to the President and Congress. This is the fifth such report. A
final report is due no later than December 17, 2007. The Panel
terminates on January 16, 2008, 30 days after the submission of its
final report.

Appendix B: Panel Correspondence and Policy Letters

April 28, 2004

The Honorable Jo Anne B. Barnhart

The Commissioner

6401 Security Blvd. Room 100 Altmeyer Baltimore, MD 21235

Dear Commissioner Barnhart:

I am writing on behalf of the Ticket to Work and Work Incentives
Advisory Panel (the Panel) to urge you to send follow up letters to
current ticket holders who received their ticket as part of the Phase I
or Phase II rollout of the Ticket to Work and Self-Sufficiency Program
(Ticket to Work Program). Many of these ticket holders received their
tickets over two years ago and have received no further communications
from SSA regarding the Ticket to Work Program or the use of their
tickets. The Panel strongly recommends that SSA notify beneficiaries at
least once every year until SSA has fully implemented public education
and marketing campaigns that operate continuously.

Ticket holders who have not used their tickets and have not heard from
SSA in the past year or two should be reminded that their ticket is
still valid and that the Ticket to Work Program is available to them to
support their work effort whenever they attempt a return to work. The
letter should also include information on interactions between the
Ticket to Work Program and related work incentives and support programs.
In addition, it should cover: how to contact the Ticket to Work Program
Manager, MAXIMUS; how to find local Employment Networks and State
Vocational Rehabilitation agencies; and how to locate and use Benefits
Planning, Assistance, and Outreach services and Protection and Advocacy
services.

The Panel understands that such high volume mailings are costly. For
this reason in our Annual Report to the President and Congress for Year
Four we recommend that funds be designated to cover SSA's costs for
on-going marketing and public education. The Panel looks forward to a
continued partnership with you and your staff and to the successful
implementation of these important new programs. On behalf of the Panel,
I am requesting a written response to this letter. If you have any
questions, please contact Marie Strahan, Executive Director for the
Panel at (202) 358-6430, or me. Thank you for your cooperation and
support.

Sincerely,

Sarah Wiggins Mitchell, Chair

cc: The Honorable Charles E. Grassley, Chairman, Committee on Finance

The Honorable Rick Santorum, Chairman, Subcommittee on Social Security
and Family Policy

The Honorable William M. Thomas Chairman, House Ways and Means

The Honorable E. Clay Shaw, Jr.: Chairman, Social Security Subcommittee

Martin Gerry, Deputy Commissioner Office of Disability and Income
Security Programs

The Honorable Max Baucus Committee on Finance

The Honorable John B. Breaux Subcommittee on Social Security and Family
Policy

The Honorable Charles B. Rangel House Ways and Means

The Honorable Robert T. Matsui Social Security Subcommittee

Marianne Daley, Acting Associate Commissioner, Office of Employment
Support Programs

TICKET TO WORK & WORK INCENTIVES ADVISORY PANEL

May 11, 2004

The Honorable Jo Anne B. Barnhart

The Commissioner

6401 Security Blvd. Room 100 Altmeyer

Baltimore, MD 21235

Dear Commissioner Barnhart:

I am writing on behalf of the Ticket to Work and Work Incentives
Advisory Panel (the Panel) to urge you to immediately launch a national
campaign for public education and training on the Ticket to Work
Program, SSDI and SSI work incentives and related employment support
programs and services. This type of public education and training
campaign should be targeted at all the partners implementing the Ticket
to Work and Work Incentives Improvement Act legislation and work
incentives, but it is especially needed for beneficiaries and SSA field
office staff.

In its recent testimony before Congress (March 18, 2004, testimony of
Sarah Wiggins Mitchell and Thomas Golden before the Social Security
Subcommittee of the House Ways and Means Committee), the Panel stated
that the lack of marketing and public education may be hindering the
success of the Ticket to Work Program: "The Panel has repeatedly
recommended that SSA undertake a national coordinated marketing and
public education campaign in order to increase awareness of and interest
in the Ticket to Work Program." Moreover, the Panel also emphasized the
need for SSA to take immediate steps: "Extensive planning activities may
delay implementation of a national marketing plan even further. It would
be reasonable to assume that marketing would occur prior to, or during,
the rollout of a new program, not after\... The Panel urges SSA to move
forward with other marketing activities immediately, such as sending a
reminder letter to all people who have received but not used their
ticket."

A public education and training campaign should be distinguished from
the national marketing effort that the Panel has recently recommended.
Our understanding is that the marketing effort is specific to the Ticket
to Work Program and its goal is to make employers, providers,
beneficiaries and other partners aware of the Ticket to Work Program,
primarily to maximize interest and encourage participation in the Ticket
to Work Program. To work, SSA's marketing effort must be complemented by
a public education and training campaign that teaches the basics of a
rather complex set of programs, work incentives and employment services
currently available to beneficiaries to assist them in their work
attempt.

For example, public education should emphasize that the Ticket to Work
Program represents a new and voluntary approach to return to work and it
may be used separately or with, traditional VR services. It can be
combined with other programs, such as Medicaid Waiver programs, Medicaid
Buy-In programs, 1619(a) and (b) programs. This is a very different
paradigm for SSA beneficiaries.

A strong public education and training campaign would address the use of
an array of services and supports available to beneficiaries and it
would explain the roles of major Federal, State and private partners in
providing employment supports and services (for example, Employment
Networks, Vocational Rehabilitation, Medicaid, Medicare, One-Stops,
Navigator Program).

From its inception, the Panel has received reports from Maximus and
public comment in the form of testimony and letters from beneficiaries,
providers and others in the field, that most beneficiaries do not
understand the older work incentives, much less the basics of the Ticket
to Work Program. They do not understand what the ticket is nor do they
know what to do with their ticket when they receive it. They do not
understand that ticket holders can choose among providers, nor do they
understand that providers can choose whether to accept their ticket.
Beneficiaries and providers have repeatedly told the Panel that ticket
holders are confused about how the ticket affects current benefits such
as health care and housing. We cannot expect to see an increase in
Ticket to Work Program participation or in any type of employment
programs until beneficiaries understand the fundamentals of the work
incentives and employment supports and services available to them,
especially the Ticket to Work\
Program since millions of beneficiaries have received their ticket in
the mail and remain confused.

Unfortunately, the Panel has received numerous reports that
beneficiaries cannot count on learning about these programs and services
from SSA field office staff. In the Panel's most recent public meeting
two beneficiaries spoke of being ill-served by SSA field staff who did
not understand the work incentives or the Ticket to Work Program. In one
case SSA ceased the beneficiary's benefit entirely for one month to
recover an overpayment, rendering the beneficiary ineligible for the
Ticket to Work Program. The beneficiary was not told that she would be
eligible again the following month. Another beneficiary was distraught
after receiving incorrect information about health insurance coverage
from SSA staff---a problem that her BPAO counselor was able to correct.

In training SSA field staff, the Panel encourages SSA to learn from its
successes. Despite the complexity of the Ticket to Work Program and
related work incentives the former Employment Support Representatives
(ESRs) and BPAO staff have been widely acclaimed for their expertise and
their effectiveness. We believe the key to this success was that the
ESRs and BPAO staff received extensive training and TA support that was
commensurate with the complexity of these programs; for example, ESRs
received six weeks of training. The Panel certainly commends SSA for
creating a credible post-entitlement workforce in its field offices,
anchored by Area Work Incentives Coordinators (AWICS) and Work
Incentives Liaisons (WILS). And, although tight personnel constraints
may prevent increasing the number of AWICS and WILS, we urge you to
establish a training objective that AWICS and WILS (and, for that
matter, One-Stop navigators) receive the same course of training as was
available to the ESRs and BPAOs. Based on the success of the ESRs and
BPAO staff, the Panel believes that the backbone of SSA's 'corps of
trained, accessible, and responsive work incentive specialists' should
be a small number of experts with in-depth training and continued access
to professional technical assistance.

In closing, I am honored to have served with you and your staff over
recent months in implementing a program to improve the lives of persons
with disabilities. Our Panel looks forward to a continued partnership
with you and your staff to successfully implement these important new
programs. On behalf of the Panel, I would appreciate a written response
to this letter. If you have any questions, please contact Marie Strahan,
Executive Director for the Panel, or me.

Thank you for your continued cooperation and support. I look forward to
hearing from you.

Sincererly,

Sarah Wiggins Mitchell, Chair

cc: The Honorable Charles E. Grassley, Chairman, Committee on Finance

> The Honorable Rick Santorum, Chairman, Subcommittee on Social Security
> and
>
> Family Policy

The Honorable William M. Thomas Chairman, House Ways and Means

The Honorable E. Clay Shaw, Jr. Chairman, Social Security Subcommittee

Martin Gerry, Deputy Commissioner Office of Disability and Income
Security Programs

The Honorable Max Baucus, Committee on Finance

The Honorable John B. Breaux Subcommittee on Social Security and Family
Policy

The Honorable Charles B. Rangel, House Ways and Means

The Honorable Robert T. Matsui Social Security Subcommittee

Marianne Daley, Acting Associate Commissioner, Office of Employment
Support

> Programs

Appendix C: Testimony before Congress

House Committee on Ways and Means

Statement of Sarah Wiggins Mitchell, Chair, Ticket to Work and Work
Incentives Advisory Panel and Thomas P. Golden, Member, Ticket to Work
and Work Incentives Advisory Panel

Testimony Before the Subcommittee on Social Security of the House
Committee on Ways and Means

March 18, 2004

Introduction

The Ticket to Work and Work Incentives Advisory Panel (the Panel) would
like to thank Chairman Shaw for holding this hearing. The Panel
appreciates the Committee's high level of interest in ongoing oversight
regarding the Ticket to Work Program and the other important programs
and policies of the Ticket to Work and Work Incentives Improvement Act.
The Panel would also like to take the time to recognize the support this
committee demonstrates for people with disabilities and the Social
Security Administration Disability programs.

Good News

The Panel believes that the Ticket to Work Program is a very popular
program with still much unrealized potential. Advocates for people with
disabilities at the national and grassroots levels are very supportive
of this program and are working with their Federal partners to make the
program succeed.

Positive Sign: Consumer Interest

Consumers are also showing great interest in the program. Forty thousand
people have assigned their tickets to receive vocational rehabilitation
and employment support services. While only about 4000 of those are with
Employment Network providers, or what we call ENs, that is a big number
for the short time that the Ticket to Work Program has been around. This
is especially true given the fact that the roll out of the Ticket to
Work Program was delayed and is not yet completed. The rest of the
Tickets have been assigned to State Vocational Rehabilitation agencies.

Even beneficiaries who have not assigned a Ticket are very interested in
finding out about the program. The Program Manager, Maximus, received
over 23,000 calls in the month of February alone. Almost 20,000 of those
were inquiries made by or on behalf on beneficiaries with interest in
the Ticket to Work Program. In addition, MAXIMUS reports that during
calendar year 2003, over 10 million hits were made to the Ticket to Work
website.

TWWIIA Support Programs are Excellent

The support programs established by the Ticket to Work and Work
Incentives Improvement Act are also proving to be very successful.
Almost 100,000 beneficiaries have sought information and assistance from
the benefits planning assistance and outreach program, or BPAO. The
results of the customer satisfaction survey that were just released by
the Social Security Administration supports what the Panel has been
hearing from beneficiaries across the country: BPAO services are
excellent and essential to people with disabilities who want to work.
Eighty nine percent of those surveyed rated the service they received as
excellent, very good, or good. And, the percent of the people who
reported they were working jumped by 19% subsequent to their contact
with the BPAO. The Panel is pleased that the BPAO program was
reauthorized in HR743 and thanks this Committee for their hard work in
passing that legislation.

Positive Implementation Step: Area Work Incentive Coordinator

The establishment of the Area Work Incentive Coordinator, or AWIC,
position within SSA is a very positive development in implementation of
the Ticket to Work Program, as well as in the overall administration of
work incentives. The Panel is very pleased that SSA decided to create a
position that is permanent and devoted full time to work incentive
duties as part of their internal corps of work incentives specialists.
The Panel has repeatedly heard very positive testimony and comments
regarding the dedicated and skilled SSA employees that fill the AWIC
positions. As we all know, the provision of accurate and timely
information on work incentives is a critical factor in making people
feel secure in their attempt to go to work. AWICs help to make that
happen for SSA beneficiaries. The Panel hopes that SSA will expand the
number of AWIC positions to meet the enormous demand for their services.

Three Areas of Concern

While the Agency is making good progress, the Panel has serious concerns
in three key implementation areas that threaten the success of the
Ticket to Work Program. Of most concern to the Panel is the current low
participation of ENs. Second, we are concerned about the lack of public
education and marketing of the Ticket to Work Program to beneficiaries,
their families, and ENs. A third major area of concern is the inadequate
training provided to SSA field staff about work incentives in general,
and the Ticket to Work Program specifically.

Concern One: EN Participation

As you probably know, the Panel issued a report last month on the crisis
in EN participation and its potential impact on the Ticket to Work
Program. The Executive Summary of that report is included at the end of
this statement (beginning on page 8).

Central to this report is the assumption that recruiting and retaining a
large number of active ENs is a critical factor in accomplishing the
primary stated goal of Ticket to Work Program -- giving people with
disabilities a real choice in rehabilitation and employment services.
Our report identified a number of issues related to the structure of the
Ticket to Work Program that are causing providers not to participate as
ENs or to drop out altogether. These are: the need for Congress to
clarify that the Ticket to Work Program should be used as a
supplemental, rather than a substitute, funding source; the design of
the EN payment system; the inadequacy of provider incentives; the
administration of claims for\
payment; marketing; EN training; and the treatment of American Indian VR
programs.

Finally, the Panel is concerned and puzzled that in the fourth year of
the Ticket to Work Program, SSA has yet to undertake a demonstration or
pilot project addressing some of these issues especially the payment
issue. The problems outlined below in the Executive Summary must be
addressed without delay to make the Ticket to Work Program more
attractive to current and potential ENs and to ensure that current ENs
to remain in the program.

Concern Two: Marketing and Public Education

The second major area the Panel believes maybe hindering the success of
the program is the lack of marketing and public education being
conducted by SSA in support of the program. The Panel has repeatedly
recommended that SSA undertake a national coordinated marketing and
public education campaign in order to increase awareness of and interest
in the Ticket to Work Program. Currently, beneficiaries are informed
only once about the Ticket to Work Program and they may not be informed
at all about other TWWIIA provisions and work incentives. The only
marketing material most beneficiaries receive on the Ticket to Work
Program is a letter describing the program when the Ticket is being
rolled out, or when they first become eligible for benefits.

The Panel is pleased that SSA has awarded a contract for the design of a
strategic marketing plan for the program that will be completed this
year. However, in the meantime, many ENs report having trouble finding
people willing to assign their Tickets and many beneficiaries and local
advocates remain completely in the dark about the Ticket to Work Program
and the other work incentives. Although these SSA contracting efforts
are very positive steps, the Panel is concerned that the next year or
two will be devoted to planning marketing efforts rather than actual
marketing of the Ticket to Work Program. Extensive planning activities
may delay implementation of a national marketing plan even further. The
Panel believes it is reasonable to expect that marketing would occur
prior to, or during, the rollout of a new program, not after. The Panel
urges SSA to move forward quickly with other marketing activities, such
as sending reminder letters to all people who have received but not yet
used their ticket.

Concern Three: Training

The final area that is of most concern to the Panel is the insufficient
training SSA field staff receives about work incentives and the Ticket
to Work Program. The Panel has heard in public testimony across the
country, stories of beneficiaries who have received inaccurate
information about work incentives from SSA staff in the field office.
Receiving bad information can cause a person not to make a job attempt,
to receive an overpayment, or to be forced to stop working. It also
increases mistrust and fear. This situation is unacceptable to the Panel
and Americans with disabilities. Every SSA field office should have
accessible and available staff that possess a thorough understanding of
the work incentives and be able to provide accurate basic information to
SSA beneficiaries with disabilities who want to work.

On that note, the Panel wants to again recognize the very positive step
the Agency took in the creation of the AWIC position as part of their
internal corps of work incentive experts. This represents the best type
of customer service. The AWICs received good basic training (two full
weeks) and many of them were former Employment Support Representatives
(with six weeks of training). AWICS are reported to be very
knowledgeable and highly regarded in the field and by beneficiaries.

There are not nearly enough AWICs to be available to answer every
question beneficiaries have but the training that AWICs have received on
SSA work incentives and the Ticket to Work Program is exemplary. SSA
cannot, however, rely on AWICs to provide all information and advice to
beneficiaries on work incentives and the Ticket to Work Program. SSA
created a filter down, train the trainer approach to build their corps
of internal work incentive specialists. AWIC's train Work Incentives
Liaisons (or WILs), the people who provide information on work
incentives on top of their regular duties in the field office. Work
Incentives Liaisons receive their limited training from the AWICs and
then are expected to train the remainder of the field office staff. SSA
work incentives and their interaction with the Ticket to Work Program
are very complicated and technical topics. The problem with SSA's
current strategy is that the necessary knowledge does not seem to filter
down to the claims representatives and service representatives who are
answering beneficiary questions about work incentives on a day-to-day
basis. We trust that SSA will make more intensive training, along the
lines of what AWICs receive, available to all SSA field staff.

Conclusion

The Panel believes the Ticket to Work Program has great potential to
help many people with disabilities improve their lives by going to work.
This statement outlines a number of concerns the Panel has about SSA's
administration of the Ticket to Work Program. While it is still early in
the implementation process of this new program, the failure of SSA to
take steps immediately to address these concerns may have a dire effect
on the success of the program.

The Crisis in EN Participation: A Blueprint for Action (February 2004)

Executive Summary

Thousands of people with disabilities and their advocates shared a dream
that the Ticket to Work and Work Incentives Improvement Act of 1999 (the
Act) would greatly expand employment opportunities for people on the
Social Security Administration (SSA) disability rolls. Three years after
enactment of the law, it is clear that their dream is faltering. The
Ticket to Work and Self-Sufficiency Program (Ticket to Work Program) is
failing to recruit the anticipated numbers of new employment service
providers, called Employment Networks (ENs). In addition, those enrolled
as ENs are serving only a fraction of the beneficiaries thought to be
interested in participating in the Ticket to Work Program. Nearly 1,000
providers have enrolled in the program, but only about one-third of
those operating have accepted any tickets. The Panel believes that
without immediate attention to the very real problems affecting EN
participation, the Ticket to Work Program will fail. The Panel urges
Congress and the Commissioner to act quickly on the following
recommendations.

Issues and Recommendations

*Ticket to Work Program as a Supplemental Funding Source --- ENs are
uncertain about whether and how they can use funds from other public
sources to serve ticket holders and have chosen not to actively
participate in the Ticket to Work Program because of fear of losing
other stable funding sources.*

Recommendations

> • Congress should develop statutory language that clearly articulates
> its original intent that the Ticket to Work Program's outcome and
> milestone payments should provide additional resources to assist
> beneficiaries in attaining and retaining employment. In general, the
> Panel believes that Congress did not intend to make beneficiaries
> ineligible for the full range of services from vocational
> rehabilitation (VR) programs, Medicaid, or other Federal and State
> programs by making them eligible for the Ticket to Work Program.
>
> • Congress should direct the Commissioner to implement the Ticket to
> Work Program as a complement to the traditional SSA VR Reimbursement
> Program, paying State VR agencies for up-front services and paying ENs
> for long-term employment outcomes.
>
> • As part of the mandated evaluation of the Ticket to Work Program,
> the Commissioner should conduct an assessment of the Ticket to Work
> Program and the SSA VR Reimbursement Program, running in combination,
> to determine whether that approach produces better long-term,
> cost-effective outcomes than the historical VR Reimbursement Program
> alone, and to ensure the financial viability of running the two
> programs in combination.

The EN Payment System --- *Two problems in the EN payment system
discourage the active participation of many providers: (1) the payment
system places too much financial risk on ENs and (2) the payment system
provides significantly lower reimbursements to ENs for serving
Supplemental Security Income (SSI) recipients than for serving Social
Security Disability Income (SSDI) beneficiaries.*

Recommendations

> • The Commissioner should immediately modify the EN payment system to
> move more of the payment into the first 12 months of employment and
> reduce the difference between the milestone and outcome payments.
>
> • The Commissioner should test two or three creative approaches that
> place more up-front financial risk on SSA but, if successful, could
> significantly increase Ticket to Work Program participation by both
> ENs and beneficiaries, thereby increasing long-term savings to SSA.
>
> • Congress should amend the statute to permit payments to ENs to be
> set at a level greater than 40 percent of average benefits for both
> SSDI and SSI beneficiaries and after the statutory change the
> Commissioner should implement an increase in EN payments for
> beneficiaries of both programs.
>
> • Congress should amend the statute to permit the Ticket to Work
> Program to increase the sum of payments available for serving SSI
> recipients to a level equal to the sum of payments available for
> serving SSDI beneficiaries.

• The changes to the EN payment system should be implemented as quickly
as possible.

*Adequacy of Provider Incentives --- Because little is known about
outcome payments for providers, the Act authorizes the Commissioner to
review, refine, and alter the payment system to ensure that it provides
adequate incentives for ENs to serve beneficiaries and produce savings
to the program. Despite major problems with the payment model, no
alterations have been made to the original program payment system. The
Commissioner has established an advisory group on Adequacy of Incentives
(AOI) to assist SSA with the design of a workable payment system,
including financial incentives to serve four groups of beneficiaries
with special needs that were referenced in the Act.*

Recommendations

> • The Commissioner should implement a modified EN payment system that
> generally incorporates the principles outlined in the AOI Advisory
> Group's interim report. (The Panel supports the principles in the
> report but has not endorsed a specific model.)
>
> • For any new payment system to be successful, the Commissioner must
> first implement the Panel's recommendations relating to the EN payment
> system and EN claims administration.
>
> • The Commissioner and Congress should make clear in statute and in
> program regulations that payments to ENs must supplement funding from
> other public programs (such as State VR, Mental Health, Medicaid,
> Housing and Urban Development, Department of Labor) and should not pay
> for services for which beneficiaries are already eligible.

*EN Payment Claims Administration --- Two factors compound the financial
risk and working capital problems of Employment Networks: (1) long-term
tracking of beneficiary earnings is labor intensive and administratively
burdensome for ENs and (2) there are often long delays in processing EN
claims for payment.*

Recommendations

> • Once a beneficiary has been certified as employed above the
> substantial gainful activity (SGA) level or leaves cash benefit
> status, the Commissioner should continue to pay the EN on a monthly
> basis as long as the beneficiary remains in zero benefit status and
> the EN\
> has not yet received 60 months of outcome payments, or until the
> beneficiary requests a new EN.
>
> • The Commissioner should refine the EN payment claims processing
> system to ensure timely payments to ENs within businesslike
> timeframes. A widely accepted business standard for turnaround time on
> receivables is 30 days.

*Marketing to ENs and to Beneficiaries --- To date, there is no national
marketing plan for the Ticket to Work Program and the Program is not
well understood by the vast majority of beneficiaries or by those who
influence a beneficiary's decision to attempt work. Further, ENs spend
considerable time explaining the Program and dispelling misconceptions.
Also, the lack of marketing contributes to the insufficient demand for
EN services. However, SSA has recently awarded contracts to support
development of a strategic marketing plan and EN marketing and
recruitment efforts. The Panel has made numerous recommendations to the
Commissioner on this issue in past reports.*

Recommendation

The Commissioner should create opportunities for the Panel to (1) review
the work plans and proposed activities under the strategic marketing
plan contract and the project designed to improve EN participation and
(2) engage in a dialogue with the contractors and relevant SSA staff so
that the Panel can provide timely and substantive input on these
marketing activities.

*EN Training and Communication --- There is inadequate training,
technical assistance (TA), and timely information available to ENs.
Existing TA and training resources are inadequate, nonuniform,
piecemeal, uncoordinated, and of varying quality, with no coordinated
means for ENs to identify and share best practices.*

Recommendations

> • The Panel, in partnership with the Commissioner, should convene a
> meeting of key stakeholders to develop a national training and
> communications conference for all ENs.
>
> • The Commissioner should appoint a working committee to develop the
> plan for this training conference and to develop the overall strategy
> for bringing together a broad-based coalition of stakeholders to
> oversee and sponsor the event. Panel members should be active
> participants.

*American Indian VR Program Eligibility for the SSA VR Reimbursement
Program --- Despite*

*having to meet the same service standards as State VR agencies,
American Indian Vocational Rehabilitation (AIVR) programs operated by
Tribal Nations programs are not exempt from the Ticket to Work Program
EN application process and are excluded from the traditional SSA
Reimbursement Program for State VR agencies.*

Recommendation

Congress should amend the statute to permit AIVR programs operating
under section 121 of the Rehabilitation Act to participate in Ticket to
Work in a manner equivalent to State VR agencies; that is, they should
be exempt from the EN application process and be subject to the same
reimbursement rules.

Appendix D: Advisory Panel Priorities

August 2004 to August 2005

House Committee on Ways and Means

Statement of Thomas P. Golden, Member, Ticket to Work and Work
Incentives Advisory Panel

Testimony Before the Subcommittee on Social Security

of the House Committee on Ways and Means

March 18, 2004

Introduction

The Ticket to Work and Work Incentives Advisory Panel (the Panel) would
like to thank Chairman Shaw for holding this hearing. The Panel
appreciates the Committee's high level of interest in ongoing oversight
regarding the Ticket to Work Program and the other important programs
and policies of the Ticket to Work and Work Incentives Improvement Act.
The Panel would also like to take the time to recognize the support this
committee demonstrates for people with disabilities and the Social
Security Administration Disability programs.

Good News

The Panel believes that the Ticket to Work Program is a very popular
program with still much unrealized potential. Advocates for people with
disabilities at the national and grassroots levels are very supportive
of this program and are working with their Federal partners to make the
program succeed.

Positive Sign: Consumer Interest

Consumers are also showing great interest in the program. Forty thousand
people have assigned their tickets to receive vocational rehabilitation
and employment support services. While only about 4000 of those are with
Employment Network providers, or what we call ENs, that is a big number
for the short time that the Ticket to Work Program has been around. This
is especially true given the fact that the roll out of the Ticket to
Work Program was delayed and is not yet completed. The rest of the
Tickets have been assigned to State Vocational Rehabilitation agencies.

Even beneficiaries who have not assigned a Ticket are very interested in
finding out about the program. The Program Manager, Maximus, received
over 23,000 calls in the month of February alone. Almost 20,000 of those
were inquiries made by or on behalf on beneficiaries with interest in
the Ticket to Work Program. In addition, MAXIMUS reports that during
calendar year 2003, over 10 million hits were made to the Ticket to Work
website.

TWWIIA Support Programs are Excellent

The support programs established by the Ticket to Work and Work
Incentives Improvement Act are also proving to be very successful.
Almost 100,000 beneficiaries have sought information and assistance from
the benefits planning assistance and outreach program, or BPAO. The
results of the customer satisfaction survey that were just released by
the Social Security Administration supports what the Panel has been
hearing from beneficiaries across the country: BPAO services are
excellent and essential to people with disabilities who want to work.
Eighty nine percent of those surveyed rated the service they received as
excellent, very good, or good. And, the percent of the people who
reported they were working jumped by 19% subsequent to their contact
with the BPAO. The Panel is pleased that the BPAO program was
reauthorized in HR743 and thanks this Committee for their hard work in
passing that legislation.

Positive Implementation Step: Area Work Incentive Coordinator

The establishment of the Area Work Incentive Coordinator, or AWIC,
position within SSA is a very positive development in implementation of
the Ticket to Work Program, as well as in the overall administration of
work incentives. The Panel is very pleased that SSA decided to create a
position that is permanent and devoted full time to work incentive
duties as part of their internal corps of work incentives specialists.
The Panel has repeatedly heard very positive testimony and comments
regarding the dedicated and skilled SSA employees that fill the AWIC
positions. As we all know, the provision of accurate and timely
information on work incentives is a critical factor in making people
feel secure in their attempt to go to work. AWICs help to make that
happen for SSA beneficiaries. The Panel hopes that SSA will expand the
number of AWIC positions to meet the enormous demand for their services.

Three Areas of Concern

While the Agency is making good progress, the Panel has serious concerns
in three key implementation areas that threaten the success of the
Ticket to Work Program. Of most concern to the Panel is the current low
participation of ENs. Second, we are concerned about the lack of public
education and marketing of the Ticket to Work Program to beneficiaries,
their families, and ENs. A third major area of concern is the inadequate
training provided to SSA field staff about work incentives in general,
and the Ticket to Work Program specifically.

Concern One: EN Participation

As you probably know, the Panel issued a report last month on the crisis
in EN participation and its potential impact on the Ticket to Work
Program. The Executive Summary of that report is included at the end of
this statement (beginning on page 8).

Central to this report is the assumption that recruiting and retaining a
large number of active ENs is a critical factor in accomplishing the
primary stated goal of Ticket to Work Program -- giving people with
disabilities a real choice in rehabilitation and employment services.
Our report identified a number of issues related to the structure of the
Ticket to Work Program that are causing providers not to participate as
ENs or to drop out altogether. These are: the need for Congress to
clarify that the Ticket to Work Program should be used as a
supplemental, rather than a substitute, funding source; the design of
the EN payment system; the inadequacy of provider incentives; the
administration of claims for payment; marketing; EN training; and the
treatment of American Indian VR programs.

Finally, the Panel is concerned and puzzled that in the fourth year of
the Ticket to Work Program, SSA has yet to undertake a demonstration or
pilot project addressing some of these issues especially the payment
issue. The problems outlined below in the Executive Summary must be
addressed without delay to make the Ticket to Work Program more
attractive to current and potential ENs and to ensure that current ENs
to remain in the program.

Concern Two: Marketing and Public Education

The second major area the Panel believes maybe hindering the success of
the program is the lack of marketing and public education being
conducted by SSA in support of the program. The Panel has repeatedly
recommended that SSA undertake a national coordinated marketing and
public education campaign in order to increase awareness of and interest
in the Ticket to Work Program. Currently, beneficiaries are informed
only once about the Ticket to Work Program and they may not be informed
at all about other TWWIIA provisions and work incentives. The only
marketing material most beneficiaries receive on the Ticket to Work
Program is a letter describing the program when the Ticket is being
rolled out, or when they first become eligible for benefits.

The Panel is pleased that SSA has awarded a contract for the design of a
strategic marketing plan for the program that will be completed this
year. However, in the meantime, many ENs report having trouble finding
people willing to assign their Tickets and many beneficiaries and local
advocates remain completely in the dark about the Ticket to Work Program
and the other work incentives. Although these SSA contracting efforts
are very positive steps, the Panel is concerned that the next year or
two will be devoted to planning marketing efforts rather than actual
marketing of the Ticket to Work Program. Extensive planning activities
may delay implementation of a national marketing plan even further. The
Panel believes it is reasonable to expect that marketing would occur
prior to, or during, the rollout of a new program, not after. The Panel
urges SSA to move forward quickly with other marketing activities, such
as sending reminder letters to all people who have received but not yet
used their ticket.

Concern Three: Training

The final area that is of most concern to the Panel is the insufficient
training SSA field staff receives about work incentives and the Ticket
to Work Program. The Panel has heard in public testimony across the
country, stories of beneficiaries who have received inaccurate
information about work incentives from SSA staff in the field office.
Receiving bad information can cause a person not to make a job attempt,
to receive an overpayment, or to be forced to stop working. It also
increases mistrust and fear. This situation is unacceptable to the Panel
and Americans with disabilities. Every SSA field office should have
accessible and available staff that possess a thorough understanding of
the work incentives and be able to provide accurate basic information to
SSA beneficiaries with disabilities who want to work.

On that note, the Panel wants to again recognize the very positive step
the Agency took in the creation of the AWIC position as part of their
internal corps of work incentive experts. This represents the best type
of customer service. The AWICs received good basic training (two full
weeks) and many of them were former Employment Support Representatives
(with six weeks of training). AWICS are reported to be very
knowledgeable and highly regarded in the field and by beneficiaries.

There are not nearly enough AWICs to be available to answer every
question beneficiaries have but the training that AWICs have received on
SSA work incentives and the Ticket to Work Program is exemplary. SSA
cannot, however, rely on AWICs to provide all information and advice to
beneficiaries on work incentives and the Ticket to Work Program. SSA
created a filter down, train the trainer approach to build their corps
of internal work incentive specialists. AWIC's train Work Incentives
Liaisons (or WILs), the people who provide information on work
incentives on top of their regular duties in the field office. WILs
receive their limited training from the AWICs and then are expected to
train the remainder of the field office staff. SSA work incentives and
their interaction with the Ticket to Work Program are very complicated
and technical topics. The problem with SSA's current strategy is that
the necessary knowledge does not seem to filter down to the claims
representatives and service representatives who are answering
beneficiary questions about work incentives on a day-to-day basis. We
trust that SSA will make more intensive training, along the lines of
what AWICs receive, available to all SSA field staff.

Conclusion

The Panel believes the Ticket to Work Program has great potential to
help many people with disabilities improve their lives by going to work.
This statement outlines a number of concerns the Panel has about SSA's
administration of the Ticket to Work Program. While it is still early in
the implementation process of this new program, the failure of SSA to
take steps immediately to address these concerns may have a dire effect
on the success of the program.

The Crisis in EN Participation: A Blueprint for Action (February 2004)

Executive Summary

Thousands of people with disabilities and their advocates shared a dream
that the Ticket to Work and Work Incentives Improvement Act of 1999 (the
Act) would greatly expand employment opportunities for people on the
Social Security Administration (SSA) disability rolls. Three years after
enactment of the law, it is clear that their dream is faltering. The
Ticket to Work and Self-Sufficiency Program

(Ticket to Work Program) is failing to recruit the anticipated numbers
of new employment service providers, called Employment Networks (ENs).
In addition, those enrolled as ENs are serving only a fraction of the
beneficiaries thought to be interested in participating in the Ticket to
Work Program. Nearly 1,000 providers have enrolled in the program, but
only about one-third of those operating have accepted any tickets. The
Panel believes that without immediate attention to the very real
problems affecting EN participation, the Ticket to Work Program will
fail. The Panel urges Congress and the Commissioner to act quickly on
the following recommendations.

Issues and Recommendations

Ticket to Work Program as a Supplemental Funding Source---ENs are
uncertain about whether and how they can use funds from other public
sources to serve ticket holders and have chosen not to actively
participate in the Ticket to Work Program because of fear of losing
other stable funding sources.

Recommendations

> • Congress should develop statutory language that clearly articulates
> its original intent that the Ticket to Work Program's outcome and
> milestone payments should provide additional resources to assist
> beneficiaries in attaining and retaining employment. In general, the
> Panel believes that Congress did not intend to make beneficiaries
> ineligible for the full range of services from vocational
> rehabilitation (VR) programs, Medicaid, or other Federal and State
> programs by making them eligible for the Ticket to Work Program.
>
> • Congress should direct the Commissioner to implement the Ticket to
> Work Program as a complement to the traditional SSA VR Reimbursement
> Program, paying State VR agencies for up-front services and paying ENs
> for long-term employment outcomes.
>
> • As part of the mandated evaluation of the Ticket to Work Program,
> the Commissioner should conduct an assessment of the Ticket to Work
> Program and the SSA VR Reimbursement Program, running in combination,
> to determine whether that approach produces better long-term, cost
> -effective outcomes than the historical VR Reimbursement Program
> alone, and to ensure the financial viability of running the two
> programs in combination.

*The EN Payment System --- Two problems in the EN payment system
discourage the active participation of many providers: (1) the payment
system places too much financial risk on ENs and (2) the payment system
provides significantly lower reimbursements to ENs for serving
Supplemental Security Income (SSI) recipients than for serving Social
Security Disability Income (SSDI) beneficiaries.*

Recommendations

> • The Commissioner should immediately modify the EN payment system to
> move more of the payment into the first 12 months of employment and
> reduce the difference between the milestone and outcome payments.
>
> •The Commissioner should test two or three creative approaches that
> place more up-front financial risk on SSA but, if successful, could
> significantly increase Ticket to Work Program participation by both
> ENs and beneficiaries, thereby increasing long-term savings to SSA.
>
> •Congress should amend the statute to permit payments to ENs to be set
> at a level greater than 40 percent of average benefits for both SSDI
> and SSI beneficiaries and after the statutory change the Commissioner
> should implement an increase in EN payments for beneficiaries of both
> programs.
>
> •Congress should amend the statute to permit the Ticket to Work
> Program to increase the sum of payments available for serving SSI
> recipients to a level equal to the sum of payments available for
> serving SSDI beneficiaries.

•The changes to the EN payment system should be implemented as quickly
as possible.

*Adequacy of Provider Incentives --- Because little is known about
outcome payments for providers, the Act authorizes the Commissioner to
review, refine, and alter the payment system to ensure that it provides
adequate incentives for ENs to serve beneficiaries and produce savings
to the program. Despite major problems with the payment model, no
alterations have been made to the original program payment system. The
Commissioner has established an advisory group on Adequacy of Incentives
(AOI) to assist SSA with the design of a workable payment system,
including financial incentives to serve four groups of beneficiaries
with special needs that were referenced in the Act.*

Recommendations

> • The Commissioner should implement a modified EN payment system that
> generally incorporates the principles outlined in the AOI Advisory
> Group's interim report. (The Panel supports the principles in the
> report but has not endorsed a specific model.)
>
> •For any new payment system to be successful, the Commissioner must
> first implement the Panel's recommendations relating to the EN payment
> system and EN claims administration.
>
> •The Commissioner and Congress should make clear in statute and in
> program regulations that payments to ENs must supplement funding from
> other public programs (such as State VR, Mental Health, Medicaid,
> Housing and Urban Development, Department of Labor) and should not pay
> for services for which beneficiaries are already eligible.

*EN Payment Claims Administration --- Two factors compound the financial
risk and working capital problems of Employment Networks: (1) long-term
tracking of beneficiary earnings is labor intensive and administratively
burdensome for ENs and (2) there are often long delays in processing EN
claims for payment.*

Recommendations

> •Once a beneficiary has been certified as employed above the
> substantial gainful activity (SGA) level or leaves cash benefit
> status, the Commissioner should continue to pay the EN on a monthly
> basis as long as the beneficiary remains in zero benefit status and
> the EN has not yet received 60 months of outcome payments, or until
> the beneficiary requests a new EN.
>
> •The Commissioner should refine the EN payment claims processing
> system to ensure timely payments to ENs within businesslike
> timeframes. A widely accepted business standard for turnaround time on
> receivables is 30 days.

Marketing to ENs and to Beneficiaries --- *To date, there is no national
marketing plan for the Ticket to Work Program and the Program is not
well understood by the vast majority of beneficiaries or by those who
influence a beneficiary's decision to attempt work. Further, ENs spend
considerable time explaining the Program and dispelling misconceptions.
Also, the lack of marketing contributes to the insufficient demand for
EN services. However, SSA has recently awarded contracts to support
development of a strategic marketing plan and EN marketing and
recruitment efforts. The Panel has made numerous recommendations to the
Commissioner on this issue in past reports.*

Recommendation

The Commissioner should create opportunities for the Panel to (1) review
the work plans and proposed activities under the strategic marketing
plan contract and the project designed to improve EN participation and
(2) engage in a dialogue with the contractors and relevant SSA staff so
that the Panel can provide timely and substantive input on these
marketing activities.

*EN Training and Communication --- There is inadequate training,
technical assistance (TA), and timely information available to ENs.
Existing TA and training resources are inadequate, nonuniform,
piecemeal, uncoordinated, and of varying quality, with no coordinated
means for ENs to identify and share best practices.*

Recommendations

> •The Panel, in partnership with the Commissioner, should convene a
> meeting of key stakeholders to develop a national training and
> communications conference for all ENs.
>
> •The Commissioner should appoint a working committee to develop the
> plan for this training conference and to develop the overall strategy
> for bringing together a broad-based coalition of stakeholders to
> oversee and sponsor the event. Panel members should be active
> participants.

*American Indian VR Program Eligibility for the SSA VR Reimbursement
Program --- Despite*

*having to meet the same service standards as State VR agencies,
American Indian Vocational Rehabilitation (AIVR) programs operated by
Tribal Nations programs are not exempt from the Ticket to Work Program
EN application process and are excluded from the traditional SSA
Reimbursement Program for State VR agencies.*

Recommendation

Congress should amend the statute to permit AIVR programs operating
under section 121 of the Rehabilitation Act to participate in Ticket to
Work in a manner equivalent to State VR agencies; that is, they should
be exempt from the EN application process and be subject to the same
reimbursement rules.

TICKET TO WORK AND WORK INCENTIVES ADVISORY PANEL PRIORITIES

August 2004 to August 2005

AOI: Eligibility for alternative payment system -- Provide advice on
categorizing disability\
beneficiaries according to whether they would be eligible for an
alternative payment system because their employment supports are more
expensive or they are considered "hard-to-serve." What criteria should
SSA use to determine whether someone would be "hard-to-serve" and will
SSA incorporate this determination into its disability determination
process? This topic should be included in ongoing progress reports from
SSA.

Action Status -- Monitor

BPAO and PABSS -- Provide advice to SSA on the funding, scope, and
authority for the BPAO and PABSS programs. Provide advice on evaluation
issues related to the BPAO customer satisfaction survey.

Action Status -- Monitor

Continuing Disability Review Protection -- Monitor progress on extending
continuing disability\
review protections currently provided in the Ticket to Work Program to
any SSA beneficiary\
participating in an approved vocational rehabilitation program leading
to employment.

Action Status - Monitor

Capitalization and Expansion through Blended Funding -- Provide advice
on redesigning\
interactions between the Ticket to Work Program and Federal/State
programs including Medicaid to address issues such as the inadequate
capitalization of ENs, increasing the number of ENs, and expanding
resources to serve individuals with the most severe disabilities.
Provide advice to increase the extent to which DOL field programs and
One-Stops serve SSI and DI beneficiaries.

Action Status -- Active

Coordination and Collaboration with Other Federal Programs -- Provide
advice to the Commissioner of SSA concerning coordination with other
Federal agencies that provide support for people with disabilities
receiving SSI/SSDI (including among others Housing and Urban
Development, Department of Transportation, Department of Agriculture).
Specific concerns to be addressed are the coordination and collaboration
of applications, eligibility requirements, and benefit loss due to
earnings.

Action Status - Active

Early Intervention -- Provide advice on the extent to which early
intervention---perhaps even as early as when an individual is still
working---will minimize services needed and maximize continued
employment. Does the Panel believe that the costs of providing early
outreach will result in savings in the long run because fewer people
will come on the rolls or because some will come on the rolls at a later
point in time? Provide advice on the possibility that more people would
apply for benefits just to obtain these services. Monitor related
research. This topic should be included in ongoing progress reports from
SSA.

Action Status -- Active

EN Issues -- Provide advice on the small number of ENs that are
authorized and accepting Tickets, raising concern about consumer choice
and the success of the Program. This topic involves consideration of
changes in the EN payment structure and other factors affecting the
number of ENs. Conduct research and provide advice on the partial
benefits issue. Provide advice on how work incentives affect consumer
choices to use ENs.

Action Status -- Monitor

Health Care -- Provide advice to CMS and the Congress as appropriate
concerning the Medicaid and Medicare provisions of TWWIIA and their
interaction with all existing policies. Specific issues to be examined
include the direction of the Medicaid Infrastructure Grants, the lack of
a definition of work in the Medicaid Buy-In and the lack of any
evaluation component for the health care provisions of TWWIIA (To what
degree have the buy-in provisions increased labor participation by
individuals with disabilities). Create a set of principles regarding
access to public and private health care for people with disabilities.

Action Status - Active

Implementation Budget -- Advice on the extent to which SSA has devoted
the necessary resources to assure successful implementation of new
programs and projects under TWWIIA, including the budgets for TWWIIA and
Ticket Implementation, the Program Manager, BPA&O and P&A Grants,
demonstration projects, administration and operations. Provide advice on
the possible use of designated appropriations for implementation by
Congress.

Action Status -- Monitor

Marketing -- Provide advice on the need for a National Marketing Plan to
market the Ticket to Work Program to Employment Networks and Employers,
covering topics such as EN diversity, level of effort, costs, other work
incentives and Medicaid. Provide advice on immediate marketing, such as
follow-up letters to beneficiaries. Provide advice relating to a
National Plan on education and training for beneficiaries and families.

Action Status -- Active

Mental Health -- Provide advice to SSA and other federal partners (e.g.
Center for Medicare and Medicaid Services, Department of Labor,
Substance Abuse and Mental Health Services Administration) on statutory,
regulatory or policy issues regarding designing employment\
supports for people with mental illness.

Action Status -- Active

Protection of Beneficiary Rights -- Provide advice to the Commissioner
of Social Security to ensure that beneficiaries are informed of their
rights to due process, Protection & Advocacy services and dispute
resolution in simple language frequently and appropriately. Provide
advice to SSA to ensure that the training provided to SSA staff (and
contractors) regarding informing consumers of their rights is adequate
and appropriate. Provide advice to SSA to ensure that the rights of
consumers are protected during any disputes with SSA or an Employment
Network participating in the Ticket to Work Program. Monitor SSA
mediation pilot services.

Action Status -- Active

Post Entitlement Issues -- Provide advice on a cluster of issues
including overpayments and the management of earnings reports, SSA
infrastructure and the extent to which the current SSA infrastructure
(Area Work Incentive Coordinators, Work Incentive Liaisons, and
workload) supports the successful implementation of TWWIIA. Should a
higher priority be given to this work at the field level? Should a
higher priority be given to how SSA could begin to implement a
nation-wide change in operations, policy and mission to integrate RTW in
all aspects of Agency operations, including 1300 field offices and
65,000 staff?

Action Status -- Active

Regulations -- Advice to SSA regarding the issuance of NPRM (notice of
proposed rulemaking) on the Ticket to Work Program including:

> •Provide formal response to proposed regulations on the Exemption of
> Work Activity as a basis for a Medical Continuing Disability Review
> (Section 111 of TWWIIA)
>
> •Provide formal response to proposed rules on the Ticket to Work
> Program, including Ticket Eligibility, State VR Partnerships, and
> Ticket Payment Options.

Regulations -- Notice of Proposed Rulemaking has been issued. Monitor
for publishing of Final Regulations:

• Section 301 coverage

• Expedited reinstatement

• VR Referral (No NPRM will be issued -- regulations to come out in
final)

Action Status -- Pending other action

Ticket Evaluation Requirements and Results -- Monitoring the Ticket to
Work Program evaluation. Provide advice on the extent to which the
overall design of the Ticket to Work Program evaluation meets the
requirements outlined in the statute. This topic should be included in
ongoing progress reports from SSA

Action Status -- Monitor

Training -- Provide advice on adequate resources for training, including
costs, of field office employees, professional training in the field of
employment services and rehabilitation, to SSA grantees, for Employment
Networks, to State Systems, etc. Should there be a National Training
Plan?

Action Status -- Active

VR -- Provide advice on concerns relating to communication between State
VR systems and Employment Networks about the Ticket to Work Program as
well interactions between VR programs and SSI/DI clients, and rules for
ticket assignment.

Action Status -- Monitor

Youth -- Monitor progress on advice provided by the Panel to SSA and
Congress on statutory, regulatory and policy issues affecting the labor
force participation of transition aged youth who are SSI/SSDI
beneficiaries. Monitor progress of Youth Demonstration projects.

Action Status -- Monitor

\$1 for \$2 -- Provide advice on the relationship between the \$1 for
\$2 demonstration and Ticket use. This topic should be included in
ongoing progress reports from SSA.

Action Status -- Active