DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
                      SMD # 10-002 
 
January 28, 2010 
 
                  Re:  Ticket to Work 
 
Dear State Medicaid Director: 
 
As you recall, on June 22, 2009, the Department of Health and Human Services commemorated 
the 10th anniversary of the Olmstead v. L.C. decision with the announcement that 2009 would be 
the Year of Community Living. To begin this Year of Community Living, HHS agencies 
were tasked with aggressively addressing barriers that prevent some Americans with disabilities 
from enjoying a meaningful life as part of their community.  
 
As part of the Community Living Initiative, this letter provides clarification regarding the receipt 
of Federal funds under the Social Security Administrations (SSA) Ticket to Work and Self-
Sufficiency program (Ticket to Work program) and encourages the utilization of the flexible 
funding the program offers.  Utilizing and coordinating such available resources is critical to 
support States continued progress in constructing a comprehensive health and employment 
services system for individuals with disabilities who want to achieve and maintain their 
employment goals. This guidance provides policy clarifications regarding State Medicaid 
providers acceptance and the treatment of SSA ticket payments.  
 
Background  
 
As required by the Ticket to Work and Work Incentives Improvement Act, Pub. L. 106-170, and 
SSAs Ticket to Work regulations, SSA issues tickets to eligible beneficiaries who, in turn, 
may assign those tickets to an Employment Network (EN) of their choice to obtain employment 
services, vocational rehabilitation services, or other support services necessary to maximize their 
economic self-sufficiency through work opportunities. 
 
As described in the Ticket to Work regulations at 20 CFR Part 411, Subpart E, an EN shall be 
either an agency or instrumentality of a State (or political subdivision of the State), or a private 
entity that assumes responsibility for the coordination and delivery of employment, vocational 
rehabilitation, or other support services to those beneficiaries who have assigned their tickets to 
the EN.  SSA pays ENs for assisting beneficiaries in achieving certain work milestones and 
outcomes, not for services. 
 
 
   
  Page 2- State Medicaid Director 
 
At issue for States participating in the Ticket to Work program as ENs is whether or not the 
acceptance of Medicaid service dollars and the subsequent receipt of ticket payments constitutes 
an overpayment of Federal dollars for services provided.  Also at issue is how the ticket 
payments can be used. 
 
Policy Clarification 
 
As a basic principle of the Medicaid program, States receive Federal financial participation 
(FFP) for services authorized in their State plan provided to eligible individuals.  A number of 
State agencies and providers that use Medicaid funding for payment of services, including 
services provided under section 1915(c) waivers, remain concerned that the acceptance of ticket 
payments subsequent to their provision of and payment for Medicaid services, might be in 
conflict with regulatory requirements surrounding conditions under which FFP is available.   
 
Ticket Outcome and Milestone payments do not conflict with regulatory requirements and do not 
constitute an overpayment of Federal dollars for services provided since EN payments are 
payment for an outcome, rather than for a Medicaid service rendered.  Furthermore, State 
agencies and/or providers interested in participating in the Ticket to Work program as ENs are 
encouraged to do so.  However, it is important for State agencies acting as ENs to keep ticket 
payment funding separate from resources used by the State to comprise the States Medicaid 
share, in accordance with applicable Federal regulations at 42 CFR 433.51. 
 
To encourage and ensure proper use of Federal dollars to support a States effort to effectively 
increase competitive and meaningful employment outcomes of individuals with disabilities, an 
additional clarification is provided regarding the prohibition of using Ticket Outcome and 
Milestone payments as the State share of financial participation.  While there is no conflict when 
a State Agency or provider receives payment from Medicaid for appropriate services, and then 
later receives Ticket Outcome or Milestone payments based on employment outcomes, the use of 
Ticket Outcome or Milestone payments to comprise the State share for Medicaid or other 
services remains prohibited, as described in 42 CFR 433.51(c). 
 
If you have questions regarding this letter, please contact Ms. Melissa Hulbert at 410-786-6568 
or melissa.hulbert@cms.hhs.gov.   For additional information on SSAs Ticket to Work program, 
please reference the SSA Work Site at http://www.ssa.gov/work/. 
 
 
            Sincerely,  
 
            /s/ 
 
            Cindy Mann 
            Director 
 
cc: 
  Page 3- State Medicaid Director 
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health 
 
Ann C. Kohler          
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.P.H. 
Director, Government Relations  
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy 
 
David A. Rust 
Deputy Commissioner for Retirement and Disability Policy 
Social Security Administration