To be eligible for Disability Insurance (DI) or Supplemental Security Income (SSI) benefits, an individual generally must have a medically determined physical or mental impairment that (1) has lasted or is expected to last at least 1 year or result in death and (2) prevents the individual from engaging in substantial gainful activity (SGA). Once an individual is receiving benefits, CDRs are periodically conducted by SSA to determine if the individual has medically improved to the point of being able to work and is no longer eligible for benefits. When an individual becomes eligible for DI or SSI benefits, SSA mails a ticket to them. Generally, DI and SSI beneficiaries from 18 to 64 years old are eligible ticket holders and may choose whether or not to use their tickets, and with which service providers. Likewise, SSA-approved ENs can decide whether to serve an individual ticket holder. Ticket holders who assign their tickets and demonstrate “timely progress” toward self- supporting employment, such as by fulfilling minimum earnings or education requirements to be reviewed regularly, are exempted from medical CDRs. This provision provides an incentive for individuals to assign their tickets who otherwise might not attempt to work out of fear that a medical CDR would cause them to lose benefit eligibility. The ticket holder’s ticket becomes “assigned” once the ticket holder and EN decide to work together and submit an individual work plan describing the services the EN will provide. A ticket holder can unassign the ticket from the EN at any time, sometimes switching to a different EN. When the ticket holder has sufficient earnings, the EN becomes eligible for payments from SSA. The EN can choose from two payment options: (1) milestone-outcome payments that begin when the ticket holder achieves a specified level of earnings and continue for a specified time after the ticket holder no longer receives benefits due to earnings, or (2) outcome-only payments that do not begin until the ticket holder is entirely off benefits. Due to low participation rates by both ticket holders and ENs, SSA revised the Ticket program regulations in 2008. The changes lowered the ticket holder earnings threshold that triggers payments to ENs. Previously, ENs were not eligible for SSA payment until a ticket holder had earnings at the SGA level or above. Now there is a first phase of four $1,275 payments over a ticket holder’s first 9 months working at the trial work level, which is below SGA and, in many cases, equates to part- time work. The EN is also eligible for a second phase of smaller monthly payments when a ticket holder has earnings above the SGA level, and a third and final phase of payments (the outcome phase) once a ticket holder is earning above SGA and no longer receives disability benefits. Another key change made in 2008 was to explicitly allow ENs to use milestone or outcome payments to make payments directly to ticket holders. Ticket holders assigning their tickets to ENs increased from about 22,000 in fiscal year 2007, before the changes to program regulations, to more than 49,000 as of July 2010. Despite the increase in numbers, those assigning their tickets to ENs represented less than 1 percent of the approximately 12.1 million eligible ticket holders as of July 2010. Representatives of the private company SSA contracts with to conduct outreach told us that while they are beginning to place more emphasis on increasing ticket holder participation, their earlier recruitment efforts prioritized increasing the supply of ENs. According to EN representatives, ticket holder participation remains low due, in part, to a lack of understanding and awareness of the program. Some disability rights advocates and EN representatives said a fear of losing benefits may also deter eligible ticket holders from participating in the program, especially DI beneficiaries who, after a 9-month trial work period, face an immediate cessation of benefits in a given month when earnings exceed SGA. Although the number of ticket holders assigning their tickets has increased since the 2008 changes, the extent to which more ticket holders are returning to work and exiting the benefit rolls is unknown. The law requires SSA to conduct ongoing independent evaluations of ticket holders’ employment outcomes, and SSA has tentative plans to study exits from the benefit rolls under the revised program regulations. Whether or not ticket holders are able to leave the rolls has implications for the program’s cost-effectiveness and ultimately, its long- term viability. In preliminary research examining the program prior to the 2008 regulatory changes, Mathematica found more exits from the rolls would be needed to offset existing operational costs. In our May report, we recommended that SSA prioritize and carry through with a study of participating ticket holders’ exits from the rolls and the agency noted it has plans to study the effects of the 2008 changes on the Ticket program. However, prioritizing and carrying through with their plans will be important going forward to determine the extent to which ticket holders actually exit the rolls due to long-term employment. Without it, an accurate and complete assessment of the Ticket program’s effectiveness cannot be made. Although an increasing number of ENs are participating in the Ticket program since the 2008 changes in regulations, many ENs are not actively participating and SSA ticket payments have remained concentrated with only 20 ENs. The number of ENs contracted by SSA increased from 1,514 in fiscal year 2007 to 1,603 as of July 2010. During this time, ENs accepting at least one ticket also increased from 752 to 1,086. The majority of EN representatives we interviewed said the regulatory changes provided greater incentive for participation because ENs can now receive payments for ticket holders with earnings earlier than before as well as for ticket holders with part-time earnings. ENs receiving ticket payments from SSA more than doubled, from 206 in fiscal year 2007 to 460 as of July 2010. Total payments to ENs grew substantially, from $3.8 million in fiscal year 2007 to $13 million as of July 2010. Yet 20 ENs, or less than 2 percent of the total number accepting tickets in fiscal year 2009, have received more than 70 percent of SSA’s ticket payments in recent years. Reasons why EN participation is not broader may be partly attributable to costs. Even though SSA officials said the 2008 regulatory changes were intended to address the costs associated with providing initial services, several EN representatives told us that financing the upfront costs of providing services can be challenging, and some said providing resource-intensive services, such as career and personal counseling, could limit profitability. Those ENs receiving some of the largest payment amounts from SSA provide a range of services, including assistance with job search and retention. But since the 2008 changes in regulations, an increasing number of ENs used service approaches targeting ticket holders who are already working or do not need assistance in obtaining employment. For example, since the 2008 regulatory changes, which explicitly allowed ENs to pay ticket holders, an increasing number of ENs shared SSA ticket payments with ticket holders who have sufficient earnings to qualify the EN for payment. This “shared payment” approach allows the EN to readily claim ticket payments while providing no direct services because the ticket holder is already working or able to find a job without assistance. This service approach accounted for an increasing proportion of total ticket payments made by SSA. In fiscal year 2007, 1 of the 20 ENs among those with the largest payment amounts used this approach and received about $787,000 in SSA payments, or one-fifth of all payments to ENs. In fiscal year 2009, 3 of the 20 ENs among those with the largest payment amounts used this approach and received over $4 million, or nearly one-third of all payments to ENs. Two of these ENs simply pass back 75 percent of SSA’s ticket payment to ticket holders and retain 25 percent for themselves; and the third offers ticket holders $500 every 3 months. Some disability rights advocates and EN representatives said that since program rules do not allow ticket holders to serve as their own ENs, this approach allows them to receive a Ticket program payment for their efforts to find a job on their own. Some EN representatives also said the payment may help a ticket holder meet needed work-related expenses such as transportation, clothing, and child care, increasing the likelihood he or she will keep a job. However, some disability rights advocates and EN representatives said this approach only works for ticket holders who can find employment on their own, and raises questions about the value these ENs add to the program. For example, one disability rights advocate said that it would be preferable for SSA to give the ticket holder the entire payment directly, rather than paying an EN a portion of the ticket payment to serve as a middleman. Additionally, the representatives told us ticket holders may need support after finding employment, such as counseling or help with a disability-related relapse, but choose an EN using the shared- payment approach because they are enticed by the financial incentive and do not anticipate future difficulties. Further, according to one EN representative, because these ENs do not provide a vocational assessment of strengths, weaknesses, and aptitude, ticket holders may end up in a job that is a poor fit, affecting their ability to retain it and, ultimately, reduce dependency on benefits. Long-term outcomes of ticket holders receiving shared payments compared to those receiving support services is unknown, because SSA does not assess the relative outcomes of ticket holders based on services received. A senior SSA official said that the program must balance the demands it places on ENs to provide services with incentives for them to participate, and that Congress’ intent was to provide ticket holders with a choice of services. However, the official acknowledged some concerns about the shared payment approach because the program was not intended to provide a wage subsidy nor assist those who can find employment on their own, but to provide tangible employment-related services to those who can benefit most.