Securing the Social Contract:

Reforming Social Security 

Disability

National Council on Disability

January 29, 2015
National Council on Disability

1331 F Street, NW, Suite 850

Washington, DC 20004

Securing the Social Contract: Reforming Social Security Disability

This report is also available in alternative formats upon request and on the National 

Council on Disability (NCD) Web site (www.ncd.gov).

January 29, 2015

202-272-2004 Voice

202-272-2074 TTY

202-272-2022 Fax

The views contained in this report do not necessarily represent those of the 

Administration, as this and all NCD documents are not subject to the A-19 Executive 

Branch review process.
National Council on Disability

An independent federal agency making recommendations to the President and Congress 

to enhance the quality of life for all Americans with disabilities and their families.

1331 F Street, NW ■ Suite 850 ■ Washington, DC 20004

202-272-2004 Voice ■ 202-272-2074 TTY ■ 202-272-2022 Fax ■ www.ncd.gov

1 

Letter of Transmittal

January 29, 2015

President Barack Obama

The White House

1600 Pennsylvania Avenue, NW

Washington, DC 20500

Dear Mr. President: 

The National Council on Disability (NCD) is pleased to submit the enclosed report, 

“Securing the Social Contract: Reforming Social Security Disability” for your 

consideration and review. The 2011 prediction of the Social Security Trustees’ Report 

that the trust fund payouts will exceed revenue still stands. The longstanding challenges 

facing recipients of Social Security Disability Insurance (SSDI) and Supplemental 

Security Income (SSI) regarding work disincentives along with the increasing numbers 

of claims linked to the nation’s slowly recovering economy have been highlighted by 

policymakers repeatedly as needing reform. 

This NCD report analyzes various proposals for SSI and SSDI reform, including the 

examination of Medicaid policy on the ability of people with disabilities to work. It also 

identifies measures that could (a) move people currently utilizing SSI/DI into the 

workforce; (b) decrease a likelihood of using such benefits for sole income; and 

(c) serve as financing options to extend the life of both programs.

Among its specific and critical research questions, NCD’s report asks: 

1. What would a fundamental restructuring of the SSI and SSDI system require to align 

it with the goals of the Americans with Disabilities Act (ADA), which celebrates its 

25th anniversary this year? In essence, how would an effective reform proposal: 

a. Eliminate the current requirement by the Social Security Administration that an 

SSDI applicant declare him/herself unable to work in order to be eligible for 

benefits; 

b. Provide job retention supports to working people with disabilities who are at risk 

of job loss as a result of their disability; and

c. Assist people with disabilities who are at risk of job loss because they are not 

receiving reasonable accommodations?
2

2. Given the extremely diverse populations served by the SSI and SSDI programs, how 

might different reform strategies disproportionately impact—(positively or 

negatively)—particular segments of the population within the disability community? 

Based on findings pertaining to these and related questions, NCD is carrying out its role 

as an independent advisor on disability matters to you, Mr. President, Congress, and 

other federal agencies. This NCD report proposes a number of policy recommendations 

to reform Social Security, such as decoupling health care benefit and cash benefit 

eligibility; providing wraparound health benefits; improving the examination, planning, 

and gradual phase-in of a revised disability definition for benefit eligibility; early 

intervention; and implementing evidence-based practices that target youth and people 

with mental health needs among vulnerable groups. 

As always, NCD looks forward to working with the Administration and Congress to 

advance thoughtful and beneficial reforms to critical programs like SSI/DI so that 

Americans with disabilities in need of income support are assisted but without sacrificing 

the goals of the ADA—equality of opportunity, full participation, independent living, and 

economic self-sufficiency. 

Sincerely, 

/s/

Jeff Rosen

Chairperson

(The same letter of transmittal was sent to the President Pro Tempore of the 

U.S. Senate and the Speaker of the House of Representatives.)
3 

National Council on Disability Members and Staff

Members

Jeff Rosen, Chairperson

Kamilah Oni Martin-Proctor, Co-Vice Chair

Lynnae Ruttledge, Co-Vice Chair

Gary Blumenthal

Chester A. Finn

Sara Gelser

Captain Jonathan F. Kuniholm, USMC (Retired)

Janice Lehrer-Stein 

Ari Ne’eman

Benro T. Ogunyipe 

Stephanie Orlando

Katherine D. Seelman

Clyde E. Terry

Royal P. Walker, Jr.

Alice Wong

Staff 

Rebecca Cokley, Executive Director 

Phoebe Ball, Legislative Affairs Specialist

Stacey S. Brown, Staff Assistant

Julie Carroll, Senior Attorney Advisor

Lawrence Carter-Long, Public Affairs Specialist

Joan M. Durocher, General Counsel & Director of Policy

James Flakes, Administrative Support Assistant

Lisa Grubb, Management Analyst

Geraldine-Drake Hawkins, Ph.D., Senior Policy Analyst

Robyn Powell, Attorney Advisor

Anne Sommers, Director of Legislative Affairs & Outreach
4

Acknowledgments

The National Council on Disability (NCD) expresses appreciation to the National Disability 

Institute (NDI) for developing this report in collaboration with the following partners 

(hereafter identified as the NDI Consortium): the University of Utah, Peregrine Public Policy 

Consulting, the University of Kansas, the Vermont Center for Independent Living, the 

Disability Law Center in Utah, and George Washington University. Contributors included 

Cathy Chambless, Ph.D., research associate, Center for Public Policy and Administration, 

University of Utah, Salt Lake City, UT; Barry S. Delin, Ph.D., researcher, College of 

Engineering, University of Wisconsin–Madison, WI; Jean Hall, Ph.D., associate research 

professor and director, Institute for Health and Disability Policy Studies, University of 

Kansas, Lawrence, KS; Ellie Hartman, project manager, Wisconsin PROMISE project, 

Madison, WI; John Reiser, president, Peregrine Consulting, Stoughton, WI; Andrew Riggle, 

advocate, Disability Law Center, Salt Lake City, UT; and James Smith, budget and policy 

manager, Vermont Division of Vocational Rehabilitation, Montpelier, VT. Other advisors 

were Allen Jensen, special advisor, Cayte Anderson, Sharon Brent, Julie DeLong, Dan 

Johnson, Sarah Launderville, Sam Liss, Anne Reither, Carol Ruddell, and Amy Thomson.

Dedication

This report honors the memory of Allen C. Jensen. He possessed a rare perspective on 

the historical evolution of disability policy from a time before the “disability rights 

movement” was referred to by that name. In 1975, Jensen moved from a position with 

the National Governors Association to the U.S. House of Representatives Committee on 

Ways and Means, where he served as Supplemental Security Insurance (SSI) specialist 

until 1989. He held numerous positions as a policy consultant and researcher, and 

wrote papers on Medicaid, SSI, Social Security Disability Insurance (SSDI), aging, 

mental health, and employment programs. Jensen passed away in April 2013 while 

working on this project. At the time of his death, he was affiliated with the Center for 

Health Policy Research at George Washington University, Washington, DC.
5

Contents

Letter of Transmittal........................................................................................................ 1

National Council on Disability Members and Staff....................................................... 3

Members ................................................................................................... 3

Staff........................................................................................................... 3

Acknowledgments........................................................................................................... 4

Dedication................................................................................................. 4

Contents........................................................................................................................... 5

Preface ............................................................................................................................. 8

Executive Summary ......................................................................................................11

Chapter 1. Individual Workplace Supports............................................................13

Goal of Chapter.......................................................................................13

Outline of Issue .......................................................................................13

Research Review Findings .....................................................................14

Demonstrations to Maintain Independence and Employment.........14

Accelerated Benefits Demonstration................................................17

Recommendation....................................................................................18

Chapter 2. Employer Incentive Mechanisms to Reduce SSDI Entry ...................19

Topic and Goal of Chapter......................................................................19

Outline of Issue .......................................................................................19

Research Review Findings .....................................................................20

Private Disability Insurance..............................................................20

Mandated Disability Benefits............................................................22

Experience Rating............................................................................23

Disability Management Strategies ...................................................24

Other Resources for Employers.......................................................28

Public Information Campaigns Focused on Employers...................29

Recommendations ..................................................................................30

Chapter 3. Health Care Access for Working People with Disabilities: 

Medicaid Buy-In ....................................................................................31

Goal of Chapter.......................................................................................31

Outline of Issue .......................................................................................31

Research Review Findings .....................................................................33

State-by-State Comparison of MBI Policies.....................................33

Identification of Promising and Best Practices................................. 35

Role of MBI as a Means to Avoid the Need for SSI/SSDI ...............37

Possible Effects of the Affordable Care Act (ACA)...........................38

Recommendations ..................................................................................40
6 

Chapter 4. Redefining Disability for SSDI and SSI, Medicaid and Medicare ......43

Goal of Chapter.......................................................................................43

Outline of Issue .......................................................................................43

How the Current Definition Discourages Work ................................45

Research Review Findings .....................................................................45

Negative Effects of the Definition on Employment Outcomes.........45

Problems with the Current Determination Process..........................48

How the Disability Definition Is Operationalized ..............................49

An Alternative Approach to a Disability Definition ............................52

Recommendations ..................................................................................54

Chapter 5. Changing the Disability Definition: Impact on the SSDI/SSI 

Population .............................................................................................57

Goal of Chapter.......................................................................................57

Outline of Issue .......................................................................................57

Populations Likely to Be Affected.....................................................58

Advantages of a New Definition.......................................................60

Recommendations ..................................................................................61

Chapter 6. Reenvision the Ticket to Work Program .............................................63

Goal of Chapter.......................................................................................63

Outline of Issue .......................................................................................63

Research Review Findings .....................................................................64

Beneficiary Participation...................................................................64

Employment Network Participation..................................................65

SVRA Participation...........................................................................65

Impact of TTW on Employment Outcomes......................................65

Recommendations ..................................................................................66

Chapter 7. Expand Other State and Federal Programs That Positively 

Affect SSA Beneficiaries and Work Opportunities.............................69

Goal of Chapter.......................................................................................69

Outline of Issues .....................................................................................69

Research Review Findings .....................................................................71

Youth in Transition............................................................................71

Mental Illnesses/Psychiatric Disabilities...........................................73

Medicaid Infrastructure Grants.........................................................75

Recommendations ..................................................................................76

Chapter 8. SSI State Supplementation...................................................................79

Goal of Chapter.......................................................................................79

Outline of Issue .......................................................................................79
7

Research Review Findings .....................................................................79

Fees for SSA to Administer State Supplements ..............................81

State Supplements and Medicaid Eligibility .....................................81

Recommendations ..................................................................................83

Appendix A. State-by-State Comparison of Medicaid Buy-In Provisions ..............85

Appendix B. Continuing Disability Review.............................................................133

Continuing Disability Review................................................................. 133

Step 1.............................................................................................133

Step 2.............................................................................................134

Step 3.............................................................................................134

Step 4.............................................................................................134

Step 5.............................................................................................134

Step 6.............................................................................................134

Step 7.............................................................................................134

Step 8.............................................................................................135

Appendix C. Medicaid Infrastructure Grants in Three States ...............................137

New York ..............................................................................................137

Integrated Data Management System...........................................137

Information Tools for Employers and Employment Support 

Providers ........................................................................................137

Asset-building Strategies ...............................................................138

Connecticut...........................................................................................138

Employment Services Maps ..........................................................138

Utah ......................................................................................................139

Single Point of Contact for Employers in VR .................................139

Endnotes......................................................................................................................141

List of Tables

Table 1. Comparison of Initial Eligibility Determination Processes: Current 

Adult, SSI Child, and Proposed Adult .....................................................53

Table A-1. Medicaid Buy-In Program: Income Eligibility Criteria...............................86

Table A-2. Medicaid Buy-In Program: Authority, Resource Limits, and 

Exclusions...............................................................................................97

Table A-3. Cost-Sharing Policies: Minimum Income Level and Premium or 

Cost-Share Method...............................................................................107

Table A-4. Work-Related Policies and Protections .................................................123
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Preface

In 1998, the National Council on Disability (NCD) partnered with the Social Security 

Administration (SSA) to conduct a national policy review of barriers to successful 

education and employment outcomes. The report, published in 2000, was motivated by 

the fact that “thousands of young people under the age of 30 come into the 

Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) 

programs and the majority of them never leave.”

1 For at least the past decade, both 

SSA and its advisory board have raised concerns, and the agency has taken actions to 

address the need for SSI and SSDI improvements with regard to disability 

determination, program data gathering, and related processes, including work 

incentives and supports.2 Despite those efforts, only a limited change in the number of 

people going on and staying on the benefit rolls has been documented during the period 

from that NCD and SSA joint review to a related NCD report in 20053 and the 

publication of this report. The report recommendations reflect NCD’s role as an 

independent federal agency charged with advising the President, Congress, and federal 

agencies on policies, programs, practices, and procedures that affect people with 

disabilities.

The report has eight chapters. Each chapter addresses a key question or questions and 

is organized into subsections: topic and goal, outline of issues, results of a research 

review, and recommendations. Chapter 1 addresses factors that could encourage 

people with disabilities to continue their work efforts and either delay applying or not 

apply for benefits. Chapter 2 examines actions employers can take to retain people in 

the workforce, thus forestalling the need for workers with disabilities to apply for SSI or 

SSDI benefits. Chapter 3 examines the current status of the Medicaid Buy-In—the 

state-optional program that allows working people with disabilities to access health care 

and provides important long-term supports and services to sustain working. In 

Chapter 4, we summarize evidence that the current Social Security definition of 

disability strongly discourages beneficiaries from working, and we propose an
10

alternative definition that does not equate disability with a complete inability to work. 

Chapter 5 discusses the implications of the proposed definition of disability for those

who are currently eligible for SSI and SSDI benefits. Chapter 6 looks at the Ticket to 

Work program’s intended objectives and at suggestions for reinvigorating the program. 

Chapter 7 reviews three examples of effective strategies for change given certain 

supports for people with disabilities: youth in transition from high school, people with 

psychiatric disabilities, and programs under the Medicaid Infrastructure Grants. Finally, 

Chapter 8 reviews the status of states’ supplemental payments to the SSI program and 

discusses whether policy action is needed. 
11

Executive Summary

“Living independently and with dignity means [having the] opportunity to participate fully 

in every activity of daily life. The ADA offers such opportunity to [people] with 

disabilities.” Cong. Rec. No.136, S9695 (July 13, 1990).

This statement from the historical debates on the Americans with Disabilities Act (ADA) 

captures U.S. Senator Robert Dole’s vision of a full, inclusive future for people with 

disabilities. By enacting the ADA, Congress recognized the need to change the 

accepted idea that people with a variety of disabilities should be relegated to a position 

outside society’s economic and social mainstream.

The 2001 amicus brief of the National Council on Disability (NCD) in support of the 

respondent (Toyota v. Williams) shows that Congress was particularly concerned about 

high unemployment faced by people with disabilities. Title I of the ADA was adopted as 

a tool to encourage workplace participation, which is a critical element of full community 

integration. Yet, nearly 30 years after ADA enactment, attitudes, access, and 

accommodations remain barriers to inclusive living and earning. 

This NCD report examines complex policy in two benefit programs linked to key aspects 

of the ADA: Social Security Disability Insurance (SSDI) and Supplemental Security 

Income (SSI). The report covers the definition of disability, related research findings, 

employment incentives in lieu of long-term social benefits as sole income, and 

recommendations for action by specific entities. The findings call attention to policies 

and practices that involve comprehensive and affordable health care, workplace 

supports and services, Medicaid Buy-In programs, tax reform, temporary private 

disability insurance funding of supports (e.g., accommodations, rehabilitation, employer 

training opportunities), technical support for problem solving, and safeguards for people 

under a revised disability definition. 
12

Among the recommendations to the Administration, federal agencies, and Congress, 

NCD proposes actions to improve equal workplace access and accommodations for 

people with disabilities. The recommendations focus primarily on decoupling health care 

benefit and cash benefit eligibility; providing wraparound health benefits; improving the 

examination, planning, and gradual phase-in of a revised disability definition for benefit 

eligibility; ensuring management proficiency, early intervention, and improved federal 

collaboration efforts; identifying ways to boost work incentives; implementing evidencebased practices that address youth and people with mental health needs among 

vulnerable groups; and reviewing state supplemental systems. 
13

CHAPTER 1. Individual Workplace Supports 

Goal of Chapter

Effective interventions prior to application for Social Security disability programs are

necessary to reduce the number of disability applications. The question addressed by 

this chapter is, “What supports are needed to prevent or forestall the progression of 

people with disabilities or disabling conditions toward applying for SSI and SSDI 

benefits?” The chapter focuses on supports that can be targeted toward people with 

potentially disabling conditions to enable them to handle impediments that may 

jeopardize their ability to work. The goal of the chapter is to describe government 

policies and private sector initiatives that can be applied to reduce the number of people 

applying for disability benefits as their long-term sole income source.

Outline of Issue

The most effective return-to-work interventions minimize or eliminate the amount of time 

a formerly employed person is out of the workforce. Because the frequency of exit from 

long-term public disability programs is low, both in the United States and in comparable 

nations,4 an effective policy approach is to incentivize continued attachment to the 

workforce and provide workplace supports to prevent the need for people to ever go on 

public long-term disability benefits in the first place. 

Return-to-work approaches can be distinguished on multiple dimensions. Approaches 

can vary on a continuum from being completely voluntary to being completely 

compulsory. They may be implemented through the public sector, the private sector, or 

both. Eligibility standards and processes can vary in rigor or be used to determine 

access to one program or multiple programs. Interventions can be provided before

application to a Social Security disability program, concurrent with the application 

process, or after claimants have gained eligibility.5 It is important that the beneficiary
14

receive some level of useful and personalized services and supports, as well as access 

to health care. 

Research Review Findings

A review of specific proposals for return-to-work interventions put forth in the past two 

decades reveals some combination of early intervention before application to SSDI or 

SSI and changes to income support and health care program rules under which 

beneficiaries can test their ability to work. Wittenburg and Loprest (20046 provide an 

excellent conceptual overview of the field. Proposals with particular relevance for the 

reform of the Social Security disability programs include Berkowitz (1996), McDonald 

and O’Neil (2006), Autor and Duggan (2010), Mann and Stapleton (2011), Burkhauser 

and Daly (2011), and Liebman and Smalligan (2013).7 In most cases, the authors are 

cautious about rapid and full implementation of their proposals, especially those that 

substantively change some aspect of the Social Security disability programs. They often 

suggest demonstration projects as a first step, both to assess the effectiveness and cost 

of rule changes and service approaches and to obtain the experience needed to 

facilitate ramping up these changes to a national scale.

There have been a few demonstrations of interventions that might help a person with a 

disability or a potentially disabling condition continue working. These interventions 

provide varying levels of useful and personalized services and supports, as well as 

access to health care. Two recent federal demonstration programs illustrate what these 

supports might be and how they might be provided.

Demonstrations to Maintain Independence and Employment 

The Demonstrations to Maintain Independence and Employment (DMIE) program has 

provided useful answers to the question of whether providing medical assistance and 

other supports will forestall or prevent the loss of employment and independence owing

to a potentially disabling condition.8 The DMIE program was authorized under 
15

section 204 of the Ticket to Work and Work Incentive Improvement Act (TW-WIIA) 

legislation and administered through the U.S. Department of Health and Human 

Services, Centers for Medicare and Medicaid Services (CMS). Funding for this initiative 

ended in September 2009. According to the original program announcement, “This 

demonstration grant provides an opportunity to investigate the question: can a program 

of medical assistance and other supports forestall or prevent the loss of employment 

and independence due to a potentially disabling and medically determinable physical or 

mental impairment?”

9 To answer this question, states were to provide “Medicaid-like” 

benefits and employment supports to people with potentially disabling conditions and 

monitor their employment and health outcomes in comparison with those of a control 

group that did not receive benefits and supports. For the purposes of the funding, 

employment at baseline for potential study participants was defined as working at least 

40 hours per month and earning at least federal minimum wage; states could not 

impose an earnings ceiling. The demonstrations were required to use an experimental 

design, with random assignment of participants to intervention and control groups.

Four states implemented DMIE projects: Hawaii, Kansas, Minnesota, and Texas. 

Across the four states, a total of 4,054 people participated in the projects; the maximum 

length of time that at least some participants received study benefits ranged from 

42 months in Kansas to just 18 months in Hawaii. Each state’s DMIE targeted different 

populations and provided different medical and support services, with the exception that 

all states provided some form of personal case management or coaching to intervention 

group members. Nevertheless, some general findings can be drawn from the states’ 

experiences.

First, targeting the correct point for intervention on the trajectory to full disability for a 

person with a potentially disabling condition is challenging. If the intervention is offered 

too soon, it is not perceived as needed. Conversely, if it is offered too late, it may not be 

sufficient to prevent the progression of the condition to full disability. Miller (2005) found 

that the trajectory from onset of illness to application for Social Security benefits 

averages seven years for men and eight years for women.10 If a person has no 
16

involvement with state or federal insurance or work support systems before reaching the 

tail end of that trajectory, it becomes virtually impossible to stop the trend. Each of the 

four DMIE programs sought to target interventions at the correct point. 

Confirming previous research,

11 the people in the DMIE programs who were most likely 

to be diverted from applying for disability benefits were those with lower incomes. In the 

Texas and Minnesota DMIE programs targeting low-income people, SSA administrative 

records showed that applications for disability benefits were slightly but significantly 

lower among intervention group members than control group members (4.8% and 6.9%, 

respectively).12 Similarly, in Kansas, when only study participants working fewer than 

90 hours per month at baseline were considered, the DMIE intervention led to a 

significantly lower number of disability applications among intervention group 

members.13 Because the SSA administrative data has a significant time lag, the 

Minnesota DMIE evaluators also collected self-reported information from participants 

regarding their applications for federal disability benefits; significantly more control group 

members (14%) than intervention group members (7%) reported applying for benefits.14

In addition to these quantitative results, state evaluators reported important findings 

based on qualitative data. For example, all states used some type of personal contact as 

part of their intervention, such as case management, program navigation, or coaching. 

Across all states, participants reported that these personal services were especially 

important in helping them manage their often complex mental and physical health 

conditions, navigate the health care system, and work toward personal and employment 

goals.15 In Minnesota, participants who were particularly engaged with these personal 

supports had significantly better outcomes with regard to disability applications.16

In Kansas, where participants were predominantly middle income, focus group meetings 

with intervention and control group members revealed that access to adequate health 

care is a much larger driver than cash assistance in the decision to apply for disability 

benefits.17 However, simply having health insurance is not sufficient to delay disability 

applications. Coverage as usual through the high-risk pool in Kansas was associated 

with extremely high premiums, deductibles, and out-of-pocket requirements for 
17

enrollees; this resulted in many people forgoing care despite being insured.18 Thus, an 

important finding as health reform is implemented is that, for people with high-cost 

chronic conditions, insurance must be comprehensive and affordable enough that 

services are used when needed to prevent the progression to disability; in other words, 

coverage with high deductibles and out-of-pocket spending requirements may not serve 

this population well nor prevent their decline to disability. 

Finally, a takeaway message from the DMIE and other federal demonstrations, such as 

the Accelerated Benefits demonstration discussed below, is that a study period of 

three years or less is likely not sufficient to document longer-term trends in health and 

employment. The progression to disability typically occurs over a period of seven to 

eight years;19 demonstrations should be designed to run at least that long, if possible.

Accelerated Benefits Demonstration

The Accelerated Benefits (AB) demonstration, administered by the Social Security 

Administration, was designed to test whether early access to health care coverage and 

related services would improve health and employment outcomes for new SSDI 

beneficiaries. In particular, the demonstration targeted beneficiaries in their 24-month 

waiting period for Medicare coverage who did not have any health insurance, a situation 

encountered by more than one in five new beneficiaries.20 A total of 2,005 people were 

recruited; 8 were determined to be ineligible for SSDI, so 1,997 participants were 

assigned randomly to one of three groups between October 2007 and January 2009, and 

were followed for 15 to 28 months.21 Eligibility criteria included being between the ages 

of 18 and 54 with reasonable expectation of returning to work; at least 18 months until 

Medicare eligibility to receive AB services soon after the onset of disability; and residing 

in one of 53 selected metropolitan areas with large numbers of SSDI beneficiaries. The 

participants were assigned to three groups: (1) control (no health insurance and no 

support services); (2) AB health benefits (health insurance covering up to $100,000 in 

services, with low copayments); and (3) AB Plus (AB health benefits plus medical case 

management, a goal attainment program, and employment and benefits counseling).
18

Overall, the people assigned to the AB and AB Plus groups used more health care and 

reported less unmet medical need than the control group members. They also spent 

less out of pocket on health care and self-reported improved health.22 Those in the AB 

Plus group were more likely to seek employment. Over the life of the study, the AB and 

AB Plus groups did not have significantly higher employment rates than the control

group.23 However, two years after the study ended, continued monitoring of outcomes 

by the Social Security Administration24 indicated that AB Plus group members had a 

5.3 percentage point (almost 50%) increase in employment and an $831 increase in 

annual earnings. These findings are promising and again illustrate the fact that changes 

in the disability trajectory and employment outcomes must be monitored over a longer 

period than that historically funded by federal demonstration projects. 

Both the DMIE and Accelerated Benefits programs illustrate the importance of access to 

comprehensive and affordable health care in encouraging employment. For example, 

some participants cited the addition of wraparound health services plus employment 

supports through the DMIE as influencing their decisions to avoid applying for benefits 

and continue working.25 Such findings about health coverage attitudes emphasize the 

importance of federal policy changes that decouple eligibility for public health insurance 

from eligibility for cash assistance.

Recommendation

Recommendation 1:

Congress should decouple eligibility for health care benefits from eligibility for 

cash benefits. Comprehensive and affordable health insurance alone is sufficient 

to support employment efforts for many people with disabilities or potentially 

disabling conditions. However, this decoupling should be in one direction only: If 

the person needs and qualifies for cash assistance, he or she should also qualify 

for and receive health care benefits.
19

CHAPTER 2. Employer Incentive Mechanisms to 

Reduce SSDI Entry 

Topic and Goal of Chapter

Some people have argued that the most efficient way to forestall applications to Social 

Security disability programs is to enhance employers’ efforts to maintain workers with 

disabilities in the workforce through various strategies.26 This chapter responds to the 

following questions posed by NCD: “What incentive mechanisms could be used to 

encourage employers to increase efforts to provide workplace accommodations for 

employees with disabilities and to encourage more employers to offer private disability 

insurance, thereby avoiding the routine of employees with disabilities going onto SSDI 

rolls? What is revealed from specific evaluation of the potential for using an experience 

rating system whereby employers whose employees have a lower rate of SSDI 

retirements pay lower SSDI payroll taxes?” The goal of this chapter is to review effective 

practices in private disability insurance, payroll tax reform, disability management, and

employer technical assistance that offer promise for policy recommendations.

Outline of Issue

The longer a person is absent from the labor force, the more difficult it is to get a job.27

Strategies to enhance workforce attachment include private disability insurance that 

provides for temporary wage replacement and incentives for employers to invest in 

rehabilitation or accommodations. We evaluate a specific proposal for payroll tax reform 

that applies an “experience rating” to incentivize retention of workers with disabilities, 

and we review other employer strategies, including so-called “disability management” 

approaches that enable employees to continue in some productive capacity. Other 

enhancements that encourage retention include various forms of technical assistance to 
20

help employers address the sometimes complex challenges of accommodating 

disability in their workplaces. 

Research Review Findings

Private Disability Insurance

Workers who experience chronic illness or disability not caused by the work environment

typically progress through various levels or types of support.

28 The sequence often 

begins with paid time off in the form of sick leave and then, if available, employersponsored short-term (or temporary) disability insurance, followed by employersponsored long-term disability insurance, and finally application for publicly funded 

Social Security Disability Insurance (SSDI). This progression is usually only available for 

full-time workers who receive employer benefits, and only if the employer provides these 

benefits. 

Workers’ compensation insurance, designed specifically to address job-related illnesses 

and injuries, is mandated by legislatures in every state. Workers’ compensation benefits 

cover approximately 90 percent of workers in the civilian labor force, compared with 

only about 38 percent of U.S. workers covered by private disability insurance that 

applies when the illness or injury is not job-related.

29 

Short-term disability30 insurance begins when sick leave runs out. This is a discretionary 

employment benefit; although common, it is not universally offered by employers.

31

Considered a wage replacement, these benefits are usually paid as a percentage of 

wages or as a flat dollar amount, typically for a 6- to 12-month period.32 Long-term 

disability insurance provides payments to workers who are unable to work for an 

extended period, usually as a percentage of the person’s previous earnings. Long-term 

disability benefits usually begin after short-term disability runs out or after an identified

waiting period. These benefits generally continue until retirement or a specified age.33

Almost all private long-term disability insurance is coordinated with SSDI benefits. This 
21

means that private long-term disability benefits are reduced dollar for dollar by the 

amount of SSA benefits.34 If it appears that a worker will be unlikely to return to work 

because of the disability, the insurance company very often will encourage the worker to 

apply for SSDI benefits so that the long-term benefits can be reduced or discontinued.

McMahon and colleagues (2000) describe the “progression of disability benefits” 

phenomenon as “predictable and progressive movement through a system of economic 

disability benefits resulting in their ultimate placement into the Social Security disability 

system.”35 The migration of disability claims follows a typical pattern: Within a three-year 

time frame, approximately one in nine (11.5%) employees who receive short-term 

disability benefits progress to long-term disability benefits; from this group, 

approximately one in three (33.9%) progress to SSDI benefits. Systematic movement 

through the progression of disability benefits is clearly related to employee age—

workers over the age of 45 progress from short-term to long-term disability and SSDI 

faster and at considerably higher rates than younger workers.

36

Stay-at-work and return-to-work are preferred options in private long-term disability and 

workers’ compensation programs, and they provide a framework for structuring health 

promotion and vocational rehabilitation interventions. When an employee is deemed

“disabled” from his or her own occupation or previous position with an employer, he or 

she may file a claim for long-term disability benefits. The definition of disability in private 

insurance is based on a contractual definition that is not necessarily the same as the 

Social Security Administration’s (SSA’s) definition. 

In examining the breakdown of private disability benefits by occupation, the data shows 

that a much larger percentage of covered workers are managerial and professional 

(51% for short-term, 57% for long-term) than middle-income workers in sales and 

support positions (36% for short-term, 31% for long-term). The lowest wage workers in 

service occupations are much less likely to have short-term disability benefits (19%) and 

very few have long-term disability benefits (9%). Compared with people who do not 

have disabilities, people with disabilities are less likely to have managerial and 

professional jobs and more likely to have service or production jobs.37 Thus, people with 
22

disabilities are much less likely than people without disabilities to be covered by 

disability insurance.

Mandated Disability Benefits

Five states require all employers to provide short-term disability benefits: California, 

Hawaii, New Jersey, New York, and Rhode Island.38 Analyses of these states’ 

experiences illustrate that employers derive a benefit from state-mandated disability 

insurance.39 Under both workers’ compensation and disability insurance systems, many 

employers have discovered inherent incentives in helping the employee return to work 

quickly. The employee has specific knowledge of the job and work environment that can 

make return-to-work quicker and more effective. The training and experience of that 

employee is an investment, and a return to work will preserve that human capital. Also, 

by retaining the worker, the employer limits the possibility of paying permanent disability 

benefits to him or her.

40 Wage replacement reduces the stress that is often associated 

with a disability. Less stress speeds up recovery time, which reduces absenteeism and 

benefits the employer’s bottom line. The employer receives some reciprocal benefits 

associated with the employee’s ability to maintain some level of consumption while 

avoiding bankruptcy. And society benefits when employees, provided with wage 

replacement through disability insurance, retain their ability to buy essential goods and 

continue to consume.41 

Mandated insurance regulations level the playing field, because all employers incur the 

same basic costs for employees.42 Otherwise, employers who generously provide 

disability benefits without a mandate are at a competitive disadvantage compared with

companies that do not provide them. Insurance rates for group disability insurance 

would be much less costly than individual policies if all workers were covered. In 

addition, there are broader societal benefits to a public policy of compulsory disability

insurance. The five states that require short-term disability insurance are, as a group, 

below the national average for per capita bankruptcy filings compared with states that 

do not have compulsory short-term disability insurance.43
23

Workers who are at risk or employed in hazardous industries are more likely to 

participate in voluntary disability insurance, thus raising the cost for all who are in the 

insurance pool. This is known as the “adverse selection problem.” Requiring all 

employers to offer such coverage—as is currently the case with unemployment 

insurance and workers’ compensation insurance—would eliminate the adverse 

selection problem.44 

Experience Rating

As mentioned above, many employers encourage their employees who are receiving 

long-term disability to apply for SSDI to reduce the employers’ long-term disability 

costs.45 Burkhauser and Daly (2012) have suggested that this incentive could be 

reversed with an “experience rating system” whereby employers’ Social Security 

contribution would depend on the percentage of their employees who end up on SSDI.46

The proposed system is intended to provide incentives for enhancing work retention 

practices and increasing investment in accommodations to help employees stay 

connected to the labor force. 

The rationale is that if the payroll tax were changed from a flat percentage of wages to a 

rate based on the occurrence of disability in that industry or company, employers would 

have more “skin in the game.” By investing in actions that reduce or delay disability 

onset and help their employees continue working, employers would avoid having to pay 

greater costs for the workers who end up on SSDI.

47 Employers would be less likely to 

shift the cost to taxpayers, because they would have more incentive to use return-towork services and provide accommodations to maintain the workers’ employment. A 

recent study of employers who provided accommodations in workers’ compensation 

situations found evidence that employers are more likely to invest in return-to-work 

services and maintain the worker in some type of job if the premiums are experiencerated.48 However there is no empirical evidence to suggest what level of payroll tax 

differential would be an optimal motivator. 
24

Experience rating might be promising when the goal is to reduce SSDI entry among 

employees with a connection to a particular employer. However, a large disadvantage 

would accrue to workers with disabilities who move between jobs and employers. 

Workers today are fairly mobile, and many do not have a strong connection to a single 

employer. These workers would find it much harder to obtain employment if their 

“disability” was associated with a higher cost to their employer, so experience rating

would have a detrimental effect on the hiring of people with disabilities. It is important 

that a reform policy not create a further disadvantage for a vulnerable group. Employers 

would be reluctant to hire people with disabilities if there was potential that their payroll 

taxes would increase. Thus, the huge potential for a negative impact on overall 

employment opportunities for people with disabilities makes experience rating an 

impractical and self-defeating solution to the problem of unemployment. 

Disability Management Strategies

Employers need specific strategies and incentives to retain workers with disabilities and 

prevent or delay early exit from the workforce and progression to the public benefit 

system. Disability management models hold promise as successful options for 

employers, employees, and the government. The process is generally voluntary for the 

employee and, in recent years, a model of partial disability similar to the workers’ 

compensation system has evolved. The partial disability model allows for some cash 

and medical benefits when the person is able to return to work in a part-time or reduced 

capacity. This approach allows the person to remain attached to the workforce longer, 

maintain earnings by combining wages and partial disability benefits, and delay 

application for Social Security benefits.

Disability management can be described in general terms as “a proactive, employerbased approach developed to (a) prevent the occurrence of accidents and disability, (b) 

provide early intervention services for health and disability risk factors, and (c) foster 

coordinated administrative and rehabilitative strategies to promote cost-effective 

restoration and return to work.”49 The primary goals of disability management are
25

improving workforce health and productivity, reducing costs associated with medical care 

and disability benefits, reducing absences and workplace disruption caused by the onset 

of disability among employees, reducing the personal cost of disability for employees, 

and complying with the Americans with Disabilities Act (ADA) and other pertinent 

legislation. Disability management is intended to coordinate disability services and 

programs; however, lack of an integrated approach can lead to employers and insurers 

shifting long-term disability expenses to public benefit programs, specifically SSDI. 

Health Promotion

One of the key components of disability management is health promotion. Perhaps the 

most straightforward way to reduce SSDI entry is to prevent long-term illness or injury. 

Businesses have successfully adopted health promotion strategies that help prevent 

disability and reduce the overall costs of the health insurance plan they provide to their 

employees. Unfortunately, only about 7 percent of employers use health promotion 

program components recommended for successful workplace health promotion.50 For 

this reason, federal initiatives need to invest in programs that promote healthy 

environments in a cost-effective way. Such programs are grounded in behavior change 

theory and are individualized for those with high health risks.51

Because employee retention and prevention of unnecessary early exit from the 

workforce are key features of disability management, the goals are to improve health, 

manage health conditions, resolve disability issues, and bring employees back to 

work.52 To better understand the effectiveness of disability management strategies, it is 

critical to incorporate the demand-side (employer) perspective. 

Retention Strategies

The Society for Human Resource Management (SHRM), in collaboration with Cornell 

University, conducted a survey of its members regarding organizational practices and 

policies related to retention and advancement of people with disabilities.53 The survey 

found that about 81 percent have return-to-work or disability management programs for 
26

employees who are ill or injured or become disabled, and more than half reported 

flexible work arrangements for all employees. Less than half (42%) of the employers 

invite employees to confidentially disclose their disability via staff surveys. The policies 

and procedures the businesses considered most effective were a disability-focused 

employee network related to retention and advancement of employees with disabilities 

(54%), return-to-work or disability management programs (49%), and flexible work 

schedules (47 percent).

Recently the Office of Disability Employment Policy (ODEP) of the U.S. Department of 

Labor summarized promising and emerging practices for the retention of people with 

disabilities identified in federal agency plans submitted under Executive Order 13548.54

This Executive Order aims to add 100,000 people with disabilities to the federal 

government workforce over the next five years. Among the promising practices are 

policies that promote workplace flexibility; support for the use of telework, flex-place, 

and flextime options; review of proposed terminations to ensure that disability 

accommodations are considered; adoption of disability management and prevention 

programs (return-to-work programs); and establishment of a mechanism such as a 

centralized accommodation fund or centralized expertise. 

The ODEP summary results were similar to those of an employer survey conducted in 

Wisconsin as part of the Medicaid Infrastructure Grant (MIG).55 In this survey, 

employers reported practicing flexibility and providing basic accommodations, but they 

said they needed assistance in finding appropriate workplace accommodation 

resources to help them match accommodations to employee needs, especially when 

the needs are complex. WorkSource Wisconsin was created as a demand-side 

organization, designed by employers for employers; however, small employers are

more likely than larger employers to use WorkSource Wisconsin as a resource. 

Technical Assistance in Disability Management

Effective disability management can be very complex and daunting, especially for 

employers that lack robust human resource assets. Habeck and colleagues (2010) 
27

found that employers with at least 1,000 employees are substantially more likely than 

those with 100 or fewer employees to report using disability management strategies

(84% to 5%).

56 This large discrepancy may be due to the costs of implementing 

disability management or to a lack of awareness by smaller employers that these 

options are available. The cost-benefit of disability management is much more likely to 

be realized by larger employers. 

The Disability Management Employer Coalition (DMEC) offers private technical 

assistance resources for small to mid-sized employers. DMEC is a nonprofit employer 

organization with more than 3,500 members; it focuses on integrated disability 

management.57 Research conducted by DMEC among its employer members provides 

compelling evidence to support the promotion and expansion of disability management 

strategies.58 Employers cited the following as the most important factors in retention 

effectiveness: (a) providing development opportunities for employees at all levels; 

(b) seeking the ideas and involvement of employees; and (c) ensuring that employees 

know how their work and performance support the company’s mission. This is 

consistent with previous demand-side research indicating that employers and 

employees have a similar need to understand that accommodations and return-to-work 

services should take place over time and are not limited to one-time interventions.59

Businesses also can network through the United States Business Leadership Network® 

(USBLN). This network helps businesses increase disability inclusion in the workplace, 

supply chain, and marketplace. With strong connections to the U.S. Chamber of 

Commerce and governors’ and mayors’ committees on disability, the USBLN provides 

national recognition for businesses that include people with disabilities in their workforce.

60 

A potential solution to ensure cost-effective disability management services for both 

small and large employers is to engage the State Vocational Rehabilitation Agency 

(SVRA) as a partner in this effort at the federal and state levels. SVRAs typically provide 

services to people with disabilities who are attempting to enter or reenter the workforce. 

In recent years there has been a growing recognition among state vocational 

rehabilitation (VR) programs of the need to focus more on the employer perspective. 
28

The National Employment Team (NET), supported by the Council of State 

Administrators of Vocational Rehabilitation, is a national initiative to help SVRAs refocus

their resources toward employers as customers. Using a “dual customer approach,” the 

NET office provides leadership and technical assistance to SVRAs in developing 

strategies and sharing best practices for the placement and retention of employees with 

disabilities.61 

The dual customer approach is a role expansion for a public agency that has traditionally 

operated from a human services model of assisting people with disabilities. By law, VR 

services must be provided to an eligible person with a disability; thus eligibility 

determination must precede provision of significant services to an employer. This process 

may create barriers to the timely provision of consultation services to an employer. For 

information about how certain states are applying the dual customer approach, see the 

websites listed in the endnotes for Vermont,62 Oklahoma,63 and Wisconsin.

64

Other Resources for Employers 

State Vocational Rehabilitation Agencies are in a position to facilitate solutions to 

employers’ human resource problems, not only through SVRA staff expertise but also 

through partnerships with a sophisticated network of technical and legal services and 

resources. Many employers are not aware of the specialized assistance available from 

the Job Accommodation Network, ADA centers, state assistive technology centers, and 

University Centers of Excellence in Developmental Disabilities. 

The Job Accommodation Network (JAN) has shown that the benefits employers receive 

from making accommodations far outweigh the costs, which are low. JAN is a free 

online network that includes a searchable accommodations database, publications and 

resources, an American Disabilities Act library, news, training, and online or phone 

consultation. Surveys of employers who use JAN have reported benefits such as 

retaining valuable employees, improving productivity and morale, reducing workers’ 

compensation and training costs, and improving company diversity.65 
29

The ADA National Network is another useful resource for businesses.

66 The network is 

composed of 10 ADA centers around the country that provide training and technical 

assistance on the ADA and its implementation. Employers who call a toll-free number 

will be connected to the center in their region. They will receive individualized 

assistance tailored to meet their particular needs and can also take advantage of the 

many free or low-cost training opportunities offered by the ADA centers, such as

webinars and state and regional conferences.

Multiple federal agencies fund programs that provide technical assistance to employers 

on hiring and supporting people with disabilities; however, there is little or no coordination 

of these resources across agencies, and the potential for overlap and gaps is great. 

Public Information Campaigns Focused on Employers

Surveys of employers have found a generally favorable view of hiring and 

accommodating people with disabilities; however, barriers still exist to hiring and retaining 

these employees.

67 These barriers include cost, ignorance, and fear of legal liability. 

Solutions include more awareness of disability and expertise in accommodations. 

Current public information campaigns that focus on hiring people with disabilities target 

both employers and potential employees. For individuals, the focus is typically on job 

readiness, interview tips, job fairs, and how to be available to employers. For 

employers, the focus is on the benefits of hiring people with disabilities. Examples of 

these campaigns include “What Can You Do?” (http://www.whatcanyoudocampaign.org)

and “Think Beyond the Label” (http://www.thinkbeyondthelabel.com). These campaigns 

rarely focus on retaining employees who have a disability. Existing public information 

campaigns could expand by explaining how retaining good workers, even those who get 

sick or injured, makes good business sense. They could also include more information 

on accommodations and on collaborating with accommodation experts—such as ADA 

centers or the Job Accommodation Network—to encourage employers to hire people 

with disabilities and to retain current employees who develop a disability. 
30

Recommendations (numbering continues from previous chapter)

Recommendation 2:

State legislatures should enact mandatory disability insurance for all workers 

similar to requirements for workers’ compensation insurance. 

Recommendation 3:

The U.S. Department of Labor (DOL) should identify and disseminate evidencebased practices in disability management to employers. Priority should be given 

to small employers that do not have specialized human resource staff. The DOL 

could award grants to build capacity among employers to share disability 

management expertise using the Disability Management Employer Coalition as a 

model. 

Recommendation 4:

The U.S. Department of Education, Office of Special Education and 

Rehabilitative Services, Rehabilitation Services Administration should promote 

the dual customer approach in the Vocational Rehabilitation program by issuing 

clarifying guidance to State Vocational Rehabilitation Agencies so that

regulations do not pose barriers to serving employed eligible people with 

disabilities. The goal should be to facilitate employee retention. 

Recommendation 5:

The Administration should assign a federal interagency work group to prepare an 

analysis of potential overlap and gaps in technical assistance to employers on 

accommodating disability in the workplace. Examples of federal programs 

include the Job Accommodation Network, the ADA National Network, Assistive 

Technology Centers, University Centers for Excellence in Disability Research, 

and Protection and Advocacy agencies. The purpose of such an analysis would 

be to better match resources with employer needs, thus increasing job retention 

of employees with disabilities. 
31

CHAPTER 3. Health Care Access for Working People 

with Disabilities: Medicaid Buy-In

Goal of Chapter

Medicaid Buy-In (MBI) programs are optional Medicaid eligibility groups that allow 

people with disabilities to begin or increase employment while maintaining their eligibility

for Medicaid; they often pay a prorated premium for coverage when earnings exceed a 

certain threshold. These programs are intended to act as a work incentive by ensuring 

continued access to Medicaid coverage even when earnings exceed typical eligibility 

limits. Chapter 3 answers these questions: “Based on the most current evidence-based 

research, does the MBI opportunity affect work activity; if so, how? How should the buyin be modified to promote work opportunities for people with disabilities?” The goal of 

Chapter 3 is to identify policy options that would continue existing programs and expand 

health care services that people with disabilities need in order to work. 

Outline of Issue

MBI programs began operating as early as 1997 and currently operate in 45 states 

under one of three federal authorities: the Balanced Budget Act of 1997 (BBA), the 

Ticket to Work and Work Incentives Improvement Act of 1999 (TW-WIIA), or 

section 1115 Demonstration Waivers. Each of these federal statutes provides broad 

rules under which the programs must operate while also giving states some flexibility in 

their rules for eligibility, resource and asset limits and exclusions, cost-sharing policies, 

and work-related requirements and protections. 

Generally, programs run under the TW-WIIA authority have more freedom with regard 

to income and asset rules, with the exception that TW-WIIA limits participation to people 

ages 16–64, while BBA imposes no age restrictions. Notably, however, both laws 
32

prevent states from establishing a minimum number of hours worked or amount earned 

in a given period for basic program eligibility. (Eligibility for the medically improved 

group under TW-WIIA is statutorily defined as working at least 40 hours per month and 

earning at least minimum wage). Variability from state to state in key program design 

features has a large influence on overall enrollment rates, which people enroll, 

employment experiences and earnings of enrollees. For example, enrollees in states 

with income floors and stringent work verification policies tend to have higher rates of 

employment and earnings.68

In 2010, MBI programs nationally had more than 175,000 enrollees.69 In general, MBI 

enrollees tend to work part time and earn less than substantial gainful activity70 (SGA) 

level. In this sense, MBIs have not typically served as programs through which people 

with disabilities quickly and completely leave the federal disability rolls. Nevertheless, 

MBIs provide many important benefits to enrollees and to the states that operate them. 

Enrollees can earn more income and accumulate greater assets while maintaining 

essential health care coverage than would be possible under traditional Medicaid. Thus 

they have opportunity to gradually stabilize their health and economic status and leave 

the rolls when and if their disability and situation allow. Recent research has shown that 

having adequate health insurance makes people with potentially disabling conditions 

less likely to apply for Social Security benefits.71

States, too, realize benefits in operating MBIs by collecting premiums, sales/use tax 

revenue, and income taxes from enrollees who otherwise might not contribute directly to 

the state’s economy. Early evidence also suggests that employment—even part-time 

employment—is associated with better health outcomes for participants, potentially 

reducing state and federal health care expenditures for them.72
33

Research Review Findings

State-by-State Comparison of MBI Policies

Most of the national-level data available on MBI programs comes from data compiled by 

Mathematica Policy Research (MPR). States with Medicaid Infrastructure Grant (MIG) 

funding were required to share data about their enrollees during their funded periods with 

MPR, which lasted through 2011. See Appendix A, Table A-1, for information on states 

operating MBI programs at the writing of this NCD report. Questions answered through 

the MBI programs in Appendix A, Table A-1 include these: “Whose income is counted? 

What is the countable income eligibility limit? What ‘disregards’ apply in determining 

countable income and whether there is a separate unearned income limit?” Appendix A, 

Table A-2, lists policy parameters operating in each state with a MIG program. Questions

in Table A-2 address resource limits, whether retirement accounts are excluded from 

countable assets, whether medical savings accounts are excluded from countable 

assets, and whether approved accounts for employment or independence are excluded. 

Appendix A, Table A-3, outlines state cost-sharing policies such as minimum income 

level and premium calculation method, as well as the income level at which premiums or 

cost shares start, the premium as a percentage of income, payment based on income 

brackets, and separate premiums or cost sharing for earned and unearned income.

Earnings among MBI enrollees have been relatively low, with an average annual 

income nationally of $8,677 in 2009.

73 Substantial variability from state to state can be 

attributed to program design features and local labor markets. Because Medicaid rules 

prohibit states from defining “employment,” enrollees include people with very low 

incomes. Many states have work stoppage protections for the MBIs, which provide a 

grace period during which an enrollee who becomes unemployed remains eligible for a 

given number of months (see Appendix A, Table A-4 for work requirements and work 

stoppage protections). States offer grace periods ranging from two months to two years, 

with most allowing six months. This feature is critical to provide ongoing access to 

health coverage during an exacerbation of a health condition, a disability, or a 
34

temporary lapse in employment, but it must be balanced against the role of MBIs as a 

work program.

Across states, certain subgroups tend to have higher earnings. For example, people in 

the medically improved group achieved mean earnings of $16,458 in 2009, 40 percent

above the Social Security Administration’s SGA limit for that year and 52 percent above 

the federal poverty level for an individual.74 Similar to the overall MBI population, people 

with psychiatric disabilities are the single largest group of people with disabilities 

represented in the medically improved population.75 An analysis found that MBI 

participants with psychiatric disabilities were younger than other participants and more 

likely to be employed and to increase their earnings over time.76 Finally, MBI 

participants with psychiatric disabilities were most likely to enter a trial work period or 

extended period of eligibility.77 

Another review of MBI programs78 showed that younger enrollees who are nonwhite 

and who have not been attached previously to SSI/Medicaid earn more than other 

enrollees. Among the top 10 percent of earners nationally, 60 percent were in the 21–44 

age range, though that group represented only 45 percent of total enrollees. In contrast 

with nondisabled workers, an inverse relationship between age and earnings exists for

MBI enrollees, with a drop of $91 in earnings for each one-year increase in age.

By working at whatever level they are able, MBI enrollees risk proving that they are “not 

disabled.” Should they become unable to maintain employment in the future, their 

participation in the MBI could be used as evidence that they are not qualified for SSDI. It 

is crucial that SSDI remain a viable safety net for people with disabilities who make the 

effort to work; thus, any refinement of the disability definition or determination process 

must include provisions that allow access to benefits even after prolonged periods of 

work activity. The disability definition in Chapter 4 includes this provision. Otherwise, 

people might not take the risk of employment. 

The MBI experience strongly suggests a need to completely delink eligibility for public 

insurance coverage from eligibility for income support, basing eligibility for insurance on 
35

medical need alone.79 As explained above, having access to adequate insurance often 

allows people with potentially disabling conditions to forgo applying for disability benefits 

as a route to needed health care. Indeed, researchers have documented a 

phenomenon they call “health insurance motivated disability enrollment” (HIMDE), 

wherein people with disabilities and high medical costs apply for federal financial 

disability programs primarily, or even exclusively, to obtain health coverage.

80 Delinking 

insurance eligibility from eligibility for cash assistance would not only relieve many of the 

current unsustainable financial strains on the SSDI program, it would also remove 

barriers to increased earnings such as the SSDI cash cliff and the 1619(b) earnings 

threshold.

The cash cliff is a major barrier to increased earnings for MBI participants. Nationally, 

the enrollee majority is for SSDI beneficiaries (71 percent in 2006).81 A study among 

MBI enrollees in Kansas, more than 90 percent of whom receive SSDI benefits, 

indicated that one-fourth would definitely work more if SSDI had a gradual benefit offset 

and an additional one fourth might work more if extra job supports were available, such 

as flexible hours, better health care, transportation, and job training. Those who said

they would work more in such a scenario were statistically more likely to have reported 

turning down a raise or increase in hours in the past to avoid losing benefits, so they 

had concrete experience with the issue.82

Identification of Promising and Best Practices

Promising and best practices for MBIs must be considered in the context of the goals of 

the program for both states and individuals.

83 These goals might be as simple as 

increased income or access to Medicaid for participants or as broad as creating a path 

off of cash benefits. The buy-in programs also must be considered in the context of the 

state’s larger Medicaid program. For example, in states with low protected income 

levels for medically needy individuals, the MBI plays a very important role in providing 

consistent access to Medicaid coverage for people with higher SSDI benefits or 
36

earnings from employment. This consistent access to Medicaid, in turn, can help to 

stabilize health and empower enrollees to increase their work efforts.84 

Regardless of other individual and state goals, policy measures that support increased 

earnings for MBI participants are likely to be beneficial for all stakeholders. And despite 

broad variation in starting points for MBIs from state to state, several program features 

are consistently associated with higher earnings. First, asset limits should be as high as 

possible in the state environment. Currently, 22 states allow assets of $10,000–$15,000 

for an individual or couple; 4 states do not have a ceiling.

85 Having cash assets allows 

for greater financial stability and the ability to deal with emergencies that might 

otherwise result in unemployment; for example, vehicle repairs. Besides cash assets, 

some states allow participants to accumulate funds in retirement accounts, medical 

savings accounts, and individual development accounts (see Appendix A, Table A-2).86

Allowing these additional modes of savings provides extra incentives for participants to 

earn more and plan for the possibility of leaving federal cash assistance programs.

States that have stricter requirements with regard to income verification tend to have 

higher earners. Although federal statutes prohibit states from defining employment, they 

can develop policies for how individuals verify their employment status (see Appendix A, 

Table A-4). For example, the Iowa MBI requires only that an employer provide a signed 

statement. In Kansas, participants must show proof of having paid FICA or SECA (selfemployment) taxes. Perhaps not surprisingly, only 43 percent of Iowa enrollees had 

earnings at a level reported to the IRS, whereas 93 percent of Kansas enrollees did. 

Similarly, in 2005, 60 percent of Iowa enrollees worked 10 hours or less per week, 

compared with 25 percent in Kansas. This report does not recommend an earnings 

floor, but NCD endorses policies that require verification of earned income for MBI 

enrollees.

Another MBI design issue related to earnings is whether spousal earnings are 

considered in determining program eligibility. Arguably, if MBIs are designed to allow a 

person to earn more and potentially separate from federal cash assistance, only that

person’s earnings should be considered. Nevertheless, 18 states consider family 
37

income, which disqualifies many people from participating. See Appendix A, Table A-1 

for a state-by-state comparison of MBI income eligibility criteria in October 2012.

Finally, MBI participants have consistently cited loss of federal and state supports as a 

result of increased income as a reason for limiting their work activity. In particular, they 

report having lost their eligibility for the following programs: Supplemental Nutrition 

Assistance Program (SNAP)/food stamps, Section 8 housing, State Children’s Health 

Insurance Program (SCHIP) coverage for their children, the Low Income Energy 

Assistance Program (LIEAP), and state childcare subsidies.87 It is a testament to the 

success of the buy-in that people are earning enough to lose eligibility for these 

programs, but it is also problematic when $10 in additional earnings results in $100 in 

lost benefits. Better coordination of the Medicaid Buy-In program with other state and 

federal programs is essential to continued increase in work activity.

Role of MBI as a Means to Avoid the Need for SSI/SSDI

As noted above, the large majority of MBI enrollees nationally are SSDI beneficiaries 

who had some attachment to SSA cash benefits before the Medicaid Buy-In. The 

proportion of SSDI beneficiaries and those with previous Medicaid eligibility on MBI 

programs varies from state to state. One state that bucks the national trend is Indiana, 

where fully 35 percent of MBI program enrollees have never received SSI or SSDI cash 

benefits.88 In the Indiana program, enrollees who do not receive cash benefits have 

higher earnings and lower medical costs than other enrollees.89 Clearly, these people

do not encounter the SSDI cash cliff as a barrier to increased earnings. The main issue 

to be resolved is whether their working with a disability will in any way endanger their 

eligibility for cash benefits later, should they need them. 

In Indiana (as in all 11 of the 209(b) states), a person must submit separate applications 

for Medicaid and for SSI benefits.90 This process might have the effect of steering 

people with disabilities away from cash benefits if Medicaid is available separately. In 

this situation, vocational rehabilitation (VR) counselors, Medicaid case workers, and 
38

other disability service providers can potentially be very important in informing 

applicants of their options. In non-209(b) states with MBI programs, a special disability 

determination process is available for people who are already working. However, states 

report difficulty operating a process that simultaneously disregards work activity above 

SGA while considering functional capacity to engage in work.91 The revised definition of 

disability later in Chapter 4 proposes a resolution to this policy dilemma. On the other 

hand, MBIs also provide a vital source of health insurance coverage for new SSDI 

beneficiaries in their 24-month waiting period for Medicare coverage.92 Indeed, the New 

Mexico MBI extends automatic eligibility to these people. 

Possible Effects of the Affordable Care Act (ACA)

Effective September 23, 2010, the ACA mandated that group and individual policies 

include coverage for dependent adult children up to age 26. This provision potentially 

allows young adults with disabilities to enter the workforce part time or with an employer 

that does not provide health insurance, and still access health insurance through a 

parent. (However, the ACA does not require employers to provide health insurance for 

part-time employees.) If the parent’s insurance is adequate to meet the adult child’s 

needs, it essentially provides the opportunity for a private “trial work period” for the 

young adult that does not necessitate any attachment to the Social Security disability 

system. 

In addition to the ACA’s provision for coverage of young adult dependents, both the 

Medicaid expansion and the health insurance marketplaces have the potential to greatly 

expand access to insurance coverage for people with disabilities. A recent simulation 

study93 suggested that at least 2 million people with disabilities would gain new 

coverage through ACA programs. As these authors pointed out, the incredible irony in 

the current U.S. health care system is that a person with a disability is more likely to be 

uninsured if he or she is working, a fact that could change under health reform. Of 

particular importance is the fact that private insurers will no longer be able to deny 

coverage on the basis of a preexisting condition. 
39

Regulations for coverage under the Medicaid expansion are still being developed, and 

final parameters will have a large effect on whether the coverage is sufficient to meet 

the needs of people with disabilities, especially those who need attendant services. A 

study of the Kansas MBI found that when attendant services were not covered, people 

with physical disabilities were less likely to enroll.94 On the other hand, eligibility for the 

Medicaid expansion under the ACA’s modified adjusted gross income (MAGI) option for 

people with incomes up to 138 percent of the federal poverty level (FPL) does not 

consider assets.95 Thus, many people who may not have qualified for Medicaid Buy-Ins 

because of their or their spouses’ assets could potentially obtain Medicaid coverage in 

2014. Federal regulations stipulate that people with disabilities will have the option of

enrolling in a state MBI program with higher income eligibility levels if the program 

would better serve their needs compared with the income eligibility limits under the 

MAGI limits. Currently, 38 state MBI programs have individual or family countable 

income limits above the MAGI option of 138 percent FPL. However, states may also 

choose not to continue Medicaid Buy-In programs, which are optional, after the 

implementation of ACA programs. Finally, it should be noted that some states are 

considering discontinuing or radically weakening their existing MBI programs once the 

Medicaid maintenance-of-effort requirements are lifted in the ACA. There is some 

evidence that this is already occurring in Kentucky and Louisiana.96

Similarly, some people with incomes above 100 percent FPL who are currently 

participating in MBIs might be able to obtain marketplace coverage with premiums that 

are cheaper (because they are subsidized for incomes up to 400 percent FPL) than the 

premiums they pay for MBI coverage. Again, the comprehensiveness of the coverage 

available in the marketplaces will play a major role in whether people with disabilities 

who need attendant services choose to enroll. As Henry, Long-Bellil, Zhang, and

Himmelstein (2011) documented, attendant services are especially important in 

supporting work efforts for many people with disabilities.97 Indeed, lack of coverage for 

attendant services in either expanded Medicaid or insurance through the exchanges 

may prove to be the single largest barrier to obtaining employment for many people with 

disabilities. The Community Living Assistance Services and Supports (CLASS) Act 
40

portion of the ACA, which would have helped pay for these services separately from 

health insurance, has been completely abandoned owing to costs.98

A final consideration related to the ACA and MBIs is the possibility of creating a national 

Medicaid Buy-In program as a means of providing wraparound coverage for people with 

disabilities who are able to obtain coverage through the Medicaid expansion or the 

marketplaces. To the extent that such a national program could provide long-term 

services and supports not available through expanded Medicaid or the marketplace, it 

could play a key role in supporting employment for people with disabilities. Moreover, 

the MBI could be specifically designed to be available separately from disability-related 

cash benefit programs. A national Medicaid Buy-In program would also address the 

current problem of extreme variation in MBI rules and policies among states by creating 

a uniform eligibility standard. Existing state-to-state variation in rules and policies has 

the potential to result in job lock for people with disabilities who want to improve their 

employment. For example, a person who lives in a state with generous income and 

asset limits might be unable or unwilling to accept a higher paying job in a state in which 

the MBI has lower income and asset limits. 

Recommendations (numbering continues from previous chapter)

Recommendation 6:

State legislatures should preserve Medical Buy-In programs that are crucial for 

supporting people with disabilities in working. A state-by-state advocacy effort 

should be launched to preserve and strengthen MBI programs. Efforts should be 

undertaken to incorporate MBI enrollment in state marketplace programs 

established through the Affordable Care Act.

Recommendation 7:

In order to facilitate access to the Medicaid Buy-In program for people who are 

not currently on SSI or SSDI, states should use an independent contractor or 
41

other disability determination evaluation process outside the Social Security 

Administration for applicants.

Recommendation 8:

Concurrent with efforts to preserve Medical Buy-In on the state level, Congress 

should authorize funding and structure of a national MBI program. The program 

should be structured in such a way that it can be used as wraparound coverage 

for people with disabilities who obtain coverage through the Medicaid expansion 

or the marketplaces. The MBI should be specifically designed to be available 

separately from disability-related cash benefit programs. 

Recommendation 9:

Congress should amend the Affordable Care Act so that people with disabilities 

can be eligible for MBI wraparound coverage in addition to subsidies for ACA 

marketplace coverage.

Recommendation 10:

The Administration should Identify and authorize collaboration by the federal 

agencies in forming an interagency work group to propose rule changes in 

federal benefit programs and reduce work disincentives linked to federal program

conflicts. This effort should begin with SSA, CMS, and Department of Labor 

programs.
42

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43

CHAPTER 4. Redefining Disability for SSDI and SSI, 

Medicaid and Medicare

Goal of Chapter

Chapter 4 briefly summarizes evidence that the current Social Security definition of 

disability strongly discourages beneficiaries from working and proposes an alternative 

definition that does not equate disability with a complete inability to work. This chapter 

responds to the following NCD question: “What would a fundamental restructuring of the 

SSI and SSDI system require to align it with the goals of the Americans with Disabilities 

Act; that is, to eliminate the requirement that SSDI applicants declare themselves 

unable to work in order to be eligible for benefits?” The goal of Chapter 4 is to propose 

an alternative disability definition and determination process—applicable to Social 

Security, Medicare, and Medicaid—that is consistent with the Americans with 

Disabilities Act (which encourages optimal work effort) and that will result in enhanced 

productivity and employment by people with disabilities. 

Outline of Issue

The basic definition of disability in the ADA is “with respect to an individual, ... a 

physical or mental impairment that substantially limits one or more major life activities of 

such individual.”

99

This definition incorporates an understanding that has been accepted in virtually all 

conceptual frameworks about disability since Saad Nagi’s development of the 

Disablement Model in the mid-1960s.100 This understanding is that disability is not 

strictly an attribute of individuals but occurs as an interaction between individuals and 

their physical and social environments. This notion has been echoed by Silverstein in 

his New Disability Paradigm.101 Moreover, the prevailing trend has been to give 
44

increased standing to the importance of environmental factors. Thus, there has been 

increased emphasis on function as a basis of assessing disability, including assessment 

not only of individuals’ levels of functional capacity in relevant environments but of how 

environmental features limit functional capacity to perform or participate.102

The statutory definition of disability contained in the Social Security Act has remained

essentially unchanged since 1967:

The inability to do any substantial gainful activity by reason of a medically 

determinable physical or mental impairment which can be expected to 

result in death or which has lasted or can be expected to last for a 

continuous period of not less than 12 months.103

Additionally, the definition specifies that impairments must be— 

Of such severity that he is not only unable to do his previous work but 

cannot, considering his age, education, and work experience, engage in 

any other kind of substantial gainful work which exists in the national 

economy, regardless of whether such work exists in the immediate area in 

which he lives, or whether a specific job vacancy exists for him, or whether 

he would be hired if he applied for work.

104

All initial adult claims for Social Security disability benefits follow a 5-step “sequential 

evaluation process” that is intended to answer the following questions:

● Step 1: Is the individual engaging in substantial gainful activity (SGA)? 

● Step 2: Does the individual have a medically determinable severe impairment?

● Step 3: Does the individual have an impairment(s) that meets or equals a Listed 

Impairment?

● Step 4: Can the individual perform any past relevant work? “Past relevant work” 

is defined as work done at the SGA level, generally within the 15-year period 
45

prior to adjudication of the claim and long enough for the applicant to have 

acquired any skills necessary to do the job.

● Step 5: Can the individual perform other work in the regional or national economy? 

How the Current Definition Discourages Work

The very wording of the disability definition has strong negative effects on the 

employment-related activities and outcomes of both claimants and those who become 

beneficiaries.105 Four features of the SSA definition discourage work effort: (1) disability is 

understood solely as inability to work; (2) inability to perform work must be shown to result 

from one or more impairments directly arising from a medical condition; (3) disability 

under this definition is an all-or-nothing condition, with no partial determination allowable; 

and (4) actual or potential monthly earnings at the SGA level, regardless of the severity of 

the medical condition, threaten eligibility for disability benefits. Thus, work that produces 

or has potential for producing SGA earnings puts access to income support, health care, 

and other in-kind benefits at risk. In the case of health care and long-term support 

services, it is likely that earnings or other income sources are insufficient to meet those 

service needs. These four features, particularly through their interactions, work against 

even modestly successful employment outcomes. 

Research Review Findings

Negative Effects of the Definition on Employment Outcomes

There is much evidence to support the claim that the current Social Security disability 

definition has powerful negative effects on employment efforts and outcomes for both 

claimants and beneficiaries beyond people’s physical or mental limitations or work

environments. This definition of disability, along with the rules and procedures used to 

conduct disability assessments, plants the seeds of failure for future return-to-work 

efforts. The current process requires that people repeatedly deny that they have the 
46

basic abilities to work. Although the definition does allow for work below the level of 

SGA, most applicants and beneficiaries do not make the nuanced distinction between 

SGA-level work and no work whatsoever.

Some studies describe ways in which the disability definition and adjudication process 

influence the behavior of claimants and beneficiaries. Some observers focus on the 

rational decision-making processes of claimants and beneficiaries, even if they use 

incomplete or erroneous information. Other observers emphasize the socialization 

process that forms an individual’s identity as a person who is incapable of working. This 

socialization can generate fear, feelings of dependency, and a sense of powerlessness 

that drive individual behavior. Some literature indicates that many people with 

disabilities choose which identity to portray and to what extent, depending on the 

situation and their goals.106 Even beneficiaries who assert that it is possible to work at 

very high levels acknowledge that it is not easy to do so and, in most cases, requires 

access to health care and long-term support.107 Yet these are the program benefits 

most at risk under the current disability definition.

Multiple surveys of adults who report living with serious disabilities have shown that 

approximately 80 percent indicate a desire to work.108 A far smaller proportion actually 

works. In the 2008 American Community Survey (ACS), just before the onset of the 

Great Recession, 39.5 percent of working-age people with disabilities reported being 

employed.109 Among these, 25.4 percent reported full-time/full-year employment. 

Another 8.7 percent, who were not currently employed, reported looking for work. Thus, 

approximately 48 percent of these ACS respondents could be viewed as being attached 

to the labor force.110 These numbers represent a broader population than adult SSDI 

and SSI beneficiaries and one that is generally believed, on average, to have lesssevere impairments and to face less-severe external barriers to working.

As the ACS does not provide information specifically about Social Security disability 

program participants, other sources must be used to get relevant information. Gina 

Livermore’s work identifying “work-oriented” beneficiaries is among the most 

valuable.111 Livermore differentiates respondents on the 2004 National Beneficiary 
47

Survey (NBS) into two groups on the basis of their answers about employment 

expectations. Approximately 40 percent of respondents met her criteria for classification 

as work-oriented. Examining respondent reports about their work, job training, and 

jobseeking activities, Livermore found that 52 percent of work-oriented beneficiaries 

reported performing at least one of these activities either currently or recently. In

contrast, among the respondents she classified as not work-oriented, only 6 percent

reported performing at least one of these activities. The combined rate across 

beneficiaries was 24 percent.

112 Using matched administrative data about employment 

outcomes for 2004 through 2007, Livermore determined that 

“as expected, work-oriented beneficiaries were significantly more likely 

than other beneficiaries to have earnings. Nearly half (45 percent) of all 

work-oriented beneficiaries had earnings in at least 1 of the 4 years, 

compared with only 15 percent of non-work-oriented beneficiaries. Among 

those with earnings, work-oriented beneficiaries had higher average 

earnings than non-work-oriented beneficiaries ($7,091 versus $5,121), 

were significantly more likely to have worked above the 

annualized SGA level in at least 1 year (28 percent versus 19 percent), 

and were more likely to have earnings in multiple years (80 percent versus 

66 percent).” 

The combined percentage of those beneficiaries with documented employment over the 

four-year period was 27 percent.

113 

These studies confirm not only that a sizable number of beneficiaries profess an interest 

in working but that they have taken significant steps to translate that interest into action, 

albeit not in ways that suggest a strong likelihood of achieving economic independence 

or of leaving benefit status for any protracted period. The studies suggest that the twofifths of beneficiaries who appear to be work-oriented and about a quarter of all 

beneficiaries who had documented employment over the four year period may 

constitute a minimum number of beneficiaries who might seriously attempt work under a 

definition that does not discourage work.

Multiple studies report that people with disabilities who are beneficiaries or claimants 

fear the loss of eligibility for Social Security disability benefits, whether the cash benefit 
48

itself or access to health care. We found no studies that indicated that these concerns 

were nonexistent or minimal. Respondents report concerns about the consequences of 

work activity during initial applications; after award, especially in anticipation of future 

continuing disability reviews (CDRs); and in any reinstatement proceedings.114 SSDI 

beneficiaries who were still in the two-year waiting period before Medicare entitlement

expressed strong concerns about endangering their eligibility through work activity.115 In 

one study, respondents clearly indicated that even if work activity did not negatively 

affect their income support and health care benefits, they worried that it might affect

their eligibility or the cost of other services they received or might seek.116

Amid the generalized fear about the consequences of work, beneficiaries who 

attempted working were especially concerned about making sure they limited their 

hours and earnings. Some people feared that work activity in itself might negatively 

affect their continued attachment to a disability program and many were concerned 

about keeping earnings below some critical level, even if they were not specifically 

aware of the SGA level.117 Multiple articles suggested that respondents had engaged in 

“parking” (intentionally earning income below the SGA level) to keep earnings under 

SGA or what they perceive or fear to be the “danger level.”

118 Studies that have 

attempted to assess the relative strength of various barriers to work have found that the 

perceived effect of the disabling condition is viewed as by far the strongest single 

barrier.119 Concern about losing benefits ranked second or was clustered in a group of 

other frequently cited barriers. Finally, several studies noted that many respondents 

either held misconceptions about some aspect of Social Security policies and 

procedures or recognized serious limitations in their understanding.120 

Problems with the Current Determination Process

The psychological experience of the disability determination process reduces the 

likelihood that a person will return to work if he or she is awarded benefits. It is a 

complex and lengthy process that can last from several months to several years. 

Claimants are required to produce comprehensive evidence to support their attestation 
49

of disability under the SSA standard. This attestation is reiterated frequently, sometimes

under oath. It is very clear to the claimant that disability and capacity to perform work 

competitively are mutually exclusive concepts.

By design, individual characteristics of age, educational attainment, and the history and 

nature of past work favor certain applicants over others. Thus, two people with the same 

medical condition can receive opposite determinations of eligibility on the basis of SSA’s 

expectations about each claimant’s ability to make a vocational adjustment to any work that 

exists in the local, regional, or national economy.

121 This set of intentional, built-in biases 

makes it more likely that older, less-educated claimants will receive benefits, especially if 

their past work involved greater physical or mental capacities and few, if any, special skills.

How the Disability Definition Is Operationalized

Initial eligibility is assessed through a 5-step sequential evaluation process.122 

● Step 1: Is the individual engaging in substantial gainful activity? 

This step is based on the logical assumption that earning at SGA is prima facie 

evidence that one is not disabled.

● Step 2: Does the individual have a medically determinable severe impairment?

At this step, a person must meet a two-part standard. First, he or she must have 

an impairment (or combination of impairments) documented by signs, symptoms, 

and laboratory findings. Second, these impairments must be “severe.” 

● Step 3: Does the individual have an impairment(s) that meets or equals a Listed 

Impairment?

The Listing of Impairments (aka “the Listings”) is a collection of more than

100 medical conditions.123 Each listing is composed of medical signs, symptoms, 
50

and laboratory findings. Documentation that these elements, or their equivalent, 

are present assumes that SGA-level work is not possible and generally ends with 

the award of disability benefits. If these elements are not found, the process 

proceeds to Step 4. It should be noted that the Listings, while written with 

employment as their context, are not primarily employment-centric. Rather, the 

limitations of functioning they describe imply significant limitations of functioning 

in every setting generally applicable to adults. This is an important concept that 

will be discussed more fully later in this chapter.

● Step 4: Can the individual perform any past relevant work?

This step first establishes the claimant’s residual physical and mental functional 

capacity (RFC) for work, then compares that to the demands of past work. The 

RFC determination evaluates the person’s ability to meet the demands of work, 

including physical demands (e.g., lifting, climbing, handling, or fingering); visual 

demands; communicative demands (hearing and speaking); environmental 

demands, (e.g., heat, cold, dust, hazardous machinery); and mental demands 

(e.g., understanding, remembering, applying instructions, interacting with others, 

acting appropriately). Given its complexity and subjective elements, this step 

results in a high degree of decisional variance, which is problematic for SSA, 

Congress, and, most important, the people who go through the process. 

● Step 5: Can the individual perform other work in the national economy? 

In this final step, the decision maker compares the applicant’s RFC with the 

physical and mental demands of jobs other than those he or she has held—jobs 

that exist in “substantial” numbers either locally or nationally. “Local” is defined as 

the entire state of residence and sometimes nearby states as well. 

The fifth step follows a set of vocational guidelines that take into account the person’s 

RFC, age, and education, and the presence or absence of skills developed during the 

performance of any past relevant work that might be useful in performing other jobs.124
51

These rules are contained in tables (vocational grids) that dictate a certain decision if all 

the factors are present and no others come into play. Specifically, the grid prescribes 

that a person is not disabled if he or she retains the capacity to perform other work that 

exists in “significant” quantity somewhere or that the person is disabled if no such jobs 

exist or their incidence is “less than significant” anywhere. The guides do not consider 

such factors as whether there are any openings for these jobs or whether the claimant 

would be hired.

The rules consider several factors to be adverse for a vocational adjustment to other 

work; for example, age 50 and above; less than 12th grade education; or lack of

substantial work in the relevant 15-year period since the onset of a disability. Local 

economic conditions can also play a role, as people with work limitations may be let go 

from their jobs more quickly than unimpaired workers in a poor economy.125 However, 

NCD was informed that this factor is not considered in SSA’s program rules.

A long-term trend in the pattern of disability allowances has been an increase in the 

number of claims made on the basis of symptoms indicating severe disability. As the 

number of claims based on such conditions has increased, so has SSA and DDS

(Disability Determination Services) dependence on functional and symptomatic 

evidence,

126 and these cases are more likely to be considered marginal. This trend 

underscores the urgent need for SSA to enhance research into functional capacity 

assessments. 

As comprehensive as these rules are, they overlook personal and circumstantial 

differences such as inordinate motivation to overcome limitations, unpredictable 

episodic exacerbations and remissions of some medical conditions that are not usually 

subject to variability, availability of part-time work, heavily accommodated work 

conditions, and the availability of certain jobs in the local/regional economy that a 

person might be considered capable of performing. 
52

An Alternative Approach to a Disability Definition

The SSI child determination process is a feasible alternative to the current process used 

for adults, because it is not work-centric; that is, it focuses on the full range of a person’s 

functioning rather than the singular capacity to work. SSA has more than two decades of 

experience performing broad-based functional assessments under the child program’s 

rules. The changes would require a paradigm shift from a definition based on work-related 

factors to one that considers the whole person. Admittedly, this will not be an incremental 

change; however, a disability definition that supports a whole person approach is much 

more likely to motivate substantial increases in employment outcomes.

The proposed definition is as follows: 

A person over the age of 18 will be found to have a disability if a medically 

determinable physical or mental impairment(s) exists that results in 

substantial limitations in the full range of adult functioning, the 

impairment(s) being one expected to result in death or which has lasted or 

can be expected to last for a continuous period of at least 12 months. 

A revised sequential evaluation process can be developed that retains important 

elements of current SSA and DDS processes and practices. The determinants of what 

constitutes a marked or extreme limitation lie in the functional limitations resulting from 

all impairments, including their interactive and cumulative effects. Consideration would 

be given to all the relevant information related to functioning, including signs, symptoms, 

and laboratory findings, as well as functional descriptions from laypersons. 

Table 1 compares the proposed changes in the process for initial adult disability 

determinations to both the sequential process for SSI child determinations and the 

proposed new adult process. For simplicity, Table 1 does not include information about 

continuing disability review processes. Additional information about CDRs is contained 

in Appendix B. Table 1 presents side-by-side questions that are used at each step of 

the eligibility determination process for the current SSI/SSDI adult process, SSI disabled 

child process, and proposed SSDI/SSI adult process.
53

Table 1. Comparison of Initial Eligibility Determination Processes: 

Current Adult, SSI Child, and Proposed Adult

Step

Current SSI/SSDI Initial 

Adult Process

SSI Disabled Child 

Process

Proposed SSDI/SSI 

Initial Adult Process

1 Is the claimant working 

at SGA? If yes, technical 

denial at SSA field office; 

if not, proceed to Step 2.

[SGA step does not 

apply to children]

Is the claimant working 

at SGA? If yes, technical 

denial at SSA field office; 

if not, proceed to Step 2.

2 Does the claimant have 

a severe impairment? If 

yes, proceed to next 

step; if not, the claim is 

denied.

Does child have a 

severe impairment? If 

yes, proceed to next 

step; if not, the claim is 

denied.

Does the claimant have 

a severe impairment? If 

yes, proceed to next 

step; if not, the claim is 

denied.

3 Does the claimant’s 

medical impairment(s) 

meet or equal the intent 

of a Listed Impairment?

If yes, the claim is 

allowed; if not, proceed 

to the next step. 

Does the child’s medical 

impairment meet or 

equal a Listed 

Impairment? If yes, an 

allowance is prepared; if 

not the process 

continues to Step 4.

Does the claimant’s 

medical impairment(s) 

meet or equal the intent 

of a Listed Impairment?

If yes the claim is 

allowed; if not, proceed 

to the next step.

4 After determination of 

residual functional 

capacity (RFC) for work, 

can the claimant perform 

past work either as 

actually performed or as 

is generally performed in 

the economy? If yes, the 

claim is denied; if not, 

proceed to the next step.

Does the child’s 

impairment(s) 

functionally equal a 

Listed Impairment? If 

yes, a favorable 

determination ensues; if 

not, a denial of benefits 

is prepared.

Does the claimant’s 

impairment(s) 

functionally equal a 

Listed Impairment? If 

yes, a favorable 

determination ensues; if 

not, a denial of benefits 

is prepared.

5 Can the claimant—on 

the basis of age, 

education, and elements 

of past work—perform 

any work that exists in 

substantial quantity in 

the regional or national 

economy? If yes, a 

denial of the claim is 

prepared; if not, an 

allowance is prepared. 

[Does not apply] [Does not apply]
54

We have a single overriding purpose in offering a revised Social Security disability 

definition that focuses on the full range of adult functioning rather than the specific 

capacity to work. That purpose is to create an environment that will encourage 

participants in the SSDI and SSI programs to attempt and to a greater extent succeed in 

work efforts consistent with economic self-sufficiency. This goal cannot be achieved 

unless a substantial portion of those who would qualify for benefits under the proposed 

disability definition can be diverted or, preferably, encouraged not to become 

permanently attached to a Social Security disability program.127

Recommendations (numbering continues from previous chapter)

Recommendation 11:

Congress should authorize SSA to identify promising models of assessing adult 

functioning and select one for testing within a given time frame. SSA should be 

directed to convene a workgroup or task force, including stakeholders with 

disabilities, to identify the most promising models of assessing adult functioning. 

Begin with models mirroring the paradigm that underlies the nature and intent of 

the whole person approach to comprehensive assessment. 

Recommendation 12:

SSA should use electronically stored cases to compare adjudication outcomes 

using the new definition with outcomes for previous claims. 

Recommendation 13:

SSA should conduct pilot demonstration projects by adjudicating claims in a sideby-side manner. Experienced claims adjudicators trained in the new process

should develop the evidentiary record as required by each definition (work-centric 

and non-work-centric) and then render simultaneous decisions to the workgroup 

or task force. 
55

Recommendation 14:

SSA should conduct analyses of state experiences with applying a less workcentric definition in their Medicaid Buy-In (MBI) initiatives. For example, 

Wisconsin DDS employed a process for Title XIX and MBI claims based on the 

current SSA definition that involved multiple determinations using the same 

evidentiary materials.

Recommendation 15:

SSA should continue to expand its support for research on how to effectively and 

efficiently assess functional capacity. The International Classification of 

Functioning, Disability and Health can be used as the conceptual starting point in 

developing an assessment framework for adult adjudication.
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57

CHAPTER 5. Changing the Disability Definition: 

Impact on the SSDI/SSI Population

Goal of Chapter

An important issue to consider when contemplating any significant policy change is 

identifying the likely winners and losers among the beneficiary population if the policy 

change is implemented. This chapter responds to the question, “Given the extremely 

diverse populations served by the SSI and SSDI programs, how might the proposed 

SSA reform strategies disproportionately affect, either positively or negatively, particular 

segments of the disability community?” The goal of Chapter 5 is to speculate on the 

implications of the proposed definition of disability (described in the previous chapter) 

for people who are currently eligible for SSI and SSDI benefits, and those who are not 

currently eligible who might benefit.

Outline of Issue

The previous chapter put forward a new definition of disability that does not use inability 

to work as its foundational criterion, so that other return-to-work supports and incentives 

(such as offsets and premiums) can be built around it. By implementing a definition of 

this type, it is hoped that, over time, the cultural understanding of what it means to have 

a disability will change from a person with a disability cannot work to a person with a 

disability faces substantial barriers that limit functioning in multiple areas of living. If 

a person wants to try working, there will be no penalty. Encouragement to work would 

be real. 

There are many challenges in moving from the current definition to a radically different 

one. In this chapter we will discuss the potential harm to those who currently benefit 

from the programs, and the potential benefits to other people with disabilities. 
58

First of all, to limit induced entry by people who would quit their jobs to apply for 

disability benefits, applicants would still have to meet the test of working below the SGA 

level to be eligible at initial application. This precaution is used in several state Medicaid 

Buy-In programs to limit the occurrence of what is sometimes referred to as “the 

woodwork effect.” Ideally, it is combined with a robust Work First policy, through which 

applicants are met with expectations and accompanying services and supports to 

maintain their workforce attachment.

The proposed new definition would not, on its own, result in dramatic changes to the 

primary outcome of the adjudication process; that is, the revised definition would not 

necessarily produce unfavorable decisions. There is nothing in the proposed definition 

that would render a currently eligible claimant ineligible or result in a favorable decision 

for a person who would not now be found eligible. The intent of the new definition is to 

remove the focus on inability to work as the primary standard for disability. To do this, 

we must eliminate the current vocational guidelines (the grids). However, we can create 

a different process using domains of adult functioning similar to those used in the SSI 

child program. The concept of “functional equals” of the Listing of Impairments would 

produce essentially the same results. Under the reform proposal, the assessment of 

functional equivalents of the Listings would rely on multiple domains of living and not 

just the domain of employment.

Populations Likely to Be Affected

Currently, the vocational grids are weighted toward a decision of “disabled” for 

applicants of advanced age who also have a lower educational level, lesser work skills, 

and limited work experience. If the grid were eliminated, this extra weighting would be 

lost to people who are older and less educated, and have fewer work skills or less 

experience. To compensate for this drawback, extra weight could be accorded findings 

of age (over 55), severity in limitations of function, combined with limited skills and 

experience. The Social Security Administration could evaluate how a new definition and 

corresponding process changes would affect eligibility decisions, by applying the new 
59

criteria to the records of current beneficiaries. SSA should have sufficient information to 

conduct this kind of review, given its longstanding evidence-gathering policies that 

stress obtaining a full picture of claimant functioning. By modeling the effect of a new 

definition, SSA could make adjustments (if it wanted to) so that there would be no 

change in the relative proportions of allowance versus denial. 

By itself, the proposed definition would not disadvantage particular groups on the basis 

of type of impairment, and the current Listings of Impairments would not require 

extensive changes. However, if other policies were implemented that required a serious 

return-to-work effort on the part of new beneficiaries, that part of the system could have 

a major impact on which individuals and groups would remain in beneficiary status. 

However, that would also be true if a stringent Work First policy were implemented 

under the current disability definition.

Owing to lower levels of education or job skills, many people with disabilities will not be 

well prepared to benefit from job preparation and supports. Others, who have been 

socialized into a “culture of low expectations,”

128 will not want to take advantage of a 

Work First environment. A similar argument could be made about the differential 

impacts on people with certain impairments if early intervention programs were 

instituted with people who have early signs and symptoms of impairment. The 

characteristics of applicants would change, but it is not possible to predict what those 

changes would look like.

The challenge in moving from the current definition to a revised definition and process is 

how to prevent substantial harm to current beneficiaries. A sudden change to a stricter 

definition could result in immediate personal and family hardship, as well as political 

backlash. Policy safeguards would have to be designed and piloted with gradual phase-in 

periods during which the new definition is applied over time through periodic medical 

reexaminations. For example, once a new policy is enacted, existing beneficiaries who 

undergo a continuing disability review (CDR) could be adjudicated under both the old and 

the new standards. If the beneficiary were found eligible under the old definition but not 

under the new, he or she would continue to receive benefits until the next CDR, at which 
60

time the new definition would be applied. Thus, the first post-revision determination would 

provide a heads-up regarding the nature of subsequent eligibility reviews.

The primary component of an effective post-entitlement return-to-work program has to 

be a system to assess and support beneficiaries in the first year or two after they enter 

the disability program. It would have to be proactive but not punitive in the sense of 

disqualifying people who make reasonable attempts to work but are unable to do so. 

One of the potential benefits of the revised definition is that it is more likely than the 

current definition to show good results from a well-designed early intervention system. A 

more positive response would arise from potential applicants’ expectations that work is 

not incompatible with disability.

Advantages of a New Definition 

The proposed disability definition would offer multiple advantages. Not only would it 

greatly reduce the perceived barriers to increased workforce participation and 

employment outcomes, but it would do so in a manner that is highly consistent with 

values of fairness and consistency, and within the administrative capacities of SSA and 

the state Disability Determination Services (DDSs). These advantages can be 

summarized as follows: 

● The definition and adjudicative process eliminates the emphasis on employment. 

Thus, it promises to greatly reduce both the psychological impediments and 

tangible disincentives experienced by claimants and beneficiaries that constrain 

work effort. 

● The revised definition would not require significant and expensive changes in 

SSA infrastructure or inter-unit relationships, specifically those involving SSA 

field offices (FOs), state DDSs, and the SSA Office of Disability Adjudication and 

Review (ODAR). In particular, it would maintain the case development and 

preparation functions of the FOs and DDSs for administrative hearings.
61

● The proposed process and methodology are familiar to adjudicators, claimant 

representatives, and advocates.

● The disability definition provides for a less jarring transition between childhood 

benefits and adult programs by increasing the coherence of the meaning of 

disability and of the determination process across the lifespan.

People with disabilities who want to work and want the freedom to try working at an 

optimal level will be the winners under the revised definition. People who fear triggering 

a medical review because of their work efforts would no longer have to minimize their 

earning potential. By having an attachment to the Social Security program while they 

are working, people would be able to access health care and long-term supports at 

reasonable costs through the Health Care Marketplace. Under the revised definition, 

more people with disabilities would be living more independently and participating in 

their communities in valued roles.

Recommendations (numbering continues from previous chapter)

Recommendation 15:

SSA and the DDSs should continue to apply the substantial gainful activity (SGA) 

test as the first step for eligibility. Subsequent disability reviews would not use 

earnings level as the sole criterion for continued disability status.

Recommendation 16:

SSA should redesign the assessment process and give extra weight to findings 

of severity in limitations of function for older workers with limited skills and 

experience. For example, similar vocational adversities could be considered a 

“moderate” limitation for a claimant under age 55 and a “marked” limitation for a 

person 55 or older.
62

Recommendation 17:

If the revised definition of disability is adopted, SSA will have to design policy 

safeguards and pilot them with gradual phase-in and periodic reexaminations. 

For example, once a new policy is enacted, existing beneficiaries who undergo a 

continuing disability review (CDR) could be adjudicated under both the old and 

the new standards. If the beneficiary were found to be eligible under the old 

definition but not under the new one, he or she would continue to receive benefits 

until the next CDR, at which time the new definition would be applied.
63

CHAPTER 6. Reenvision the Ticket to Work Program

Goal of Chapter

Chapter 6 assesses whether the Ticket to Work program has achieved its intended 

objectives and what actions, if any, might reinvigorate the program. This chapter 

responds to the following questions: “To what extent has the Ticket to Work initiative 

been evaluated? What lessons can be drawn from the challenges the program has 

faced in achieving its intended goals? If sufficient information is available to make a 

determination, what reforms to the Ticket to Work program are recommended?” The 

goal of this chapter is to summarize the results of a series of program evaluations of the 

Ticket to Work program conducted by numerous researchers over 12 years. 

Outline of Issue

The Ticket to Work (TTW) program was designed to increase employment and earnings 

of SSI and SSDI beneficiaries by expanding choice and diversity of rehabilitation and 

employment service providers using a market-driven approach. The assumption was 

that providing payments directly to service providers (called Employment Networks) for 

employment outcomes of beneficiaries would produce greater choice for beneficiaries 

and competition among providers. The ultimate result would be that more beneficiaries

would become financially self-sufficient and able to go off benefits. One aim of the 1999 

Ticket to Work and Work Incentives Improvement Act (TW-WIIA), the authorizing 

legislation for TTW, was to reduce disability program costs. The following questions 

address the effectiveness of this program: Has the Ticket to Work increased choice and 

diversity of providers? Are beneficiaries who otherwise would not have been employed 

now working? Has the program resulted in net savings to the U.S. Treasury?
64

Research Review Findings

Although the TTW program has been in place for 12 years, the program rules have 

evolved significantly, and other changes have occurred since the initial rollout in 2002. 

Under the original rules, participation was low (about 2%), and only about 9 percent of 

the participants used the new providers; instead, most participants assigned their tickets 

to State Vocational Rehabilitation Agencies (SVRAs).129 In 2008, the Social Security 

Administration implemented major regulatory changes that significantly increased 

incentives for Employment Networks (ENs) to participate. In 2011, SSA responded to 

findings from the Government Accountability Office (GAO)130 that were critical of 

program oversight, introducing administrative changes that tightened requirements for 

organizations seeking to become ENs. This NCD research review compares outcomes 

of the original Ticket to Work program that began in 2002 with outcomes after the

reforms in 2008 and later.

Beneficiary Participation

Participation is measured by the number of “tickets” assigned to an Employment 

Network or to an SVRA acting as an EN. Beneficiaries assign their tickets when they 

seek rehabilitation or employment assistance. In December 2005, the participation rate 

for beneficiaries ages 18 to 40 years was 3.6 percent, compared with 1.9 percent for 

beneficiaries ages 40 to 49, and just 0.6 percent for those 50 and older.131 The size of 

the participant pool from January through December 2005 was 45, 257.

132 

Compared with earlier reports, the 2010 evaluation showed an increase in the 

proportion of younger participants (ages 18 to 24), as well as increases in the number of 

participants who had a psychiatric disability, those who were more likely to be 

dependent on other benefits, and those who were less likely to have ever worked. 

These findings suggest that ENs were beginning to serve people who are perceived as 

harder to serve. 
65

Employment Network Participation

The number of ENs that accepted at least one ticket doubled, from 305 as of June 2008 

to 639 as of December 2009.133 The number that accepted five or more tickets 

increased from 147 in June 2008 to 344 in December 2009, and 40 ENS had accepted 

100 or more tickets. The 2008 regulations did attract more private ENs into the market, 

which had been dominated by SVRAs. However, there is room for private ENs to 

participate in the program at a more substantial level. 

SVRA Participation

There also is need for additional SVRAs to embrace the TTW, either as ENs or through 

Partnership Plus or other options. Under Partnership Plus, both SVRAs and ENs can 

receive payment for serving a beneficiary sequentially. SSA and its contractors heavily 

marketed the Partnership Plus model for SVRAs as the preferred method of 

participation in 2008; however, early data suggested low participation, with only 

786 beneficiaries being served under Partnership Plus as of December 2009.134 Only a 

small number of SVRAs seem to have embraced the approach in a substantial way. 

Altshuler et al. (2009) found multiple barriers to implementation of Partnership Plus, 

including a lack of ENs to partner with, SVRA staff challenges, and a perception that 

SVRA and EN interests are in conflict.135 

Impact of TTW on Employment Outcomes

TTW employment outcomes thus far have been less than promising. Between 2002 and 

2006, between 2 percent and 4 percent of participants left the rolls for one year because 

of employment, compared with 5 percent of nonparticipants. Participants served by 

private ENs were more likely to leave the rolls than beneficiaries served by SVRAs.136

However, this difference can be attributed to the different mandate of the SVRA system, 

which has a statutory requirement to serve beneficiaries and not screen out individuals 

who are unlikely to work at the substantial gainful activity (SGA) level. The same 
66

evaluation was not able to identify any significant impact of the TTW on beneficiary 

earnings or benefit status. The beneficiaries who did work above SGA may have 

achieved this outcome without the benefit of the TTW. The evaluation noted that 

79 percent of beneficiaries who left the benefit rolls because of employment did so 

without enrolling in TTW or an SVRA. In impact analyses as recent as 2013, 

researchers have found no consistent evidence of impact on employment outcomes of 

beneficiaries.137 Any reduction of benefits paid to TTW participants has not offset the 

costs of operating the TTW program to result in savings to the U.S. Treasury. 

Twelve years after the launch of the TTW program, it appears that the program has 

fallen short of achieving its objectives and has had little impact on the service system for 

people with disabilities. The original hope was that a market-based approach would 

bring new employment service providers into the system; however, few new providers 

started serving beneficiaries as a result of the TTW.. 

A significant historical challenge for the TTW program was its implementation at the 

federal level primarily through contractors working directly with beneficiaries and local 

ENs. Under the federal statute, the state governments are not mandated to have a role 

in the TTW program. However, most employment services for people with disabilities 

are administered at the state level through entities such as SVRAs, state mental health 

agencies, state developmental disability agencies, and state departments of labor. As 

federal partners continue working to boost state-level and EN participation, SSA can 

share more recent data about any progress being made.

Recommendations (numbering continues from previous chapter)

Recommendation 18:

Congress and SSA should identify and implement appropriate ways to engage 

the states directly in the TTW program. One option would be to test alternative 

partnership options that might blend TTW more effectively with state funding 

sources. Partnership Plus is a start, but it needs to be improved by encouraging 
67

partnerships between SVRAs and ENs that are collaborative rather than 

competitive.

Recommendation 19:

SSA should explore collaborative strategies with the states to more broadly 

support the return-to-work efforts of SSI/SSDI beneficiaries. Currently, state and

county governments have very little reason to align their efforts with SSA’s efforts 

to help people return to work at substantial levels. The states could potentially 

have a huge influence on how state programs either support or undermine 

return-to-work efforts of SSI/SSDI beneficiaries. 
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CHAPTER 7. Expand Other State and Federal 

Programs That Positively Affect SSA 

Beneficiaries and Work Opportunities 

Goal of Chapter

This chapter responds to NCD’s question, “What changes, if any, did the research 

reveal to other federal programs that would have a positive impact on the health and 

effectiveness of the Social Security programs and work opportunities for SSDI and SSI 

beneficiaries?” Chapter 7 examines system strategies that have been used to support 

particular subgroups of people with disabilities: youth in transition from high school to 

adult living, and people with mental illnesses/psychiatric disabilities. The chapter also 

examines a system improvement strategy that has been used to facilitate infrastructure 

changes in states to improve outcomes for all people with disabilities. The goal of 

Chapter 7 is to identify effective workforce participation practices that should be 

considered for expansion nationally to target specific populations and benefit people 

with disabilities generally.

Outline of Issues

Youth and young adults with disabilities require particular attention because of the

challenges they face during the transition into adult living. One issue is the ongoing 

crisis of persistently low labor force participation rates of people with disabilities. 

Senator Tom Harkin (D-IA) referred to the generation of people with disabilities who 

have come of age since the passage of the American with Disabilities Act (ADA) as “the 

“ADA Generation.”

138 While some people of the ADA Generation have attained 

unprecedented educational levels in inclusive settings, not all young people with 

disabilities have had access to the general education curriculum and opportunities. Yet, 

all have a right to be included as valued members of the American workforce. The 
70

United States is failing to ensure training for all to encourage full inclusion, workforce 

readiness, employment access, appropriate accommodations, and supports for job 

retention. This failure jeopardizes the civil rights of the ADA Generation and does not 

fully leverage their talents. 

Another population group to consider when proposing changes to Social Security is 

people with mental illnesses/disorders or psychiatric disabilities. On the basis of 

available raw data for fiscal year 2008,139 over one-third of all SSDI beneficiaries under 

the age of 50 have mental health disabilities as their primary disability.140 These 

beneficiaries tend to stay on the rolls longer because they are younger when they first

receive SSDI; therefore, the lifetime costs are greater than for other beneficiary 

groups.141 The data on these beneficiaries from 14 and 25 years ago also shows a low 

rate of employment earnings: only 1 percent had any earned income.142 Clearly, more 

current evidence-based research is needed for informed policy and decision making. 

Health care coverage is critical for people with psychiatric disabilities to fund

medications, therapy, counseling, and links to supports such as rehabilitation and other 

services that will help them maintain the functioning essential to participate in the 

workforce. People with psychiatric disabilities are often among the applicants/claimants 

to Social Security disability programs who present the most complex cases.143

Beneficiaries with mental health needs also may be seen by the labor market and 

service providers as hard to serve.144 

The third and final topic in this chapter is a systems change process—the Medicaid 

Infrastructure Grant (MIG) program. Fragmentation in health and human service 

delivery at the community level has long been recognized as a problem for service 

beneficiaries. Multiple sources of funding for health and employment programs for 

people with disabilities create a “silo syndrome.”

145 The silo metaphor is used to 

suggest that agencies interact primarily within their own tower, leading to insular 

thinking, separate organizational cultures, and redundancies. This can be frustrating, 

time-consuming, and discouraging for beneficiaries, especially when services cannot be 

obtained elsewhere. The solution to the silo syndrome is to adopt a collaborative 
71

culture, including interactive processes and tools. The MIG initiative was an attempt to 

address the problem of silos while improving systems of support for people with 

disabilities. 

Research Review Findings 

Youth in Transition

To further the goal of increasing employment of people with disabilities,146 the SSA

Youth Transition Demonstration (YTD) project was designed to coordinate the 

fragmented transition support system; address low individual, family, and employer 

expectations; and raise awareness about available incentives.147 One employment 

barrier is lack of information about the effect of earnings on SSI payments. It was 

anticipated that YTD projects could “provide youths and their families with the skills and 

knowledge necessary to achieve independence and self-sufficiency. In turn, participants 

would become less reliant on SSI and other assistance programs, such as Medicaid, 

thus lowering public costs.”

148 

According to interim reports, the intensity of service and focus on employment was high

in four of the six completed YTD projects. “Three of those projects had positive and 

statistically significant impacts on paid employment during the year following random 

assignment, and two of them also had significant positive impacts on annual earnings. 

[SSA’s evaluation] found no impacts on employment and earnings for the two projects in 

which the intensity of services and focus on employment were low.”

149

According to SSA data, total SSI payments of $7.8 billion in 2010150 and nearly 

$7.5 billion in 2009 were made to more than a million youth ages 13 to 25. Another 

196,000 people ages 25 and under received SSDI with an aggregate value in excess of 

$1 billion.

151 Using SSA records and results from the National Survey of Children and 

Families, researchers found that 41 percent of those who received SSI were employed 
72

at age 19, and only 14 percent were earning more than their annual SSI payment at 

17 years of age.152 

Approximately one-third of childhood SSI recipients lose benefits when they turn age 18 

because they do not meet the adult eligibility criteria or they leave the program for other 

reasons.153 Only 61 percent of people in this category were working at age 19, 

compared with 29 percent of those working who were on SSI. Just 25 percent of the 19-

year-olds earned enough to replace their childhood SSI benefits.154 Also, 39 percent of 

youth ages 19 to 23 had dropped out of high school. Approximately one-fifth of these 

dropout youth had been arrested, and 57 percent did not participate in any 

postsecondary school, vocational rehabilitation program, or employment activity. Of the 

19- to 23-year-olds who no longer received SSI, only 41 percent were employed.155

Reported problems were especially high among the 19- to 23-year-olds with mental 

health needs and behavioral disorders: 45 percent had dropped out of school, 

52 percent reported being expelled or suspended from school, and 28 percent reported 

a previous arrest.156 On the positive side, 49 percent of this age group was employed, 

but only 10 percent earned more than $2,000 per year. Conversely, people with sensory 

impairments had an employment rate of only 31 percent, and 17 percent of them earned 

over $2,000 a year.

157

A systematic review was conducted of 22 studies to identify predictors of improved postschool education, employment, or independent living outcomes for young people with 

disabilities.

158 Results showed 16 indicators that correlated with increased success in 

one or more of those three areas: career awareness, community experiences, exit exam 

requirements/high school diploma status, inclusion in general education, interagency 

collaboration, occupational courses, paid work experience, parental involvement, 

program of study, work study, work experience/paid employment, vocational education, 

self-advocacy/self-determination, self-care/independent living, social skills, and student 

support. In terms of employment, all 16 indicators predicted improvement in post-school 

outcomes. The five indicators associated with improved outcomes in employment only

were community experiences, exit exam requirements/high school diploma status, 
73

parental involvement, program of study, and work study. Finally, four factors showed 

strong correlation with improved employment outcomes: inclusion in a regular education 

classroom, work experience/paid employment, vocational education, and work study.159 

The four factors are confirmed and expanded upon by analysis of the National 

Longitudinal Transition Study-2.160 These results showed that holding a community-based 

job in high school, having more independence in self-care, better social skills, more 

household responsibilities during adolescence, and higher parental expectations related 

to future work were all associated with increased odds of employment after school for 

young adults with severe disabilities. Hemmeter et al. (2009) also found that early work 

experience appears to correlate with post-age-18 employment outcomes. High earners at 

age 19 were most likely to have had high earnings before age 18, while those who were 

not employed were least likely to have had high earnings before age 18.161

Beginning in 2013, Congress and the White House agreed to fund PROMISE 

(Promoting the Readiness of Minors on Supplemental Security Income) grants to 

states.

162 The funding focus is on developing and implementing model demonstration 

projects that promote positive outcomes for youth with disabilities who receive SSI. 

PROMISE is a joint initiative of the Social Security Administration and the

U.S. Departments of Education, Labor, and Health and Human Services.

163 The grants 

were awarded to five large-population states and a consortium of six smaller states. 

These five-year projects are required to use an experimental design and develop 

comprehensive family-focused interventions founded on the best evidence-based 

practices. Each demonstration project must enroll a minimum of 2,000 youth ages 14 to 

16. The projects represent a huge investment in applying the lessons learned from the 

Youth Transition Demonstrations and the Longitudinal Transition Surveys. 

Mental Illnesses/Psychiatric Disabilities

SSA sponsored the Mental Health Treatment Study (MHTS) in which more than

2,200 SSDI beneficiaries from 23 research sites were studied over two years in a 
74

random-assignment experimental design.164 Study participants were recruited from a list 

of SSDI beneficiaries provided by the Social Security Administration. Compared with 

previous studies, a very high percentage of participants had serious physical health 

problems and medical conditions. Researchers found that many of them were not 

receiving mental health services before they enrolled in the study.

165 The researchers 

expected to see worse employment outcomes than previous studies of individualplacement-supported employment.

The study provided intervention group participants with a comprehensive package of 

employment services and health benefits. The package included supported employment 

using the Individual Placement and Support (IPS) model, systematic medication 

management (including facilitation by a care coordinator), behavioral health services 

(such as therapy and substance abuse counseling), benefits counseling, and insurance 

coverage for medication and co-pays. SSA suspended medical CDRs for the intervention 

group for three years from the date of enrollment. In addition, whenever possible the 

supported employment services were provided by the same organization that provided 

the mental health services and thus were well coordinated. The package of services was 

designed to reflect the most effective evidence-based practices at the time.166

The outcomes of the MHTS were unequivocally positive. The intervention group had 

significantly better employment outcomes than the control group in terms of average 

time in employment, weekly earnings, hours per week, and hourly wages.167 Also, the 

intervention group showed significant improvements in mental health status and selfreported quality of life, lower inpatient hospital use, and greater use of outpatient clinic 

services than the control group. Despite greater increases in employment and wages for 

the intervention group, there was no difference between the groups in the percentage of 

participants that earned more than the current SGA level (8%).

168 The outcomes 

provide strong evidence for the effectiveness of a comprehensive set of services, 

including health care subsidies for those who do not have insurance. The implications 

are that significant improvement in employment, mental health, and quality of life is 

possible for SSDI beneficiaries with serious psychiatric disabilities who want to work. 
75

The MHTS added to knowledge about the potential for outcomes that can be achieved 

with access to health care, access to evidence-based supported employment, and 

management of complex, co-occurring physical and mental conditions.169

Medicaid Infrastructure Grants

The Medicaid Infrastructure Grant (MIG) program was established by Section 203 of the 

Ticket to Work and Work Incentives Improvement Act (TW-WIIA).

170 The funding was 

intended to support enhancements to state Medicaid programs and services that would 

result in increased employment for people with disabilities. Funding was initially targeted 

toward implementing Medicaid Buy-In programs and increasing the availability of 

attendant services for workers with disabilities.171 After reaching these goals, states 

were eligible to request funding to support comprehensive employment initiatives that 

bridged services across a wide range of agencies and programs. MIG funding was 

available between 2000 and 2011.

The amount of MIG funds awarded during the initial phase was approximately $500,000 

per state.172 Once a state had a Medicaid Buy-In (MBI) program, subsequent MIG 

funding was based on the yearly service expenditures. Thus, states that invested early 

in growing their MBIs were rewarded with larger grants for infrastructure development. 

For example, in 2008, MIG funding to 21 states ranged from a minimum of $500,000 per 

year to a high of $6.7 million awarded to the state of Wisconsin.173 Overall, 49 states 

plus the District of Columbia and the Virgin Islands received MIG funding for at least 

one year.

174 Funding for the MIG program ended in 2011.

Comprehensive MIG funds gave states the opportunity to innovate in removing barriers

to employment identified through a state-based strategic planning process. The grants

encouraged states to build partnerships and interagency collaboration, to foster 

leadership among people with disabilities, and to test innovative approaches to 

employment for adults and youth with disabilities.175 States used MIG funds to support 

and enhance other federal and state employment initiatives such as Ticket to Work, 
76

benefits counseling, employer partnerships, and education and outreach to 

stakeholders. MIG funding was also used for formative evaluation of demonstration 

projects and for piloting new state-driven initiatives. For examples of state innovations 

developed through MIG funding, see Appendix C—Medicaid Infrastructure Grants in 

Three States. 

A long-term outcome measure used to evaluate the overall MIG initiative was the 

employment rate of people who receive federal disability benefits. An independent 

evaluation of all states showed slightly higher rates in 2009 for SSDI beneficiaries who 

had their benefits withheld or terminated because of substantial work in MIG states (1%) 

compared with non-MIG states (0.7%). The differences were not statistically significant. 

For SSI recipients, the employment rate in 2009 was significantly higher in MIG states 

(7.3%) than in non-MIG states (4.6%). However, because of the wide variability in 

supports for people with disabilities across states, it is not possible to attribute these 

differences to the MIG programs.176 Although there does not appear to be a relationship 

between MIG projects and the rates at which beneficiaries return to work, there are 

myriad examples of concrete structural and policy changes brought about as a result of 

long-term investment by CMS. These mechanisms allowed the states to choose the

paths that worked best in their environments. 

Recommendations (numbering continues from previous chapter)

Recommendation 20:

The Social Security Administration and U.S. Departments of Education, Labor, 

and Health and Human Services should issue a joint report on the results of an 

evaluation of the PROMISE initiative, expanding evidence-based practices for 

youth in transition from school to adult living.

Recommendation 21:

Congress and the White House should initiate a national demonstration of 

evidence-based practice to benefit people with psychiatric disabilities/mental 
77

illnesses. Begin by using a funding approach similar to PROMISE that would 

replicate the Mental Health Treatment Study model. The Substance Abuse and 

Mental Health Services Administration could be the lead agency in ensuring that

interventions are based on evidence-based practices.

Recommendation 22:

CMS should assist reform by reinstituting the Medicaid Infrastructure Grant (MIG) 

approach to funding strategic state-level system improvements. 

Recommendation 23:

CMS should work with states to incorporate benefits counseling within state 

home- and community-based services waivers.
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CHAPTER 8. SSI State Supplementation 

Goal of Chapter

Chapter 8 reviews the interaction of federal and state policies regarding state 

supplemental payments to the SSI program. The question posed by NCD was, “Could 

an incentive mechanism be developed to encourage states to supplement the SSI 

program with state funds? If so, describe the mechanism.” The goal of this chapter is to 

explore the question of whether changes in policies for state SSI supplement payments 

would encourage employment. An unanticipated finding of this research produced a 

recommendation for further study.

Outline of Issue

A focus on state SSI supplements is germane to a discussion about work incentives for 

people receiving federal SSI and SSDI benefits. State supplements not only affect 

recipients of SSI but also have the potential to affect the receipt of SSDI benefits, 

because beneficiaries whose SSDI benefit amount is below the minimum SSI benefit 

level can access SSI. State supplements increase the total SSI benefit amount and raise

the threshold for losing benefits. A person with earnings continues to receive a declining 

amount of SSI payment as his or her earnings increase. Because of the state SSI 

supplement, this person will continue to receive some SSI up to a higher earnings level 

than if the state’s SSI benefit standard were the same as the federal standard. If the total 

SSI benefit amount were increased through supplementation, SSI recipients and dual 

SSI/SSDI beneficiaries would have a stronger incentive to work at higher levels.

Research Review Findings

When they created the Supplemental Security Income program in 1972, Congress and 

the Nixon Administration sought to establish a minimum level of subsistence across the 
80

country for low-income people who were aged, blind, and disabled. This program was 

designed to replace the patchwork of public benefits operated by states.

177 Thus, the 

SSI program replaced individual state-run programs of assistance. State supplemental

payments can trace their origins back to the authorizing legislation of the SSI program. 

Before that time, individual states provided widely varying amounts of cash assistance 

for people with disabilities and the elderly, with various income and asset limits. The SSI 

legislation provided for two types of state supplementation: mandatory and optional. 

Mandatory supplements were required for states whose benefit amounts were greater 

than the federal minimum at that time, to ensure that recipients under the new federal 

system would not receive a lower benefit than they had received before federalization. 

Optional supplements allowed a state to provide benefits in excess of the minimum 

federal benefit amount. Increases in federal benefits over the years have left only a few 

SSI beneficiaries receiving mandatory payments today.178 

Forty-six states and the District of Columbia offer some type of optional SSI state 

supplement.179 Even though a large majority of states provide the optional benefits, a 

number of factors diminish the significance of these supplemental programs. First, only 

23 states provide supplemental payments to the approximately 90 percent of SSI 

recipients who live independently in their own homes.180 The remaining states provide 

supplements to the less than 10 percent of SSI recipients who live in congregate 

housing.181 In 22 states, the SSI supplementation is only for group living 

arrangements—primarily relatively large nonmedical facilities.182 

State supplements also have a decreased impact because states do not adjust 

supplements for inflation.183 Over the years, there have been few changes to the means 

test criteria and no adjustment for inflation in these criteria, meaning that the amount of 

income that will disqualify a person for SSI has fallen in real terms. Simply put, the 

means test has become more restrictive. The real value of the median state 

supplemental payment to people who are living independently declined by about 

60 percent between 1975 and 1997.

184 Meanwhile, the state share of payments to 

individuals declined from approximately 27 percent of total SSI payments in 1975 to 
81

about 11 percent of annual SSI expenditures in 2001.

185 State supplement payments 

have not been a high priority policy focus for disability advocates because the payments 

support people who are living in provider-owned, less independent settings, and the 

supplements are less and less valuable in real dollars.186 

The SSI law was amended in 1974 to provide for an annual cost of living adjustment 

(COLA) in the federal benefit. At the same time, the law prohibits states from decreasing 

their own SSI supplementation benefit levels or total expenditures in response to a cost 

of living increase in the federal benefit. This is referred to as the “maintenance of effort” 

requirement.

Fees for SSA to Administer State Supplements

The SSI legislation permits states to develop an agreement with the Social Security 

Administration (SSA) to administer a state’s SSI supplement; alternatively, states may 

administer the supplement themselves. In the mid-1990s, Congress allowed SSA to 

begin charging a fee for administering state SSI supplements. This has added to the 

cost for states and created a disincentive for them to have an SSI supplement. The SSA

administers state supplements in 13 states and the District of Columbia.187 

State Supplements and Medicaid Eligibility

Existing SSI and Medicaid laws include numerous work incentives designed to achieve 

the overall policy objective of enhancing the level of economic self-sufficiency of people

with significant disabilities by ensuring their ongoing eligibility for health care. The work 

incentives are intended to provide an integrated and seamless package of income and 

health services and supports for a person who attempts to work despite a significant 

disability. Specifically, the work incentive provisions in Section 1619 of SSI law and 

Section 1905(q) of Medicaid law are intended to reduce the uncertainty and risks felt by 

people with disabilities by enabling them maintain a connection to both the SSI income 
82

assistance program and the Medicaid program when they work or increase their level of 

earnings.

To integrate income assistance and Medicaid programs, Congress enabled states to 

provide automatic eligibility for Medicaid to people who receive an SSI payment from 

SSA. An SSI beneficiary can be eligible for Medicaid without having to make a separate 

application to the state or local agency that administers the Medicaid program. A state 

can choose to enter into an agreement with SSA to administer the state SSI 

supplementation program and provide automatic Medicaid eligibility for people who are

not eligible for cash benefits under the federal SSI program but who receive cash 

benefits under the state SSI supplementation program. If a state enters into such an 

agreement, it must use the same income disregards and asset criteria for its 

supplement as the federal SSI program uses. 

SSI recipients retain their eligibility for Medicaid even when they no longer receive any 

federal SSI cash benefits because of higher earnings. There is a seamless continuation 

of Medicaid eligibility without requiring a new application for Medicaid. This automatic 

eligibility for Medicaid occurs by means of an electronic transfer of information from SSA 

to the state Medicaid agency. 

In states without automatic Medicaid eligibility for SSI recipients, the person must make 

a separate application to the Medicaid agency to be determined eligible. A high level of 

communication and cooperation among those who administer these programs at the 

federal, state, and local levels is required to ensure that people with significant 

disabilities receive integrated and ongoing benefits and supports. 

The policy issue facing states is whether the methods chosen for administering the state 

SSI supplementation and the Medicaid program facilitate or impede access to and use 

of work incentives designed to increase the level of economic self-sufficiency of people

with significant disabilities. A recommendation in Chapter 1 favors separating the 

application for cash benefits from that for health care benefits in order to make health 

care benefits available to those who would prefer to forgo cash assistance.
83

Should people with disabilities be expected to work? If yes, then policies targeting 

people with disabilities—particularly the young—would be better focused on education, 

rehabilitation, job training, and accommodation than on increasing or expanding 

transfers. Likewise, for children with disabilities, investing more time, energy, and 

resources to enhance their education and development might be more effective than 

focusing solely on supplementing the income of their households.188 

Recommendations (numbering continues from previous chapter)

Recommendation 24:

Congress should repeal the current provision in federal law that requires SSA to 

charge states a fee to administer their SSI supplements. This action would

encourage an increase in state supplementation and simplify access for SSI 

beneficiaries. 

Recommendation 25:

Consistent with the Supreme Court’s 1999 decision in Olmstead v. L.C., 

Congress should ensure that SSA prohibits the use of SSI supplement programs 

that incentivize congregate or institutional living environments and work with 

states to shift existing arrangements with minimal disruption to remove incentives 

for congregate care in the operation of SSI supplements.

Recommendation 26:

SSA should develop policy that provides waivers permitting states to increase 

their SSI supplements—including pass-through of COLAs—when a state 

describes a plan for using supplements to support beneficiaries in least restrictive 

settings. For example, states could coordinate increases in SSI supplements with 

Money Follows the Person projects.
84

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85

Appendix A. State-by-State Comparison of Medicaid 

Buy-In Provisions189

Table A-1. Medicaid Buy-In Program: Income Eligibility Criteria

● Whose income is counted?

● What is the countable income eligibility limit?

● What disregards apply in determining countable Income?

● Is there a separate unearned income limit?

Table A-2. Medicaid Buy-In Program: Authority, Resource Limits, and 

Exclusions 

● What is the resource limit?

● Are retirement accounts excluded from countable assets? 

● Are medical savings accounts excluded from countable assets? 

● Are approved accounts for employment or independence excluded?

Table A-3. Cost-Sharing Policies: Minimum Income Level and 

Premium Method

● Income level at which premiums or cost shares start

● Premium is a percentage of income

● Payment based on income bracket

● Separate premiums or cost share for earned and unearned income

Table A-4. Work-Related Policies and Protections

● Work requirements

● Protections for temporary loss of employment

● Protections when returning to other eligibility categories

Note: Data for the four tables were compiled by Allen Jensen, George Washington 

University Center on Study of Disability Policy, and updated in October 2013 by Julie 

Delong, University of Utah Center for Public Policy and Administration.
86

Table A-1. Medicaid Buy-In Program: Income Eligibility Criteria

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Alaska Individual and 

spouse for total 

income

Individual for 

unearned income

Family net income 

<250% FPL

Standard SSI disregards Yes

Unearned income

≤$1,252/month

Arizona Individual 250% FPL Disregard unearned 

income and standard SSI 

disregards, including

disregarding IRWEs

No

Arkansas Individual 250% FPL Standard SSI disregards Yes

Unearned income 

must be less than SSI 

standard plus $20

California Individual and 

spouse

$2,000 individual

$3,000 couple for entry 

into program

Standard SSI disregards No cap on assets once 

enrolled

Funds must be in 

separate identified 

account

Colorado Individual 450% FPL Standard SSI disregards No

Connecticut Individual Up to $75,000/year Standard SSI disregards No

Georgia Individual 300% FPL Standard SSI disregards $699/month
Table A-1 (continued)

87

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Idaho Individual ≤500% FPL (excludes 

retirement accounts, life 

insurance) earned income

>15% of total earned and 

unearned income

Standard disregards under 

state Aid to the Aged, 

Blind, and Disabled

No

Illinois Individual and 

spouse

200% FPL net after taxes

Increased to 350% in 

February 2009

Standard SSI disregards 

and work-related 

expenses

No

Indiana Individual 350% FPL Standard Medicaid income 

disregards including IRWE

No

Iowa Individual and 

spouse

250% FPL for family size Standard SSI disregards No

Kansas Individual and 

spouse

300% FPL Standard SSI disregards 

plus IRWEs

No

Kentucky Individual, but 

married if >$45,000

250% FPL SSI Federal Benefit Rate 

plus the standard 

$20 exclusion

Yes

Louisiana Individual 250% FPL Standard SSI disregards No
Table A-1 (continued)

88

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Maine Individual and 

spouse

Up to 250% FPL on total 

income

Up to 100% FPL on 

unearned income

Standard SSI disregards, 

plus additional state 

disregard on unearned or 

earned income of $55.

Yes

Unearned income limit 

is 100% FPL plus $75

Maryland Individual and 

spouse

300% FPL Standard SSI disregards No

Massachusetts

Sec. 1115 

Medicaid Waiver 

N/A No income eligibility 

maximum

N/A N/A

Michigan Individual Pre-enrollment total 

countable income

Unearned may not 

exceed 100% FPL using 

the SSI methodology

Standard SSI disregards Yes

Unearned income limit 

is 100% FPL 

Minnesota Individual No income limit

Must have monthly wages 

or self-employment 

earnings of >$65

1902(r)(2). All earned and 

unearned income ignored

No
Table A-1 (continued)

89

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Mississippi Individual and 

spouse

250% of FPL

Individual limit - 

$4,929/month (meaning 

an unmarried individual)

Couple limit - 

$6,619/month (meaning 

either one or both 

members of the couple 

are disabled and applying 

for Medicaid)

Standard SSI disregards 

and IRWEs

135% of FPL

Gross unearned 

income cannot 

exceed:

Individual limit - 

$1,363/month

Couple limit - 

$1,820/month
Table A-1 (continued)

90

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Missouri Individual and 

spouse 

300% FPL All earned income of the 

disabled worker

Standard $20 income 

disregard

Standard SSI disregards 

of nondisabled spouse’s 

earned income

All SSI payments

Health insurance 

premiums

Up to $75 of dental and 

optical insurance

Impairment-related 

expenses up to 1/2 of 

earned income

Yes

85% FPL after 

disregarding $50 of 

SSDI

Standard $20 income 

disregard

Standard SSI 

disregards of deemed 

income from nondisabled spouse

All SSI payments

Health insurance 

premiums

Up to $75 of dental 

and optical insurance

After taking all the 

disregards in 

determining countable 

income, the net 

income may not 

exceed the net income 

for non-spend-down 

eligibility in Missouri 

Health Net, which is 

85% FPL.
Table A-1 (continued)

91

250% FPL

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Montana

Effective July 1, 

2010

Individual and 

deemed income as 

provided under SSI

Standard SSI disregards + 

PASS

No

Nebraska Individual and 

spouse

Two-part test:

(1) Sum of spouse’s 

earned income and 

applicant’s unearned 

income must be less than 

SSI standard ($698 for an 

individual and $1,048 for 

a couple in 2012)

(2) countable income up 

to 250% FPL (includes 

spousal income)

Standard SSI disregards

Individual’s earned income 

disregarded in part 2 of 

eligibility test

Individual’s unearned 

income if from trial work 

period

Yes

Unless an individual is 

in a trial work period or 

extended period of 

eligibility, SSDI income 

(minus disregards)

must be less than SSI 

income standard.

Nevada Individual 250% FPL earned income

$699 on unearned income

Taxes

Some income disregards 

(not all SSI)

No

(effective October 1, 

2007)

Yes

(before that, 

$699/month)

New Hampshire Individual and 

spouse

450% FPL on earned 

income

Standard SSI disregards No
Table A-1 (continued)

92

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

New Jersey Individual and 

spouse

250% FPL on earned 

income

Up to 100% FPL on 

unearned income 

disregarding SSDI 

benefits received under 

individual’s account (SSN, 

not survivor’s SSN)

Standard SSI disregards Yes

Unearned income 

other than SSDI or SSI

Limit is 100% FPL

New Mexico Individual 250% FPL on earned 

income

Up to $1,226/month on 

unearned

Must earn at least 

$970/quarter

Standard SSI disregards 

and IRWEs and workrelated expenses, 

including cost of health 

insurance

Yes

Unearned income 

<$1,090/month

New York Individual and 

spouse

250% FPL Standard SSI disregards No

North Dakota Family 225% FPL Standard SSI disregards No

North Carolina Individual 450% FPL phased 

implementation open to 

people up to 150% FPL

by December 2009

Standard SSI disregards No
Table A-1 (continued)

93

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Ohio Individual 250% FPL (countable 

income limit is 250% FPL

Income above FPL is 

disregarded up to 

$20,000)

Standard SSI disregards No

Oregon Individual 250% FPL on adjusted 

earned income

All unearned income, 

standard SSI disregards, 

and employment and 

independence expenses 

No

Pennsylvania Individual 250% FPL Standard SSI disregards No

Rhode Island Individual 250% FPL Standard SSI disregards 

including IRWEs

Yes

Unearned income no 

>100% FPL or would 

meet the eligibility 

requirements under 

the state’s Medically 

Needy program 

South Carolina Individual 250% FPL Standard SSI disregard Yes

Unearned income no 

more than federal SSI 

standard
Table A-1 (continued)

94

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

South Dakota Individual 250% FPL Standard SSI disregards No

Texas Individual 250% FPL (excludes 

spousal income; must 

earn $1,090 in qualifying 

SSA quarter before 

application date)

No information No

Utah Individual and 

spouse

250% FPL Standard SSI disregards No

Vermont Individual and 

spouse

Before July 1, 2005: twopart test. 

1. Family net income 

<250% FPL

2. Family net income does 

not exceed either 

Medicaid’s protected 

income level for one or 

the SSI/AABD payment 

level for two, whichever is 

higher, after disregarding 

the earnings, SSDI 

benefits, and any 

veterans disability 

benefits

Standard SSI disregards. 

Disregard all earnings and 

$500 of SSDI for part 2 of 

eligibility test.

Effective July 1, 2005: 

SSDI and veterans 

benefits no longer count 

toward unearned income 

limit

Yes

Unearned income limit 

is the Medically Needy 

Program’s protected 

income level plus 

$500.

No

Effective July 1, 2005, 

SSDI and veterans 

benefits no longer 

counted toward 

unearned income limit
Table A-1 (continued)

95

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Virginia Individual and 

spouse

80% FPL Standard SSI Disregards, 

including IRWEs

Yes

Unearned income limit 

is 80% FPL

Washington Individual and 

spouse, 

but only individual 

income if spouse’s 

income is equal to or 

less than 1/2 of the 

SSI standard

220% FPL Standard SSI disregards 

and IRWEs 

No

West Virginia Individual 250% FPL. Unearned 

income must be equal to 

or less than SSI benefit 

plus $20

Standard SSI disregards, 

including IRWEs

Yes

The individual’s 

unearned income that 

does not exceed the 

SSI federal benefit 

standard plus the 

general income 

exclusion ($20) 

Wisconsin Individual and 

spouse

250% FPL Standard SSI disregards No
Table A-1 (continued)

96

State

Whose Income

Is Counted?

What Is The

Countable Income 

Eligibility Limit?

What Disregards

Apply in Determining 

Countable Income? 

Is There a 

Separate Unearned

Income Limit?

Wyoming Individual $2,022 (applicant’s gross 

countable income only)

No disregards No information

Note: AABD – Aid to the Aged, Blind and Disabled

FPL – Federal Poverty Level 

IRWE – Impairment Related Work Expense

MNIL – Medically needy income level

N/A – Not applicable

SSDI – Social Security Disability Insurance

SSI – Supplemental Security Insurance
97

Table A-2. Medicaid Buy-In Program: Authority, Resource Limits, and Exclusions

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Alaska Balanced Budget Act 

of 1997

$10,000 Individual

$15,000 couple

No No No

Arizona TW-WIIA Basic + 

Medical 

Improvement

No resource limit Yes Yes Yes

Arkansas TW-WIIA Basic $4,000 individual

$6,000 couple

No No Yes

Up to $10,000 in an 

approved account

Interest on account 

not counted toward 

limit

California Balanced Budget Act 

of 1997

$2,000 individual

$3,000 couple

Yes No Individual

development 

accounts (IDAs) and 

deferred 

compensation plans

Colorado TW-WIIA Basic None Yes Yes Yes
Table A-2 (continued)

98

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Connecticut TW-WIIA Basic, 

Medical 

Improvement, BBA 

(added October 

2006)

$10,000 individual

$15,000 couple

Yes Yes Yes

Delaware Insufficient information available

Georgia TW-WIIA Basic $2,000 individual

$3,000 couple

Yes Yes Yes

Idaho TW-WIIA Basic $10,000 individual

$15,000 couple

Yes No No

Illinois TW-WIIA Basic $10,000 (includes 

spousal 

resources)

Increased to 

$25,000 and 

exempts 

retirement and 

medical savings 

accounts

No No No
Table A-2 (continued)

99

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Indiana TW-WIIA Basic $2,000 (excludes 

spousal 

resources)

Yes No Yes

Up to $20,000 as 

approved by state

Iowa Balanced Budget Act 

of 1997

$12,000 individual

$13,000 couple

Yes Yes Yes

Assistive technology 

accounts

Kansas TW-WIIA Basic + 

Medical 

Improvement

$15,000 (includes 

spousal 

resources)

Yes No IDA accounts 

excluded

Kentucky TW-WIIA Basic $4,000 personal 

assets

Yes

Any employer or 

individual 

retirement plan 

approved by the 

Internal Revenue 

Code is 

permissible under 

the program (for 

example, an 

individual 

retirement account)

No — 
Table A-2 (continued)

100

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Louisiana TW-WIIA Basic $25,000 Individual Yes Yes No

Maine Balanced Budget Act 

of 1997

$12,000 (includes 

spousal 

resources)

No No No

Maryland TW-WIIA Basic $10,000 (includes 

spousal 

resources)

Yes

First $4,000 does 

not count toward 

resource limit

No No

Massachusetts 1115 Demonstration 

Waiver

No limit N/A N/A N/A

Michigan TW-WIIA Basic $75,000 individual Yes No No

Minnesota Balanced Budget Act 

(before 10/2000)

TW-WIIA Basic (as 

of 10/2000)

$20,000 individual Yes Yes No

Mississippi Balanced Budget Act 

of 1997

$24,000 Individual

$26,000 Couple

No No No
Table A-2 (continued)

101

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Missouri TW-WIIA Basic + 

Medical 

Improvement

$999.99 for 

individual

$2,000 for couple

No Yes

Up to $5,000 if 

deposited from 

earned income 

while an 

individual is in the 

Medicaid Buy-In 

program

Interest on these 

accounts is also 

excluded

Yes

Up to $5,000 

deposited from 

earned income while 

an individual is in the 

Medicaid Buy-In 

program

Interest on these 

accounts is also 

excluded

Montana Balanced Budget Act 

of 1997

$8,000 individual

$12,000 couple

Yes No PASS accounts 

excluded

Nebraska Balanced Budget Act 

of 1997

$4,000 individual

$6,000 couple

No No No

Nevada TW-WIIA Basic $15,000 individual — — — 

New Hampshire TW-WIIA Basic $24,991 individual

$37,487 couple

No No Yes
Table A-2 (continued)

102

Yes

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

New Jersey TW-WIIA Basic $20,000 individual Yes No No

New Mexico Balanced Budget Act 

of 1997

$10,000 individual Yes No No

New York Balanced Budget Act 

of 1997

$13,800 individual

$20,100 couple

No No No

North Carolina TW-WIIA Basic + 

Medical 

Improvement

$20,880 couple No No

North Dakota TW-WIIA Basic $13,000 couple No No Yes

Up to $10,000 from 

earnings in approved 

plan for achieving 

self-support

Ohio TW-WIIA Basic + 

Medical 

Improvement

$10,580 couple No No No

Oregon Balanced Budget Act 

of 1997

$5,000 individual Yes Yes Yes
Table A-2 (continued)

103

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Pennsylvania TW-WIIA Basic + 

Medical 

Improvement

$10,000 couple No No No

Rhode Island Balanced Budget Act 

of 1997

$10,000 individual

$20,000 couple

Yes Yes Yes

Approved items 

necessary due to 

disability for 

employment (e.g., a 

wheelchair-accessible 

van) are not counted 

as assets

South Carolina Balanced Budget Act 

of 1997

$2,000 individual

$3,000 couple

No No No
Table A-2 (continued)

104

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Texas Balanced Budget Act 

of 1997

$5,000 individual 

1/2 of any jointly 

owned (with 

spouse) assets 

considered

Yes No Yes

Individual may 

deposit up to 50% of 

gross earned income 

during a SSA 

qualifying quarter into 

the account. Funds in 

this account may only 

be used for health 

care or work-related 

expenses. 

Utah Balanced Budget Act 

of 1997

$15,000 couple Yes No No

Vermont Balanced Budget Act 

of 1997

$5,000 individual

$6,000 couple

Disregards assets 

accumulated from 

earnings since 

enrollment

Yes, if from 

earnings after 

enrollment

Yes, if from 

earnings after

enrollment

Yes, if from earnings 

after enrollment
Table A-2 (continued)

105

State Federal Authority

What Is the 

Resource Limit?

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Virginia TW-WIIA Basic $2,000 individual

$3,000 couple

Yes, if from 

earnings after 

enrollment

Yes, if from 

earnings after 

enrollment

Yes, if from earnings 

after enrollment

Washington TW-WIIA Basic + 

Medical 

Improvement

No resources test No resources test No resources test No resources test

West Virginia TW-WIIA Basic + 

Medical 

Improvement

$2,000 ($5,000 

liquid asset 

exclusion)

Yes No Yes

Independence

accounts from a 

recipient’s earnings

Wisconsin Balanced Budget Act 

of 1997

$15,000 individual Yes

Retirement 

accounts initiated 

after Buy-In 

enrollment are not 

counted

Retirement 

accounts existing 

before Buy-In 

enrollment are 

counted

No Yes

Independence 

accounts
Table A-2 (continued)

106

State Federal Authority

Retirement 

Accounts 

Excluded from 

Countable 

Assets?

Medical Savings 

Accounts 

Excluded from 

Countable 

Assets?

Approved Accounts 

for Employment or 

Independence 

Excluded?

Wyoming TW-WIIA Basic $2,022 individual

gross countable 

income only

No No No

Note: IDA – Individual Development Account

MBI – Medicaid Buy-In

N/A – Not applicable

PASS – Plan to Achieve Self Support

SSA – Social Security Administration

TW-WIA – Ticket to Work-Workforce Incentive Act

What Is the 

Resource Limit?
107

Table A-3. Cost-Sharing Policies: 

Minimum Income Level and Premium or Cost-Share Method

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Alaska 100% FPL A sliding scale premium 

as a fixed percentage of 

income

Maximum premium is 

10% of net family 

income

No No

Arizona $500 of monthly 

earned income

Sliding scale premium 

not to exceed 2% of net 

earned income 

Yes

Not in institution $10/mo. at 

$500–$750

Countable earnings after SSI 

disregards increasing by $5 

for each $250 of earnings 

until $35/mo. at $1,750–

$1,846 of earnings

No

Arkansas No premium 

required

Co-payments 

higher than those 

for regular Medicaid 

are required when 

income is above 

100% FPL 

N/A No No
Table A-3 (continued)

108

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

California 200% FPL A sliding scale premium 

based on net countable 

income

For income from 

$1–250% FPL, 

premiums from: 

$20–$250 for an 

individual

$30–$375 for a couple 

Yes

$20/month to a maximum of: 

$250/month for an individual

$25–$375 for a couple

No

Colorado 41% FPL No Yes

41%–133% FPL, $25

134%–200% FPL, $100

201%–300% FPL, $225

301%–450% FPL, $400

No

Connecticut 200% FPL Yes

10% of family income

No No

Georgia A minimum of 

$35/month

No No No
Table A-3 (continued)

109

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Illinois $250 income/month Yes

Premium payment 

categories are calculated 

using a premium table 

(table is based on the 

sum of 7.5% of 

unearned and 2.5% of 

earned income) 

Yes Yes

Premiums are calculated on 

approximations of 7.5% of 

unearned and 2% of earned 

income

Idaho 133% FPL Income 133%–250% 

FPG, $10

250%–500% FPG, 

greater of $10 or 7.5% of 

income above 250% 

FPG 

Income 133%–250% FPG, 

$10

250%–500% FPG, greater of 

$10 or 7.5% of income above 

250% FPG

No

Indiana When individual 

and spouse gross 

income exceeds 

150% FPL

Based on percentage of 

applicant’s and spouse’s 

gross income according 

to family size

Yes

Six brackets with a maximum 

of $187/month when over 

350% FPL

No

Iowa 150% FPL gross 

individual income

Based on sliding scale 

premium schedule with 

18 premium brackets, 

ranging from $34–$660 

Yes

Eleven brackets with monthly 

range from $20–$207

No
Table A-3 (continued)

110

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Kansas 100% FPL Sixteen premium 

amounts based on 

income brackets from: 

$55–$152 for individual

$74–$205 for two or 

more

May not exceed 7.5% of 

income 

Yes

Eight brackets

No

Kentucky 139%–400% FPL Not more than 9.5% of 

income <400% of FPL

Yes — 

Louisiana 150% FPL $80 for 150%–

200% FPL

$110 for 200%–

250% FPL

Yes

150%–200% FPL net 

income, $80/mo.

200%–250% FPL net 

income, $110/mo.

No

Maine 150% FPL net 

family income

No premium if 

paying Medicare 

Part B 

$10 premium for 150%– 

200% FPL

$20 for 200%–

250% FPL 

Yes

150%–<200% FPL, $10 

monthly

200%–<250% FPL, $20 

monthly

No
Table A-3 (continued)

111

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Maryland 100% FPL Countable income to 

100% FPL, no premium

Over 101% FPL–

200% FPL, $25/month

201%–249% FPL, 

$40/month

250%– 300% FPL, 

$55/month

Yes

Countable income up to 

100% FPL, no premium

Over 100% FPL–200% FPL, 

$25/month

Over 200% FPL–250% FPL, 

$40/month

Over 250% FPL–300% FPL, 

$55/month 

No

Massachusetts 150% FPL Premiums based on two 

sliding scales—one for 

enrollees with other 

health coverage and one 

for enrollees without it

Premiums begin at 

100% and increase in 

increments of $5–$16 

based on 10% 

increments of FPL 

Premiums are based on one 

of two different sliding 

scales, one for those with 

and one for those without 

other insurance.

Premiums begin at 

100% FPL and increase in 

increments of $5–$16 based 

on10% increments of FPL, 

and ranging from $15–

$912/month (the upper range 

is at 1000% FPL)

— 
Table A-3 (continued)

112

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Michigan 250% FPL using 

SSI methodology

Based on sliding scale 

ranging from $50–

$920/month

Yes

$50/month up to $33,000 

income

$190/month up to $47,868 

income

$460/month up to $75,000 

income

Countable earned income is 

gross earned income less 

allowable disregards

No

Minnesota All enrollees must 

pay a minimum 

premium of $35 

Premiums based on a 

minimum of $35 or a 

sliding fee scale based 

on income and 

household size

Premium gradually 

increases to 7.5% of 

income at or above 

300% FPL

Must also pay 0.5% of 

unearned income

No maximum premium 

amount 

No Yes

Effective in 2014 MN has an 

active Assisters network to 

help the population address 

cost share and related 

matters. 

https://www.mnsure.org
Table A-3 (continued)

113

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Mississippi For working 

disabled:

$2,983 gross 

earnings for an 

individual or

$3,999 for a couple

The premium is equal to 

5% of the amount 

Medicaid considers to 

be “countable” earnings

Countable earnings are 

less than 1/2 of the 

gross earned income 

amount × 5%

No No

Missouri When gross income 

exceeds 100% FPL

No >100% but <150% FPL pays 

4% of 100% FPL

150%–199% FPL pays 4% of 

150% FPL

200%–249% FPL pays 5% of 

200% FPL

250%–299% FPL pays 6% of 

250% FPL

No

Montana

Effective July 1, 

2010

All must pay some 

premium 

No Yes

100% FPL or less, $35

Up to 150% FPL, $67

Up to 200% FPL, $100

Up to 250% FPL, $135

No
Table A-3 (continued)

114

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Nebraska 200% FPL net 

family income

Sliding scale based on 

income ranging from 2% 

of income (if income is 

200%–210% FPL) to 

10% of income (if 

income is 240%–

250% FPL)

Yes

Five income bands with 

premiums from 2%–10%

No

Nevada All enrollees pay at 

least 5%

Combined net income 

<200% FPL, pay a 

monthly premium of 5% 

of combined net income

Combined net income 

between 200% and 

250% FPL, pay a 

monthly premium of 

7.5% of combined net 

income 

Yes No

New Hampshire 150% FPL net 

family income

Six brackets from $102–

$271 for individuals

Those with gross income 

(including spousal 

income) that exceeds 

$75,000 are required to 

pay the full premium

Yes

Six income bands from $80–

$220 (2002 figures) 

No
Table A-3 (continued)

115

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

New Jersey 150% FPL

Flat rate: 

$25 individual

$50 couple

Flat rate: 

$25 individual

$50 couple 

No No

New Mexico Co-pays required at 

all income levels

No co-pays for 

Native Americans

No premium required

Co-pays higher than 

those for regular 

Medicaid are required at 

all income levels

Clients are responsible 

for keeping track of copays

No No

New York 150% FPL of net 

income

Yes No Yes

7.5% of unearned income, 

plus 3% of earned income

Moratorium on premiums 

until automated premium 

collection and tracking 

available
Table A-3 (continued)

116

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

North Dakota $3,006 Must pay a premium

Beginning July 1, 2009, 

premiums and 

enrollment fees are not 

charged to Native 

Americans due to federal 

statute 

No No

North Carolina Annual enrollment 

fee

No Premiums based on a sliding 

scale 

No

Ohio Premiums when

total family income 

exceeds 150% FPL

Premium charged is 

10% of the difference 

between 150% FPL and 

total income

No No
Table A-3 (continued)

117

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Oregon $651 Premium based on 

sliding scale 

Yes

Participant fees

Countable income

$651–$866.99, $50

$867–2167.99, $100

$2,168 and above, $150

Yes

Cost share is all unearned 

income above SSI income 

standard and special 

maintenance allowance, 

cost of mandatory taxes and 

cost of approved 

employment and 

independence expenses

Premium is on earned 

income—between 2% and 

10% of individual’s earned 

income above 200% of FPL 

and remaining unearned 

income

Pennsylvania All participants pay 

a premium (5% of 

countable income)

Premiums of <$10 

are waived 

Yes

Premium of 5% of 

countable monthly 

income

Option for payroll 

deduction to pay the 

monthly premium

Premiums of <$10 are 

waived 

No No
Table A-3 (continued)

118

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Rhode Island Premiums begin at 

100% FPL

All unearned 

income over the 

state’s Medically 

Needy Protected 

Income Level is

owed as premium

Based on formula 

counting individual’s 

or couple’s earned 

income 

Sliding scale in 

accordance with a 

monthly payment or 

payment formula 

counting a portion of an 

individual’s or couple’s 

earned income 

Yes

Countable earned income 

with premium:

100%–149% FPL, $42

50%–184% FPL, $62

185%–199% FPL, $82

200%–250% FPL, $100

Yes

All unearned income over 

the state’s Medically Needy 

Protected Income Level is

owed as premium

South Carolina No premiums or 

cost sharing

No No No

South Dakota No premiums or 

cost sharing

No No No
Table A-3 (continued)

119

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Texas Unearned income 

above federal SSI 

benefit standard

Earned income 

above 150% FPL

All unearned income 

above SSI federal 

benefit rate ($674 in 

2009), plus $20–

$40/month depending on 

FPL category of earned 

income, with a cap of 

$500/month

$20–$40 maximum with 

no unearned income 

based on FPL category 

of earned income 

Yes

Earnings. premiums: 

150%–185% FPL, $20

186%–200% FPL, $25

201%– 250% FPL, $30

Above 250% FPL, $40

Yes

All unearned income over 

the SSI benefit rate

Utah 100 % FPL Yes

100%–110% FPL, 5% 

premium

111%–120% FPL, 10% 

premium

Over 120% FPL, 15% 

premium

No No
Table A-3 (continued)

120

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Vermont No premiums due 

to administrative 

cost to states

No

Premium eliminated in 

June 2004 

No

Discontinued premiums due 

to administrative cost to state

Previously were as follows:

185%–225% FPL, $10

225%–250% FPL, $12 with

private insurance or $25 with 

no private insurance

No

Virginia No premiums for 

first six months of

program (Jan. 1– 

June 30, 2007)

Premium schedule 

will be established 

on a sliding scale 

based on individual 

enrollee income

Must receive minimum 

wage at the prevailing 

wage rate in the 

community and must 

provide documentation 

that payroll taxes are 

withheld

Self-employment must be 

documented through a 

federal income tax return 

or business records

The applicant’s signed 

allegation is acceptable if 

no other evidence can be 

obtained

A premium schedule will be 

established on a sliding scale 

based on individual enrollee 

income

No

Payment Based on 

Income Bracket
Table A-3 (continued)

121

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Washington $65 earned income

$623 unearned 

income 

Yes

The lesser of 7.5% total 

income or a total of the 

following:

50% unearned income 

above MNIL plus 5% total 

unearned income plus 

2.5% earned income after 

deducting $65 

No Yes

50% of unearned income 

above MNIL ($571) plus 5% 

of total unearned income

plus 2.5% of earned income 

after first deducting $65

Total premium may not 

exceed 7.5% of total income

West Virginia All participants pay 

a $50 enrollment 

fee, which includes 

the first month’s 

premium

Minimum monthly 

premium of $15 

Yes

3.5% of monthly gross 

income with a $15 

minimum amount

Must also pay an 

enrollment fee of $50, 

which includes the first 

month’s premium

No No
Table A-3 (continued)

122

State

Income Level 

at Which 

Premiums or 

Cost Shares Start

Premium Is a 

Percentage of Income

Payment Based on 

Income Bracket

Separate Premiums or 

Cost Share for Earned and 

Unearned Income

Wisconsin Gross individual 

income below 

150% FPL for 

enrollee’s family 

size 

Equal to the sum of 3% 

of an individual’s earned 

income and 100% of 

unearned income, minus 

certain needs and 

expenses and other 

disregards

If the second calculation 

is <$25, this component 

of the premium is zero

No Yes

100% of the individual’s 

unearned income minus 

standard living allowance, 

work expenses, and medical 

and remedial expenses 

3% of individual’s earned 

income

Minimum premium is $25

If calculation is <$25, the 

person pays nothing

Wyoming All participants pay 

a premium

Yes

Premium is 7.5% of total 

gross earnings from 

work, less a $50 

deduction from unearned 

income

No Yes

7.5% of unearned income in 

excess of $600/year (data 

may be impacted by the 

Affordable Care Act

WY had no state 

marketplace at the writing of 

this report)

Note: FPG – Federal Poverty Guidelines

FPL – Federal Poverty Level

MNIL – Medically needy income level

N/A – Not applicable 
123

Table A-4. Work-Related Policies and Protections

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Alaska Must have earned income None None

Arizona Paid for working and paying 

FICA taxes

Guaranteed six months of 

eligibility the first time approved 

for program unless in institutional 

living arrangement

None

Arkansas “Working” means employed in any 

ongoing work activity for which 

income is reported to the IRS

Employment must be verifiable 

with paycheck stubs, tax returns, 

1099 forms, or proof of quarterly 

estimated tax

Yes. Up to six months and states 

that he/she intends to return to 

work

No

California Provide proof of employment 

(e.g., pay stubs or written 

verification from the employer)

Self-employed, or contractor 

provide records (e.g., W-2 forms, 

1099 IRS form)

No No

Colorado Has earned income and is 

working part time or full time, or 

is self-employed

No No

Connecticut Must make FICA contributions May continue Buy-In for one year

after losing employment

Assets in retirement, medical 

savings accounts, and 

approved accounts not counted 

during the individual’s lifetime
Table A-4 (continued)

124

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Georgia “Working” is defined as activity

for which income is reported to 

the IRS

Earnings must be verified by 

paycheck stubs, tax returns, 

1099 forms, etc.

N/A N/A

Idaho Is employed, including selfemployment, and has provided 

the Department of Health and

Welfare with satisfactory written 

proof of employment

N/A N/A

Illinois Employment must be verifiable 

by pay stubs and employer 

documents that show income is 

subject to income tax and FICA

No No

Indiana Employment must be verifiable 

by pay stubs and employer 

documents that show income is 

subject to income tax and FICA 

Yes

May continue Buy-In for one year

after losing employment

None

Iowa Must have earned income Yes

May remain eligible for 

six months after work stoppage

None
Table A-4 (continued)

125

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Kansas Employment must be verifiable 

by pay stubs and employer 

documents that show income is 

subject to income tax and FICA

Yes

May remain eligible for 

six months after work stoppage

None

Kentucky Employed or self-employed Yes

May remain eligible for six 

months after work stoppage

None

Louisiana Employed Yes

May remain eligible for

six months after work stoppage

No

Maine Must have earned income None None

Maryland Employed. Must provide W2, 

paystubs, business ledgers, or 

other evidence of employment

Yes

Remains eligible for up to 

four months after loss of 

employment due to illness or 

reasons beyond the individual’s 

control 

No

Massachusetts Must be employed at least 

40 hours per month, if less must 

have been employed 240 hours 

in the past 6 months

Continued eligibility for up to 

3 months after termination of 

employment if they continue to 

pay premiums

— 
Table A-4 (continued)

126

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Michigan Is employed on a regular and 

continuing basis

Up to 24 months if 

unemployment is the result of an 

involuntary layoff or determined 

to be medically necessary

No

Minnesota Must document earned income 

tax withholding and FICA tax 

withheld

Must have sufficient monthly 

gross earning to qualify for initial 

earned income disregard of 

$65/month to be eligible

If loss of employment is not 

attributable to the enrollee, may 

continue for four months, but 

must pay premiums

— 

Missouri Document that Medicare and 

Social Security taxes paid on 

income 

None None

Mississippi 40 hours each month at some 

type of paid activity

— — 

Montana Require proof of FICA or, if selfemployed, other proof of a 

business 

No None

Nebraska Must have earned income None None
Table A-4 (continued)

127

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

New Hampshire Be working—proven with a pay 

stub or 1099 estimated tax 

statement if the individual is selfemployed

Yes

Buy-In recipients who lose their

jobs through no fault of their own 

can remain on Buy-In for 

12 months, as long as they 

intend to go back to work within 

the next 12 months 

Yes

Earned income accounts—

resources from earnings that a 

person puts into a special 

account will not be counted 

toward any Medicaid eligibility 

for the person’s lifetime

New Jersey Be employed either full or part 

time

None None

New Mexico Proof of wages to show that the 

applicant has earned or expects 

to earn a sufficient amount in the 

current calendar quarter or in the 

last quarter of the previous year 

to have that quarter count toward 

Social Security coverage

($970/quarter in 2006)

Work requirement waived during 

two year waiting period for 

Medicare for SSDI recipients 

None — 
Table A-4 (continued)

128

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

New York Be working A grace period can be for up to 

six months in a 12-month period

Multiple grace periods may be 

granted as long as the sum of 

the grace periods does not 

exceed six months in a 12-month

period

Grace periods may be for 

medical reasons or job loss 

through no fault of the 

participant, and he or she

intends to return to work

No

North Dakota Gainfully employed No No

Ohio Must be working and earning 

income

Program participants will be 

allowed a six-month grace period 

if they lose their job or their 

disability improves

Intention is to allow the person to 

find another job, plan for a 

transition back to regular 

Medicaid, or (in the case of 

medical improvement) plan for a 

transition off Medicaid 

— 

Oregon Must be attached to the 

workforce (defined as earning at 

least $920/calendar quarter)

None None
Table A-4 (continued)

129

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Rhode Island Have proof of active, paid 

employment such as a pay stub 

or—for those who are selfemployed—a quarterly IRS tax 

statement 

Yes

People who lose employment 

may retain eligibility for up to 

four months by paying a 

premium equal to all of their 

unearned income over the 

Medically Needy Income Level 

Yes

Pennsylvania Employed and receiving 

compensation

Yes

Two months 

No

South Carolina Earning at least $830/month None — 

South Dakota Must pay Social Security/FICA 

taxes

None No

Texas A person’s earnings and FICA 

contributions must be enough in 

a calendar quarter to count as a 

Social Security Administration 

qualifying quarter

None No

Utah Pay stubs or a business plan 

needed to verify employment

Yes

A person may continue to qualify 

under the increased assets limit 

for 12 months following job loss

No

Vermont Must have earned income None None
Table A-4 (continued)

130

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Virginia Applicant/enrollee must be 

engaged in competitive 

employment in an integrated 

setting and receive 

compensation at or above the 

minimum wage from which 

payroll taxes are withheld 

(documentation required)

If self-employed, earnings must 

be demonstrated through 

documentation of IRS filings, 

quarterly estimated taxes, 

business records or a business 

plan 

Yes

Enrollees who are unable to 

maintain employment due to 

illness or unavoidable job loss 

can remain in the program as 

unemployed for up to six months 

with the continued payment of 

any required monthly premium

Enrollees who are unable to 

sustain employment and must 

terminate from the program will 

be evaluated expeditiously by 

the local Department of Social 

Services to determine whether

they meet the eligibility 

requirements for any other 

Medicaid covered groups

This evaluation will be completed 

before an enrollee is terminated 

from the program 

Resources accumulated after 

enrollment in the Medicaid BuyIn program from enrollee 

earnings that are held in WIN 

accounts and are no greater 

than the WIN limit will not be 

counted in the eligibility 

determination for other 

Medicaid covered groups

If found eligible and enrolled in 

another Medicaid covered 

group, the individual will have 

up to one year to dispose of 

these funds before they are 

counted toward ongoing 

Medicaid eligibility

Resources accumulated after 

enrollment from earnings held 

in the following IRS-approved 

accounts that have been 

designated as I WIN accounts 

will not be counted in any future 

eligibility determinations: 

retirement, medical savings, 

education and independence 

accounts 
Table A-4 (continued)

131

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Washington Get paid for working; have 

earnings that are subject to 

federal income tax; and have 

payroll taxes taken out of wages, 

unless self-employed

If self-employed, must provide 

tax forms such as IRS Schedule 

SE form or legitimate business 

records

If enrollee loses job after 

enrolling in the state HWD 

program he or she may choose 

to continue enrollment in the 

HWD program through the end 

of their current certification 

period (up to 12 months), if loss 

of employment is due to a health 

crisis or involuntary dismissal, 

they intend to return to work after 

the health crisis has passed or 

continue looking for new 

employment, and they continue 

paying the monthly premium 

based on their remaining income

None 

West Virginia Engaged in competitive 

employment, including selfemployment or nontraditional 

work, and the work results in 

remuneration at or above the 

minimum wage in an integrated 

setting 

Yes

Up to six months from the 

involuntary loss of employment

Individual must maintain a 

connection to the workforce 

None
Table A-4 (continued)

132

State Work Requirements

Protections for Temporary 

Loss of Employment

Protections When Returning 

to Other Eligibility Categories

Wisconsin Must be working or enrolled in an 

employment counseling 

program. May remain in 

employment counseling for up to 

one year

May enroll in health and 

employment counseling (timelimited and restricted to twice in 

a five-year period)

Work requirement may be 

waived for six months due to a 

health setback

None

Wyoming No specific provision in state 

legislation

None None

Note: FICA – Federal Insurance Contributions Act

HWD – Healthcare for Workers with Disabilities

IRS – Internal Revenue Service

MNIL – Medically Needy Income Level

N/A – Not applicable

WIN – Work Incentive account(s)
133

Appendix B. Continuing Disability Review

This appendix describes the continuing disability review (CDR) process which SSA uses 

for periodic reconsiderations of a beneficiary’s disability status. The CDR includes eight 

steps that address whether a person remains eligible to receive federal benefits. For 

adult beneficiaries the notion is that sometimes medical improvement may lessen the

vocational impact of a person’s disability. However, the presumption is that the 

beneficiary remains unable to work unless the converse is documented.

Continuing Disability Review 

For adults in disability status, periodic reviews are triggered by (a) a presumption that 

from a year to three years post-entitlement, medical improvement related to the ability to 

work may have occurred or (b) the passage of time (three to seven years postentitlement) makes it prudent to review the factors that led to disability and determine 

whether they are still present. The process assumes that the person is still under a 

disability; thus, the burden of proof to show that the disability no longer exists lies with 

the SSA decision maker. 

Although beneficiaries are presumed to still have a disability, the CDR process requires 

them to attest that they cannot work substantially; in other words, that their work 

capacity is so limited as to be negligible. The adjudicator must make a two-part 

assessment: (1) Has there been improvement in the impairment(s) that was originally 

the basis for finding that work was not possible? (2) Is/are the change(s) related to the 

ability to work? This step involves the Medical Improvement Review Standard (MIRS). 

This element of the process adds several steps to those applied in initial adjudication, 

stretching the process from five to eight steps. 

Exceptions to MIRS can be applied at several steps in the CDR sequential process, but 

these will not be included in this discussion for sake of simplicity. The adult CDR 

process is as follows. 

Step 1 

Is the individual engaging in SGA? If not, the adjudicator moves to Step 2. If yes, is the 

individual using an SSA work incentive provision known as “trial work”? If not, disability 

has ceased. If the individual is doing trial work, the performance of SGA itself cannot be 

the basis for loss of benefits, and the work itself cannot be considered as past work for 

application of the step concerned with ability to do any past work. However, the 

activities required to perform even trial work can be brought to bear by the decision 

maker. See Step 6. 
134

Step 2

Does the individual have a current impairment(s) that meets or equals a Listed 

Impairment? If yes, disability continues. If not, the process moves to the next step.

Step 3

Has there been medical improvement in the individual’s condition? If no, disability 

continues. If yes, the decision maker moves to the next step.

Step 4

Is the individual’s medical improvement related to his or her ability to work? If not, 

disability continues. If yes, the decision maker moves to the next step.

Step 5

Determine whether any of the exceptions apply. If exceptions from 20 C.F.R. 416.994(b) 

(3) apply, go on to step 6. If any exceptions from 20 C.F.R. 416.994(b) (4) apply, 

disability ends.

Step 6

Are the individual’s current impairments severe? If not, disability ends. If yes, a 

determination is made of the individual’s residual functional capacity.

The activities demonstrated in doing trial work can be used in the formulation of medical 

severity. This is particularly critical for impairments that lack strictly objective findings 

(e.g., EKGs, pathology or surgical findings, X-rays, CT or MRI findings) but instead rely 

on subjective observations relating to such factors as pain, fatigue, anxiety, or 

depression. This element of the disability determination process has a particularly 

negative effect on return-to-work outcomes. Although many beneficiaries know that SSA 

regulations allow SGA without loss of benefit access under the trial work provisions and 

that work well below the SGA limit will not in itself disqualify them from ongoing benefits, 

the many attestations of inability to work they have been required to make haunt 

employment-related decision making. The fear of inadvertently providing evidence of 

medical improvement through the use of SSA work incentives or less than SGA-level 

employment effectively creates a barrier to employment apart from impairment itself.

Step 7 

Can the claimant return to his or her past relevant work, either as he or she performed it 

or as it is performed in the economy? If yes to either question, disability ends. If return 

to past work is not possible, move to Step 8. 
135

Step 8 

Can the beneficiary do any other work that exists in “substantial numbers” (loosely and 

variously defined) in the local or national economy? If yes, disability ends; if not, 

disability continues.

It is the thesis of this presentation that the eventuality of the CDR reinforces 

beneficiaries’ reluctance to reenter the workforce. All the stress, fear, and uncertainty 

experienced during initial adjudication—with its foundation in the definition of disability— 

recur in the review process. While SSA encourages beneficiaries to test out working by 

holding them harmless as far as earnings and SGA issues are concerned, any workrelated functioning they exhibit during these efforts can be used to support a finding that

medical improvement related to the ability to work has been, at least in part, 

documented and the disability standard is no longer met. It is not surprising that a

beneficiary who has previously attested to an inability to work and who is facing the dire 

consequences of an adverse CDR decision—both financially and in terms of health care 

access—might avoid work to preserve the benefits already in hand.

Many people believe that negative interactions with SSA—especially regarding 

reporting earnings, over- and underpayments, and attempting to understand and use

available work incentives—have tended to decrease beneficiaries’ aspirations for work 

and increase their fears of negative consequences, further strengthening the value 

placed on continued attachment to SSDI or SSI.190
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137

Appendix C. Medicaid Infrastructure Grants in Three 

States 

To illustrate the types of changes in state support systems that have been facilitated by 

the Medicaid Infrastructure Grant (MIG) projects, we describe a few exemplary 

initiatives in three states: New York, Connecticut, and Utah.

New York

The MIG in the state of New York was named New York Makes Work Pay (NYMWP). 

This project is a good example of how a large state with a very complex and fragmented 

disability employment service system has attempted to streamline services to improve 

employment outcomes for people with disabilities. Three key problem areas on which 

the NYMWP project focused its efforts were (1) the barriers created by fragmentation in 

policies and service delivery across agencies, (2) low workplace demand for employees 

with disabilities owing to employers’ lack of knowledge, and (3) low participation in 

asset-building strategies by people with disabilities. The strategies New York is using to

address these barriers are a redesigned data system to allow sharing across agencies, 

increasing and incentivizing positive relationships with businesses, and strategies to 

improve the economic self-sufficiency for New Yorkers with disabilities.191

Integrated Data Management System

New York State has seven primary state agencies that provide employment services for 

people with disabilities. Each agency tracks program participation, earnings, and healthrelated data, but there is no tool in place to coordinate employment service delivery 

across multiple public and private agencies and populations. NYMWP developed a 

disability services portal as part of New York’s comprehensive New York Employment 

Services System’s (NYESS) employment case management data system.192 By 

creating a cross-agency data warehouse to manage the data and measure key 

outcomes and indicators, NYESS is attempting to create a virtual “no wrong door” to 

jobseekers and employers. The system will provide the information that decision makers 

need, such as connecting jobseekers to available jobs, generating useful statistics 

linking data to policies and funding, and improving coordination and communication 

across agencies.193

Information Tools for Employers and Employment Support Providers

Businesses need supports to help people with disabilities meet their workplace 

demands; conversely, suppliers of workforce resources need to understand employers’ 

perspectives and needs. The NYMWP concluded that workplace demand for employees 

with disabilities was low because of employers’ limited knowledge about or access to 

the largely untapped pool of jobseekers and workers with disabilities. The project 
138

partnered with the U.S. Business Leadership Network (USBLN) and regional BLNs in 

New York State to develop information tools and disseminate information relevant to 

businesses. Training strategies incorporating online resources include a “Disability as 

Diversity” training series, employer/service provider forums, and just-in-time training for 

businesses provided by Cornell University.194 

Asset-building Strategies

A full 28 percent of New Yorkers with disabilities live at or below the poverty line (2007 

data), and yet very few participate in asset-building strategies to improve their economic 

situation. Earned income tax credits, individual development accounts (IDAs), microloans for entrepreneurship, and other sources of capital are available and can improve 

economic self-sufficiency, but these programs only work if people know about and 

participate in them. Work incentives planning, Medicaid Buy-In for Working People with 

Disabilities (MBI-WPD), and asset accumulation strategies will create new opportunities 

for New Yorkers with disabilities by helping them build resources to improve their 

economic self-sufficiency. Key implementation activities have been to expand the 

number of credentialed benefits and work incentive counselors and increase 

participation in programs to strengthen the economic position of people with disabilities, 

including earned income tax credits, IDAs, and micro-loans.195

Connecticut

Employment Services Maps

The Connect-Ability project in Connecticut used Medicaid Infrastructure Grant funds to 

conduct a needs assessment in 2006 as part of a strategic planning effort. The 

assessment found that a major barrier to effective employment outcomes was lack of 

understanding by providers and consumers of the range of programs and pathways of 

service delivery. Thus, the project developed and updated employment services maps 

for four state agencies (vocational rehabilitation, blind, mental health, and 

developmental services). These maps identify service gaps, overlaps, and points of 

access for consumers to improve coordination across the system. The partnerships 

created as a result of the Connect-Ability project led to enhancement in employment 

processes in all four agencies, most significantly in mental health and developmental 

services, where employment was not a focus before the MIG.196 Connecticut also used 

MIG funding to support data integration across multiple agencies within the Bureau of 

Rehabilitation Services, which has enabled the state to collect and analyze information 

on Medicaid Buy-In participants, consumers of vocational rehabilitation (VR) services, 

and the use of benefit counseling services to improve the employment outcomes of 

people with disabilities.197 
139

Utah

Single Point of Contact for Employers in VR

The Work Ability Utah project (the state’s Medicaid Infrastructure Grant) provides an 

example of how a small state with large expanses of rural areas has addressed 

challenges in employment for people with disabilities. In its attempt to improve 

employment outcomes for people with significant disabilities, the Work Ability project 

decided to focus on the disconnect between the labor supply of people with disabilities 

and employer demand for employees. In collaboration with the Vocational Rehabilitation 

program in Utah, Work Ability created the job network called PWDNET to serve both

businesses and jobseekers with disabilities. It was felt that the VR agency needed a 

person internally to provide a “business perspective,” so the agency created a position 

for a business relations specialist to serve as the single point of contact for employers to 

connect with qualified candidates with disabilities who are seeking employment.198 The 

business relations specialist conducts regular job fairs at which employers and 

jobseekers can meet and connect. Businesses are provided with individualized support 

and training on disability issues, accommodations in the workplace, effective 

recruitment strategies, assistive technology, retention practices, tax credits, and the 

Americans with Disabilities Act. Customized workshops are held at employers’ request, 

and consultation on individual workplace accommodations is provided. On the supply 

side, benefits counseling is provided to jobseekers, and job openings are sent via email 

to a statewide list of employment providers. Employers who use these services are 

highly satisfied. More than 350 Utah businesses participate in PWDNET, and the 

number is increasing steadily.199 The local offices of several international corporations 

have adopted these practices at the corporate level. Both Convergys and United Parcel 

Service (UPS) are examples of this Utah-to-national practice.

The Utah business relations model is being replicated in many other states, with the 

help of the National Employment Team (the NET) of the Council for State 

Administrators of Vocational Rehabilitation (CSAVR). This national office coordinates 

with business consultants in 80 SVRAs in the United States. The NET supports a “dual 

customer” approach to meeting the employment needs of businesses. For VR 

consumers, the NET provides access to national employment opportunities; for 

businesses, it provides access to job applicants and to support services from the 

SVRAs and partners. The national office also facilitates the sharing of employment 

resources, best practices, and business connections among the states.200 This 

collaborative effort is another example of an initiative begun with MIG funds that has 

become an ongoing program.
140

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141

Endnotes

1 National Council on Disability, “Transition and Post-School Outcomes for Youth with 

Disabilities: Closing the Gaps to Post-Secondary Education and Employment” (2000), 

http://www.ncd.gov. 

2 Social Security Advisory Board, “Aspects of Disability Decision Making: Data and 

Materials” (2012), http://www.ssab.gov/Publications/Disability/GPO_Chartbook_FINAL_

05212012.pdf. 

3 National Council on Disability, “The Social Security Administration’s Efforts to Promote 

Employment for People with Disabilities: New Solutions for Old Problems” (2005), 

http://www.ncd.gov. 

4 Organization for Economic Co-operation and Development, “Sickness, Disability and 

Work: Breaking the Barriers. A Synthesis of Findings across OECD Countries” (2010), 

http://ec.europa.eu/health/mental_health/eu_compass/reports_studies/disability_

synthesis_2010_en.pdf. 

5 David R. Mann and David C. Stapleton, Mathematica Policy Research, Center for 

Studying Disability Policy, “Fiscal Austerity and the Transition to Twenty-First Century 

Disability Policy: A Road Map” (2011), http://www.mathematica-mpr.com/ourpublications-and-findings/publications/fiscal-austerity-and-the-transition-to-twentyfirstcentury-disability-policy-a-road-map. 

6 David Wittenburg and Pamela Loprest, Urban Institute, “A More Work-Focused 

Disability Program? Challenges and Options” (2004), http://www.urban.org/

uploadedPDF/411013_disability.pdf. 

7 Monroe Berkowitz, “Improving the Return to Work of Social Security Disability Beneficiaries,” 

in Disability, Work, and Cash Benefits, ed. Jerry L. Mashaw, Virginia P. Reno, Richard V. 

Burkhauser, and Monroe Berkowitz (Kalamazoo, MI: W.E. Upjohn Institute for Employment 

Research, 1996), 331–53; Bryon R. MacDonald and Megan O’Neil, “Being American: The 

Way out of Poverty; Poverty and Disability in the U.S.” (2006), http://wid.org/publications/

being-american-the-way-out-of-poverty-poverty-and-disability-in-the-u-s; David H. Autor and 

Mark Duggan, “Supporting Work: A Proposal for Modernizing the US Disability Insurance 

System” (Washington, D.C.: Center for American Progress and The Brookings Instution 

Hamilton Project, 2010), http://www.brookings.edu/research/papers/2010/12/disabilityinsurance-autor; Richard V. Burkhauser and Mary C. Daly, The Declining Work and Welfare of 

People with Disabilities: What Went Wrong and a Strategy for Change (Washington, DC: AEI 

Press, 2011), 103; Jeffrey B. Liebman and Jack A. Smalligan, “An Evidence-Based Path to 

Disability Insurance Reform,” in 15 Ways to Rethink the Federal Budget (Washington, D.C.: 

The Brookings Institution Hamilton Project, 2013), http://www.hamiltonproject.org/papers/an_

evidence-based_path_to_disability_insurance_reform/. 
142

8 U.S. Department of Health & Human Services, Centers for Medicare & Medicaid 

Services (CMS), “Program Announcement: Demonstration to Maintain Independence 

and Employment” (2007), http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/ActiveProjectReports/Active-Projects-ReportsItems/CMS1187325.html. 

9 CMS, “Program Announcement.” 

10 National Council on Disability (NCD), “Early Intervention and Diversion Strategies as 

a Means for Stemming the Growth in Social Security Disability Programs” (2005), 

http://www.ncd.gov. 

11 NCD, “Early Intervention;” Todd C. Honeycutt, “Program and Benefit Paths to the 

Social Security Disability Insurance Program,” Journal of Vocational Rehabilitation 21, 

no. 2 (2004): 83–93.

12 Denise Whalen et al., Mathematica Policy Research, “Demonstration to Maintain 

Independence and Employment” (2012), http://www.mathematica-mpr.com/publications/

PDFs/Disability/DMIE_Final.pdf. 

13 Ibid. 

14 Karen W. Linkins et al., “Influencing the Disability Trajectory for Workers with Serious 

Mental Illness: Lessons from Minnesota’s Demonstration to Maintain Independence and 

Employment,” Journal of Vocational Rehabilitation 34 (2011): 107–118. doi: 

10.3233/JVR-2010-0539.

15 Rebecca Rude Ozaki et al., “Personal Navigation, Life Coaching, and Case 

Management : Approaches for Enhancing Health and Employment Support Services,” 

Journal of Vocational Rehabilitation 34 (2011): 83–95. doi: 10.3233/JVR-2010-0537.

16 Linkins et al., “Disability Trajectory.” 

17 Shawna L. Chapman, Jean P. Hall, and Janice M. Moore, “Health Care Access 

Affects Attitudes About Health Outcomes and Decisions to Apply for Social Security 

Disability Benefits,” Journal of Disability Policy Studies (2012), doi: 

10.1177/1044207312437743.

18 Chapman, Hall, and Moore, “Health Care Access”; Jean P. Hall, Shawna L. Carroll, 

and Janice M. Moore, “Processes among Enrollees in a State High-Risk Insurance 

Pool: Focus Group Findings,” American Journal of Health Promotion, Inc (2010): 304–

11, doi:10.4278/ajhp.0806l3-QUAL-91; Jean P. Hall and Janice M. Moore, “Does Highrisk Pool Coverage Meet the Needs of People at Risk for Disability?” Inquiry: A Journal 

of Medical Care Organization, Provision and Financing 45, no. 3 (2008): 340–52, 

http://inq.sagepub.com/content/45/3/340.full.pdf. 

19 NCD, “Early Intervention.” 
143

20 Charles Michalopoulos et al., “The Effects of Health Care Benefits on Health Care 

Use and Health: A Randomized Trial for Disability Insurance Beneficiaries,” National 

Center for Biotechnology Information 50, no. 9 (2012): 764–71, doi: 

10.1097/MLR.0b013e31825a8bfc. 

21 Charles Michalopoulos et al., “The Accelerated Benefits Demonstration and 

Evaluation Project: Impacts on Health and Employment at Twelve Months; Volume 1” 

(2011), http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2031259. 

22 Michalopoulos et al., “Effects of Health Care Benefits.” 

23 Ibid.

24 Robert R. Weathers and Michelle S. Bailey, “The Impact of Rehabilitation and 

Counseling Services on the Labor Market Activity of Social Security Disability Insurance 

(SSDI) Beneficiaries,” Journal of Policy Analysis and Management 33, no. 3 (2014): 

623–48.

25 Chapman, Hall, and Moore, “Health Care Access.” 

26 Gilbert Gimm et al., “Impact of Early Intervention Programs for Working Adults with 

Potentially Disabling Conditions : Evidence from the National DMIE Evaluation,” Journal 

of Vocational Rehabilitation 34 (2011): 71–81, doi:10.3233/JVR-2010-0536.

27 Kory Kroft, Fabian Lange, and Mathew J. Notowidigdo, “Duration Dependence and 

Labor Market Conditions: Theory and Evidence from a Field Experiment,” (working 

paper 18387, National Bureau of Economic Research, Cambridge, MA, 2012). 

28 Brian T. Mcmahon et al., “The Progression of Disability Benefits,” Journal of 

Vocational Rehabilitation 15 (2000): 4, http://www.researchgate.net/profile/

Brian_Mcmahon7/publication/258032417_The_progression_of_disability_benefits/links/

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=true. 

29 U.S. Department of Labor, Bureau of Labor Statistics, “National Compensation 

Survey: Employee Benefits in the United States, March 2012” (2012), 

http://www.bls.gov/ncs/ebs/benefits/2012/ebbl0050.pdf. 

30 “A temporary income replacement benefit for which employers can insure or selfinsure. The benefit usually has a brief waiting period (1 to 7 days) that is coordinated with 

sick leave, and it typically replaces between 60 percent and 80 percent of an employee’s 

wages.” Christopher C. Wagner et al., “Older Workers’ Progression from Private Disability 

Benefits to Social Security Disability Benefits,” Social Security Bulletin 63, no. 4 (2009): 

27–37, http://www.socialsecurity.gov/policy/docs/ssb/v63n4/v63n4p27.pdf. 

31 Wagner et al., “Older Workers’ Progression.” 
144

32 Ishita Sengupta et al., “Workers’ Compensation: Benefits, Coverage, and Costs, 

2010” (Washington, D.C.: National Academy of Social Insurance, 2012), 

http://www.workcompcentral.com/pdf/2013/misc/nasiRptWkrsComp11v3b.pdf; 

U.S. Department of Labor (DOL), Bureau of Labor Statistics, “National Compensation 

Survey: Glossary of Employee Benefit Terms” (2012), http://www.bls.gov/ncs/ebs/

glossary20112012.pdf. 

33 DOL, “Glossary of Employee Benefit Terms.” 

34 Sengupta et al., “Workers’ Compensation.” 

35 Mcmahon et al., “Progression of Disability Benefits.” 

36 Ibid. 

37 Terence M. Mcmenamin, “People with a Disability in 2012: A Visual Essay,” Monthly 

Labor Review (2013): 3–15, http://www.bls.gov/opub/mlr/2013/images/people-with-adisability-in-2012-a-visual-essay.pdf. 

38 California and Rhode Island do not require employer contributions but Hawaii, New 

Jersey, and New York do require employers to contribute to the premium cost. 

Sengupta et al., “Workers’ Compensation.” 

39 Autor and Duggan, “Supporting Work.” 

40 Wittenburg and Loprest, “Work-Focused Disability Program.”

41 Alena Allen, “State-Mandated Disability Insurance as Salve to the Consumer 

Bankruptcy Imbroglio,” Brigham Young University Law Review (2011): 1327–71, 

http://digitalcommons.law.byu.edu/cgi/viewcontent.cgi?article=2831&context=lawreview. 

42 Autor and Duggan, “Supporting Work.” 

43 Allen, “State-Mandated Disability,” 

44 Autor and Duggan, “Supporting Work.” 

45 Richard V. Burkhauser and Mary C. Daly, “Social Security Disability Insurance: Time 

for Fundamental Change,” Journal of Policy Analysis and Management 31, no. 2 (2012): 

454–61, doi: 10.1002/pam.21618; Mcmahon, et al., “Progression of Disability Benefits,” 

3–15. 

46 Ibid.

47 Monroe Berkowitz and David Dean, “Facilitating Employment through Rehabilitation,” 

in New Approaches to Disability in the Workplace, ed. Terry Thomason, John F. Burton, 

and Douglas Hyatt (Ithaca, N.Y.: ILR Press, 1996), 183–200.
145

48 Richard V. Burkhauser, Maximilian D. Schmeiser, and Robert Weathers,. “The 

Importance of Anti-Discrimination and Workers Compensation Laws on the Provision of 

Workplace Accommodations Following the Onset of a Disability,” Industrial & Labor 

Relations Review 65, no. 1 (2012), doi: 10.1177/001979391206500109.

49 Rochelle Habeck et al., “Employer Factors Related to Workers’ Compensation Claims 

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50 Ron Goetzel and R. J. Ozminkowski, “The Health and Cost Benefits of Work Site 

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http://staff.washington.edu/ostergrn/CommuterProfiles/health%20promotion/Health_

CostBenefits_WorksiteHealthPromotions.pdf. 

51 Ibid. 

52 Rochelle Habeck, A. Hunt, C. Rachel, J. Kregel, and F. Chan, “Employee Retention 

and Integrated Disability Management Practices as Demand Side Factors,” Journal of 

Occupational Rehabilitation 20, no. 4 (2010): 443–55, doi:10.1007/s10926-009-9225-9. 

53 Cornell University School of Industrial and Labor Relations Employment and Disability 

Institute and the Society for Human Resource Management (SHRM), “SHRM Survey 

Findings: Employing People With Disabilities: Practices and Policies Related to 

Retention and Advancement” (2012), http://www.shrm.org/research/surveyfindings/

articles/pages/employingpeoplewithdisabilitiespracticesandpoliciesrelatedtoretentionand

advancement2.aspx. 

54 U.S. Department of Labor, Office of Disability Employment Policy, “Summary of 

Promising and Emerging Practices for Enhancing the Employment of Individuals with 

Disabilities Included in Plans Submitted by Federal Agencies Under Executive Order 

13548” (2012), http://www.dol.gov/odep/pdf/2012EO13548.pdf. 

55 Renee S. Surdick, Jeffrey Gianforte, and Liubov Samsonova, “WorkSource Wisconsin: 

An Employers Guide on Disability and Employment Employer Quantitative Research” 

(2006), http://www.nasuad.org/sites/nasuad/files/hcbs/files/145/7243/WorkSource_

needs_assessment_report_WI.pdf. 

56 Habeck et al., “Employee Retention.” 

57 Disability Management Employer Coalition’s website, accessed June 2014, 

http://www.dmec.org. 

58 Habeck et al., “Employee Retention.” 

59 Rochelle Habeck et al., “Salient and Subtle Aspects of Demand Side Approaches for 

Employment Retention: Lessons for Public Policymakers,” Journal of Vocational 

Rehabilitation 26 (2007): 21–7, doi:10.1177/1044207311425383. 
146

60 “Our Mission, Vision and Strategic Plan,” U.S. Business Leadership Network website, 

last modified April 4, 2014, accessed June 2014, http://www.usbln.org/about-us_

mission.html. 

61 Council of State Administrators of Vocational Rehabilitation’s website, accessed June 

2014, http://www.rehabnetwork.org. 

62 “For Employers,” Vermont Agency of Human Services, Division of Vocational 

Rehabilitation website, accessed June 2014, http://www.vocrehab.vermont.gov/employers. 

63 “Employment Services for Your Business,” Oklahoma Department of Rehabilitation 

Services website, accessed June 2014, http://www.okrehab.org/drupal/employers/home. 

64 “DVR Business Services,” State of Wisconsin Department of Workforce Development, 

Vocational Rehabilitation website, accessed June 2014, http://www.dwd.wisconsin.gov/

dvr/business_services. 

65 Beth Loy, Job Accommodation Network, “Workplace Accommodations: Low Cost, 

High Impact” (2012), http://askjan.org/media/lowcosthighimpact.html. 

66 ADA National Network’s website, last modified 2013, accessed June 2014, 

http://www.adata.org/. 

67 H. Stephen Kaye, Lita H. Jans, and Erica C. Jones, “Why Don’t Employers Hire and 

Retain Workers with Disabilities?” Occupational Rehabilitation 21 (2011): 526–36, 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217147/. 

68 Brigitte Gavin, Marci McCoy-Roth, and Vasudha Gidugu, Boston University Sargent 

College, Center for Psychiatric Rehabilitation, “Review of Studies Regarding the Medicaid 

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69 Denise Hoffman and Jody Schimmel, Mathematica Policy Research, “Which Medicaid 

Buy-In Participants Use SSA Work Supports?” in Working with Disability: Work and 

Insurance in Brief (Washington, D.C.: Mathematica Policy Research, 2012), 

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Buy-In.pdf. 

70 Substantial gainful activity (SGA) is work involving significant physical or mental 

activities for pay or profit and is represented by a dollar amount that, when exceeded, 

suggests the claimant is not disabled under the Social Security Act. The SGA amount

reported as a per month sum is established annually by the Administration. The 2014 

higher amounts are $1,070 for non-blind individuals and $1,800 for people who are blind. 

“Determinations of Substantial Gainful Activity (SGA),” Social Security Administration, 

accessed June 2014, http://www.socialsecurity.gov/OACT/COLA/sga.html. 

71 Chapman, Hall, and Moore, “Health Care Access.” 
147

72 Jean P. Hall, Noelle K. Kurth, and Suzanne L. Hunt, “Employment as a Health 

Determinant for Working-age, Dually-eligible People with Disabilities,” Disability and 

Health Journal 6, no. 2 (2013): 100–6, doi: 10.1016/j.dhjo.2012.11.001.

73 Sarah Croake and Su Liu, Mathematica Policy Research, “A Government 

Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure 

Grants Program as of 12/31/08” (2009), http://www.oregon.gov/dhs/vr/cep/2009-gprareport.pdf. 

74 Kathleen C. Thomas and Jean Hall, “The Medicaid Medically Improved Group: Losing 

Disability Status and Growing Earnings,” Medicare & Medicaid Research Review 4 

(2014): 1, doi: 10.5600/mmrr.004.01.a02. 

75 Thomas and Hall, “Medically Improved Group.” 

76 Croake and Liu, “GPRA Medicaid Infrastructure 12/31/08.” 

77 Hoffman and Schimmel. “SSA Work Supports?” 

78 Gavin, McCoy-Roth, and Gidugu, “Review of Studies Regarding the Medicaid Buy-In 

Program.” 

79 Anna S. Sommers, “Access to Health Insurance, Barriers to Care, and Service Use 

among Adults with Disabilities,” Inquiry : A Journal of Medical Care Organization, 

Provision and Financing 43, no. 4 (2007): 393–405, doi: 10.5034/inquiryjrnl_43.4.393; 

Chapman, Hall, and Moore, “Health Care Access.” 

80 Jae Kennedy and Elizabeth Blodgett, “Health Insurance-Motivated Disability 

Enrollment and the ACA,” New England Journal of Medicine 16, no. 1 (2012): 14–6, 

doi:10.1056/NEJMp1208212.

81 S. Liu, H. Ireys, C. Thornton, “Participants in the Medicaid Buy-In Program, 2000–

2004: Characteristics, Earnings, and Medical Expenditures,” Journal of Disability Policy 

Studies (2008), doi: 10.1177/1044207308315282.

82 Jean Hall, “Will Medicaid Buy-In Participants Work and Earn More If Social Security 

Rules Change?” in Working Healthy: Making Health Care Work (Lawrence, KS: 

University of Kansas Medicaid Infrastructure Change Evaluation Project, 2007), 

http://kuscholarworks.ku.edu/bitstream/handle/1808/6915/Will%20Medicaid%20BuyIn%20Participants%20Work%20and%20Earn%20More%20if%20Social%20Security%2

0Rules%20Change.pdf?sequence=1&isAllowed=y. 

83 Ticket to Work and Work Incentives Improvement Act of 1999, 42 USC §§ 1320b-19 

et seq.

84 Jean P. Hall and Michael H. Fox, “Policy Issues for Working Healthy and Other States’ 

Medicaid Buy-Ins: The Good, the Bad, and What Remains to Be Seen” in Working 

Healthy: Making Health Care Work (Lawrence, KS: University of Kansas Medicaid 
148

Infrastructure Change Evaluation Project, 2004), http://kuscholarworks.ku.edu/bitstream/

handle/1808/6917/Policy%20Issues%20for%20Working%20Healthy%20and%20Other%

20States%27%20Medicaid%20Buy-Ins.pdf?sequence=1&isAllowed=y. 

85 Allen Jensen, “State Medicaid Buy-In Programs: Implementation Status, Enrollment and 

Program Design Features,” (draft updated April 2010), http://www.realeconomicimpact.org/

UploadedDocs/Documents/Buy-In_Program_April_2010.doc. 

86 Jensen, “State Medicaid Buy-In Programs.” 

87 Hall and Fox, “Policy Issues for Working Healthy”; Jean Hall and Shawna Carroll, 

“Kansans with Disabilities Speak out about Employment Opportunities” in Working 

Healthy: Making Health Care Work (Lawrence, KS: University of Kansas Medicaid 

Infrastructure Change Evaluation Project, 2008), http://health.kucrl.org/images/

workinghealthy/WHPolicyBriefno10.pdf. 

88 Allen Jensen and Becky Banks, “Indiana Medicaid and Employment Evaluation” 

(Indianapolis, I.N.: Indiana Family and Social Services Administration, Office of Medicaid 

Policy and Planning, 2009), http://www.nasuad.org/sites/nasuad/files/hcbs/files/188/

9383/Evaluation-MEDWorks1208.pdf. 

89 Ibid. 

90 Ibid. 

91 Gina Livermore et al., “Premium Increases in State Health Insurance Programs: 

Lessons from a Case Study of the Massachusetts Medicaid Buy-in Program,” Inquiry:

The Journal of Health Care Organization, Provision, and Financing 44, no. 4 (2013): 

428–42, doi: 10.5034/inquiryjrnl_44.4.428.

92 Ibid. 

93 Alice R. Levy, Brian K. Bruen, and Leighton C. Ku, “The Potential Employment Impact 

of Health Reform on Working-Age Adults with Disabilities,” Journal of Disability Policy 

Studies (2012), doi:10.1177/1044207312446225.

94 Jean P. Hall, Michael H. Fox, and Emily Fall, “The Kansas Medicaid Buy-In: Factors 

Influencing Enrollment and Health Care Utilization,” Disability and Health Journal 3, 

no. 2 (2010): 99–106, doi: http://dx.doi.org/10.1016/j.dhjo.2009.05.001. 

95 Timothy Jost, “Implementing Health Reform: Medicaid Asset Rules and the Affordable 

Care Act,” Health Affairs (blog), February 24, 2014, http://healthaffairs.org/blog/2014/02/

24/implementing-health-reform-medicaid-asset-rules-and-the-affordable-care-act/. 

96 Jean Hall and Nanette Relave, personal communication January 23, 2014. With the 

ACA’s maintenance of effort requirement for state Medicaid programs running out in 

2014, there are reports of states eliminating or radically scaling back their Medicaid 

Buy-In programs. Currently, Kentucky is trying to eliminate the program completely and 
149

Louisiana has cut thousands of people from the program by slashing income limits from 

250 percent of FPL to 100 percent of FPL effective January 1, 2014. State of Louisiana 

Department of Health and Hospitals, “Medicaid: Changes to Medicaid Eligibility Criteria 

Effective January 1” (2013), http://dhh.louisiana.gov/index.cfm/newsroom/detail/2854. 

97 Alexis D. Henry et al., “Unmet Need for Disability-related Health Care Services and 

Employment Status among Adults with Disabilities in the Massachusetts Medicaid 

Program,” Disability and Health Journal 4, no. 4 (2011): 209–18, doi: 

http://dx.doi.org/10.1016/j.dhjo.2011.05.003. 

98 Ibid. 

99 42 U.S.C. § 12102. 

100 Saad Nagi, “Some Conceptual Issues in Disability and Rehabilitation,” in Sociology 

and Rehabilitation, ed. Marvin B. Sussman (Washington, D.C.: American Sociological 

Association, 1965), 100–113.

101 Robert Silverstein, “Emerging Disability Policy Framework,” Iowa Law Review 85 

(2000): 1713–16, http://www.ncwd-youth.info/assets/framework/silverstein_framework.pdf. 

102 Alan M. Jette and Elizabeth Badley, “Conceptual Issues in the Measurement of Work 

Disability,” in The Dynamics of Disability: Measuring and Monitoring Disability for Social 

Security Programs, ed. Gooloo S. Wunderlich, Dorothy P. Rice, and Nicole Amado 

(Washington, DC: National Academy Press, 2002),185–98. 

103 42 U.S.C. §§ 423, 1382c. 

104 Gooloo S. Wunderlich, Dorothy P. Rice, and Nicole Amado.. The Dynamics of 

Disability: Measuring and Monitoring Disability for Social Security Programs

(Washington, DC: National Academy Press, 2002), 17–18. 

105 John Bound, “The Health and Earnings of Rejected Disability Insurance Applicants,” 

American Economics Review 79, no. 3 (1989): 482–503, http://public.econ.duke.edu/

~hf14/teaching/socialinsurance/readings/Bound91(5.9).pdf; Marjorie F. Olney and Cindy 

Lyle, “The Benefits Trap: Barriers to Employment Experienced by SSA Beneficiaries,” 

Rehabilitation Counseling Bulletin 54, no. 4 (2011): 205–07, doi: 10.1177/

0034355211400209; David C. Stapleton, et al., “Dismantling the Poverty Trap: Disability 

Policy for the Twenty-First Century,” Milbank Quarterly 84, no. 4 (2006): 716–17, 

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1245&context=edicollect. 

106 Keith Brown et al.,” Doing Disability: Disability Formations in the Search for Work,” 

Sociological Inquiry 79, no. 1 (2009): 12, doi: 10.1111/j.1475-682X.2008.00269.x.

107 Joe Entwisle, “Debunking the Disability Trap,” The Huffington Post, November 15, 2012, 

http://www.huffingtonpost.com/joe-entwisle/disabled-people-working_b_2078762.html. 
150

108 U.S. Senate Committee on Health, Education, Labor, and Pensions, Unfinished 

Business: Making Employment of People with Disabilities a National Priority

(Washington, DC: United States Senate Committee on Health, Education, Labor, and 

Pensions, 2012), 9, http://www.mncdhh.org/file_download/240/Senate+Report+on+

Making+Employment+a+Priority.pdf. 

109 Erickson, William, Camille G. Lee, and Sarah von Schrader, 2008 Disability Status 

Report: The United States (Ithaca, NY: Cornell University Rehabilitation Research and 

Training Center on Disability Demographics and Statistics, 2010), 6, 

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1285&context=

edicollect. 

110 Erickson, Lee, and von Schrader, 2008 Disability Status Report. 

111 Gina A. Livermore, “Social Security Disability Beneficiaries with Work-Related Goals 

or Expectations,” Social Security Bulletin 71, no. 3 (2011): 64–65, http://www.ssa.gov/

policy/docs/ssb/v71n3/v71n3p61.html. 

112 Ibid. 

113 Ibid, 72.

114 John Gettens et al., “The Prospect of Losing Benefits and the Work Decisions of 

Participants in Disability Programs: A Cross-Program Comparison,” Journal of Disability 

Policy Studies 23, no. 3 (2012): 186–89, doi:10.1177/1044207311429345; Mary B. 

Killeen and Bonnie L. O’Day, “Challenging Expectations: How Individuals with Psychiatric 

Disabilities Find and Keep Work,” Psychiatric Rehabilitation Journal 28, no. 2 (2004): 152, 

doi:10.2975/28.2004; Pamela Loprest and Elaine Magg, Urban Insitute, “Barriers to and 

Supports for Work Among Adults with Disabilities: Results from the NHIS-D” (Washington, 

D.C.: U.S. Department of Health and Human Services, Office of Disability, Aging and 

Long-Term Care Policy, 2001), http://aspe.hhs.gov/daltcp/reports/barriers.htm; 

Kim L. MacDonald-Wilson et al., “A Study of the Social Security Work Incentives and 

Their Relation to Perceived Barriers to Work among Persons with Psychiatric Disability,” 

Rehabilitation Psychology 48, no. 4 (2003): 48, doi:10.1037/0090-5550.48.4; Judith 

Barfield and Pamela Hanes Spohn, “Employment Experiences of Working-Age Adults 

with Severe Physical Disabilities in Dane County, Wisconsin” in Employment Initiatives for 

Persons with Physical Disabilities (Madison, WI: Employment Resources, 1993), 24, 34; 

Olney and Lyle, “Benefits Trap,” 205–6.

115 Bob Williams et al., “Waiting for Medicare: Experiences of Uninsured People with 

Disabilities in the Two-Year Waiting Period for Medicare” (New York, N.Y.: The 

Commonwealth Fund and Christopher Reeve Paralysis Foundation, 2004), vii, 18, 

http://www.commonwealthfund.org/usr_doc/786_williams_waiting_for_medicare.pdf. 

116 Barfield and Spohn, “Employment Experiences,” 39–40.
151

117 Gettens et al., “Prospect of Losing Benefits,” 187; Fear of benefits loss can be 

viewed as a complex concept with multiple components. The material here focuses on 

three types: getting or keeping benefit eligibility, getting reinstatement if the benefit is 

lost (for example because of a successful return-to-work effort), and concern about 

benefit loss at a particular earnings level (in this case the SGA “cash cliff” for those in 

SSDI). However, other fears may be pertinent depending on the features of a given 

program. Ibid., 179–80.

118 Bonnie O’Day and Mary Killeen, “Does U.S. Federal Policy Support Employment and 

Recovery for People with Psychiatric Disabilities?” Behavioral Law and the Sciences 20 

(2002): 567–68, doi:10.1002/bsl.514; Killeen and O’Day, “Challenging Expectations,” 

159; Olney and Lyle, “Benefits Trap,” 205–6.

119 Barfield and Spohn, “Employment Experiences,” 24; Loprest and Magg, “Supports 

for Work,” 7. 

120 O’Day and Killeen, “Employment and Recovery for People with Psychiatric 

Disabilities,” 575; Williams et al., “Waiting for Medicare,” 12–14. 

121 20 C.F.R. §§ 404.1562, 1569; 20 C.F.R. Part 404 Appendix 2. 

122 Current processes are defined at 20 C.F.R. § 404.1501 for SSDI and 20 C.F.R. §

416.960 for SSI. 

123 20 C.F.R. § 404.1525; 20 C.F.R. Part 404 Appendix 1.

124 20 C.F.R. Part 404 Appendix 1. 

125 Kalman Rupp, “Factors Affecting Initial Disability Allowance Rates for the Disability 

Insurance and Supplemental Security Income Programs: The Role of the Demographic 

and Diagnostic Composition of Applicants and Local Labor Market Conditions,” Social 

Security Bulletin 72, no. 4 (2012): 12, 20–1, http://www.ssa.gov/policy/docs/ssb/v72n4/

v72n4p11.html. 

126 Jennifer Erkulwater, Disability Rights and the American Social Safety Net (Ithaca, 

N.Y.: Cornell University Press, 2006), 177–81.

127 Generally, controlling the rates of entry to public programs is more effective, in terms 

of lessening both administrative costs and the use of overt coercion. Moreover, such 

gatekeeping is usually more effective when potential applicants have alternatives they 

value and positive incentives to choose not to apply to or remain in the programs. 

Burkhauser and Daly, “Declining Work and Welfare.” 

128 D. Stapleton et al., “Poverty Trap.” 

129 Norman Altshuler et al., Mathematica Policy Research, “Provider Experiences under 

the Revised Ticket to Work Regulations” (2011), http://www.mathematica-mpr.com/~/

media/publications/pdfs/disability/ttw_process.pdf. 
152

130 U.S. Government Accountability Office, “Ticket to Work Participation Has Increased, 

but Additional Oversight Needed” (2011), http://www.gao.gov/products/GAO-11-324. 

131 David Stapleton, Cindy Gruman, and Sarah Prenovitz, Mathematica Policy 

Research, “Work Activity and Use of Employment Supports under the Original Ticket to 

Work Regulations Participation in Ticket to Work Continues to Grow but Assignments 

under the Traditional Payment System Still Dominate Final Report” (2009), 

http://www.mathematica-mpr.com/publications/PDFs/disability/TTW_participation.pdf. 

132Jody Schimmel and David C. Stapleton, “Disability Benefits Suspended or Terminated 

Because of Work,” Social Security Bulletin 71, no.3.(2011). http://www.socialsecurity.gov/

policy/docs/ssb/v71n3/v71n3p83.html. 

133 Altshuler et al., “Provider Experiences.” 

134 Ibid.

135 Ibid.

136 Stapleton et al., “Work Activity and Use of Employment Supports.” 

137 Jody Schimmel et al., Mathematica Policy Research, “Participant and Provider 

Outcomes since the Inception of Ticket to Work and the Effects of the 2008 Regulatory 

Changes” (2013), http://www.mathematica-mpr.com/~/media/publications/pdfs/disability/

ttw_part_provid_outcomes.pdf. 

138 U.S. Senate Committee on Health, Education, Labor, and Pensions, “High 

Expectations: Transforming the American Workforce as the ADA Generation Comes of 

Age” (2013), http://www.help.senate.gov/newsroom/press/release/?id=8c890e1c-27fd4599-b040-0e2631a96212&groups=Chair. 

139 The raw data permits research of age breakdown for diagnostic groups. Other related 

SSA data such as in the Annual Statistical Report on the Social Security Disability 

Insurance Program 2008, stops at the end of December 2008—a period of time different 

from the fiscal year—and are not disaggregated. Social Security Administration, Office of

Retirement and Disability Policy, Office of Research, Evaluation, and Statistics, “Annual 

Statistical Report on the Social Security Disability Insurance Program, 2008” (2009), 

http://www.ssa.gov/policy/docs/statcomps/di_asr/2008/di_asr08.pdf. 

140 C. L. Barrett, “Number of SSDI Beneficiaries under Age 50 with a Primary Impairment 

of a Mental Disorder in Payment in July 2006, from the Social Security Administration 

Continuing Disability Review Selection File FY 2008” (unpublished raw data).

141 Donna D. McAlpine and Lynn Warner, Rutgers State University, Institute for Health, 

Health Care Policy and Aging Research, Center for Research on the Organization and 

Financing of Care for the Severely Mentally Ill, “Barriers to Employment Among Persons 

with Mental Illness: A Review of the Literature” (2000), http://www.dri.illinois.edu/research/

p01-04c/final_technical_report_p01-04c.pdf; John C. Hennessey and Janine M. Dykacz, 
153

“Projected Outcomes and Length of Time in Disability Insurance Program,” Social Security 

Bulletin 52, no. 9 (1989)” 2–41, http://www.ssa.gov/policy/docs/ssb/v52n9/v52n9p2.pdf. 

142 Monroe Berkowitz, “The Ticket to Work Program: The Complicated Evolution of a 

Simple Idea,” and Chad Newcomb, Suzanne Payne, and Mikki D Waid, “What Do We 

Know About Disability Beneficiaries’ Work and Use of Work Incentives Prior to Ticket?” 

in Paying for Results in Vocational Rehabilitation: Will Provider Incentives Work for 

Ticket to Work?, ed. Kalman Rupp and Stephen H. Bell (Washington, D.C.: Urban 

Institute, 2003).

143 Kalman Rupp and Stephen H. Bell, “A Ticket to Work? A Preliminary View of 

Provider Incentives and Access to Services in the Ticket Program,” in Paying for 

Results in Vocational Rehabilitation: Will Provider Incentives Work for Ticket to Work?, 

ed. Kalman Rupp and Stephen H. Bell (Washington, D.C.: Urban Institute, 2003) 

http://www.urban.org/url.cfm?ID=310603&renderforprint=1. 

144 Ibid. 

145 Evan Rosen, “Smashing Silos,” Bloomberg Business Week, February 5, 2010, 

http://www.businessweek.com/managing/content/feb2010/ca2010025_358633.htm. 

146 Social Security Administration, Office of Retirement and Disability Policy, “2012 Red 

Book: A Summary Guide to Employment Supports for Persons with Disabilities under the 

Social Security Disability Insurance and Supplemental Security Income Programs” (2012), 

http://www.socialsecurity.gov/redbook/eng/The%20Red%20Book%202012.(F).pdf. 

147 Christa Bucks Comacho and Jeffrey Hemmeter, “Linking Youth Transition Support 

Services: Results from Two Demonstration Projects,” Social Security Bulletin 73, no. 1 

(2013), http://www.socialsecurity.gov/policy/docs/ssb/v73n1/v73n1p59.html#mt1. 

148 “That goal [to increase the self-sufficiency of transition-age youth with disabilities], 

which may not be realized until many years after YTD participation, generally takes the 

form of increased employment and decreased dependence on public benefits, along 

with improved quality of life.” Ibid., 60. 

149 Comacho and Hemmeter, “Linking Youth Transition Support.” 

150 Mathematica Policy Research, “Youth Transition Demonstration: Helping Youth with 

Disabilities Become Employed 2005–2014,” http://www.mathematica-mpr.com/ourpublications-and-findings/projects/youth-transition-demonstration. 

151 Thomas Fraker, Mathematica Policy Research, Center for Studying Disability Policy, 

“The Youth Transition Demonstration: Interim Findings and Lessons for Program 

Implementation” (2011), http://www.mathematica-mpr.com/~/media/publications/pdfs/

disability/ytd_brief11-04.pdf; Livermore, “Social Security Disability Beneficiaries with 

Work-Related Goals.” 
154

152 Jeffrey Hemmeter, Jacqueline Kauff, and David Wittenburg, “Changing 

Circumstances: Experiences of Child SSI Recipients before and after Their Age-18 

Redetermination for Adult Benefits,” Journal of Vocational Rehabilitation, 30 (2009): 

201–21, doi:10.3233/JVR-2009-0462. 

153 Ibid.

154 Ibid.

155 Pamela Loprest and David Wittenburg, Urban Institute, “Choices, Challenges, and 

Options: Child SSI Recipients Preparing for the Transition to Adult Life” (2005), 

http://www.urban.org/UploadedPDF/411168_ChildSSIRecipients.pdf. 

156 Ibid. 

157 Ibid. 

158 David W. Test et al., “Evidence-Based Secondary Transition Predictors for Improving 

Postschool Outcomes for Students With Disabilities,” Career Development for 

Exceptional Individuals, 32, no. 3 (2009):160–81, 170, doi: 

10.1177/0885728809346960. 

159 Ibid. 

160 Erik W. Carter, Diane Austin, and Audrey A. Trainor, “Predictors of Postschool 

Employment Outcomes for Young Adults With Severe Disabilities,” Journal of Disability 

Policy Studies, 23, no. 1 (2011): 50–63, doi: 10.1177/1044207311414680. 

161 Hemmeter, Kauff, and Wittenburg, “Changing Circumstances: Experience of Child 

SSI Recipients.” 

162 U.S. Department of Education, Office of Special Education Programs, Office of 

Special Education and Rehabilitative Services, “Fiscal Year 2013 Applications for New 

Awards” (August 2013), http://www2.ed.gov/programs/oseptad/2013-326s.doc. 

163 Applications for New Awards; Promoting the Readiness of Minors in Supplemental 

Security Income (PROMISE), 78 Fed. Reg. 98 (Sept. 2013).

164 William Frey et al., Social Security Administration, “Mental Health Treatment Study 

Final Report” (2011), http://socialsecurity.gov/disabilityresearch/documents/MHTS_

Final_Report_508.pdf. 

165 Ibid. 

166 Ibid. 

167 Ibid.
155

168 Ibid. 

169 Ibid. 

170 Croake and Liu, “GPRA Medicaid Infrastructure 12/31/08.” 

171 Ibid. In order to qualify for progressive steps in the Medicaid Infrastructure Grant 

program, states needed to first demonstrate a basic level of Medicaid services that 

focused on assisting people with disabilities to work: (a) a Medicaid Buy-In program and 

(b) personal assistance services that could be used to support eligible individuals in 

employment either at home or at work. States that met these benchmarks set by CMS 

were then eligible for additional MIG funding. Ibid.

172 Ibid. 

173 Ibid. 

174 Matthew Kehn, Sarah Croake, and Jody Schimmel, Mathematica Policy Research, 

“A Government Performance and Results (GPRA) Report: The Status of the Medicaid 

Infrastructure Grants Program as of 12/31/09” (2010), http://www.mathematicampr.com/~/media/publications/PDFs/disability/GPRA_09.pdf. 

175 American Public Human Services Association, Center for Workers with Disabilities, 

“Medicaid Infrastructure Grants: Impacts and Outcomes” (2010), 

http://nasuad.org/hcbs/article/medicaid-infrastructure-grants-impacts-and-outcomes. 

176 Kehn, Croake, and Schimmel, “GPRA Medicaid Infrastructure 12/31/09.” 

177 U.S. House of Representatives, Committee on Ways and Means, “1998 Green Book: 

Background Material on Data and Programs within the Jurisdiction of the Committee on 

Ways and Means” (Washington, DC: U.S. Government Printing Office, 1998), 

http://www.gpo.gov/fdsys/pkg/GPO-CPRT-105WPRT37945/content-detail.html. 

178 Mary C. Daly and Richard Burkhauser, “The Supplemental Security Income 

Program,” in Means-Tested Transfer Programs in the United States, ed. Robert A. 

Moffitt (Chicago, IL: University of Chicago Press 2003), 97. 

179 Social Security Administration, “A Guide to Supplemental Security Income (SSI) for 

Groups and Organizations” (2014), http://www.ssa.gov/pubs/EN-05-11015.pdf. 

180 Allen Jensen et al., “Policy Frameworks for Designing Medicaid Buy-In Programs 

and Related State Work Incentive Initiatives” (Washington, D.C.: U.S. Department of 

Health and Human Services, Office of the Assistant Secretary for Planning and 

Evaluation 2002), http://aspe.hhs.gov/daltcp/reports/2002/polframe.pdf. 

181 Daly and Burkhauser, “Supplemental Security Income Program,” 97. 

182 Jensen et al., “Policy Frameworks for Designing Medicaid Buy-In Programs.” 
156

183 Daly and Burkhauser, “Supplemental Security Income Program,” 97.

184 U.S. House of Representatives, “1998 Green Book.” 

185 Vee Burke, Congressional Research Service, “Cash and Noncash Benefits for 

Persons with Limited Income: Eligibility Rules, Recipient and Expenditure Data, 

FY 1996–FY 1998” (Report Code no. RL30401, Washington, DC: Library of Congress, 

1999), http://congressionalresearch.com/RL30401/document.php?study=Cash+and+

Noncash+Benefits+for+Persons+with+Limited+Income+Eligibility+Rules+Recipient+and

+Expenditure+Data+FY1996-FY1998. 

186 Social Security Administration, “Annual Report of the Supplemental Security Income 

Program” (Washington, DC: U.S. General Printing Office, 2002), 

http://www.ssa.gov/oact/ssir/SSI02/ssi2002.pdf. 

187 Ibid, 7.

188 Daly and Burkhauser, “Supplemental Security Income Program.” 

189 Data on state Medicaid Buy-In policies is updated from the most recent report. 

Matthew Kehn, Mathematica Policy Research, “Enrollment, Employment, and Earnings 

in the Medicaid Buy-In Program, 2011, Final Report” (2013), http://www.mathematicampr.com/~/media/publications/PDFs/health/medicaid_buyin_enrollment.pdf. 

190 NCD, “Social Security Administration’s Efforts,” 59–61.

191 John Allen, “New York Ticket-to-Work Medicaid Infrastructure Grant Summary” 

(Washington, D.C.: U.S. Department of Health and Human Services, Centers for 

Medicare & Medicaid Services, 2012).

192 “Developing a Path to Employment for New Yorkers with Disabilities,” New York 

Makes Work Pay website, accessed June 2014, http://www.nymakesworkpay.org/. 

193 New York Makes Work Pay, “Abstract: Address Policy and Practice Barriers to 

Employment” (2010), http://bbi.syr.edu/docs/projects/mig/goals/MIG_WIIN_abstracts_1.pdf.

194 William Erickson, Camille Lee, and Sarah von Schrader, Cornell University 

Employment and Disability Institute. “2011 Disability Status Report: United States” 

(2012), http://www.disabilitystatistics.org/StatusReports/2011-PDF/2011-

StatusReport_US.pdf. 

195 Ibid. 

196 Kate Kellet, et al., University of Connecticut Health Center, “Connect-Ability 

Infrastructure Change Annual Report: January-December 2007,” 

http://www.ct.gov/connect-ability/lib/connect-ability/research/JanuaryDecember_2007_Infrastructure_Change_Report_revised_Final.pdf. 
157

197 Croake and Liu, “GPRA Medicaid Infrastructure 12/31/08.” 

198 Carol Ruddell, “Utah Ticket-to-Work Medicaid Infrastructure Grant Summary” (2011), 

http://dehpg.net/TicketToWork/ReportMS-2.aspx. 

199 Sara McCormick, University of Utah, Center for Public Policy and Administration, 

“Survey of Employers Participating in Utah’s Persons with Disabilities Network 

(PWDNET)” (2011),http://cppa.utah.edu/_documents/publications/workforce/pwdnetsurvey-report-final-3-2011.pdf. 

200 Kathy West-Evans, “Business,” Council of State Administrators of Vocational 

Rehabilitation, accessed June 2014, http://www.rehabnetwork.org/customers-2/

business/. 
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National Council on Disability

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