On December 28, the Social Security Administration (SSA) published final regulations for the new "Ticket" program authorized by Congress under the 1999 Ticket to Work and Work Incentives Improvement Act (TWWIIA, P.L. 106-170). TWWIIA is a major effort on the part of Congress to try and end the pervasive disincentives to employment inherent in SSA's disability income support and health coverage programs (SSI, SSDI, Medicare and Medicaid). TWWIIA has received broad bipartisan support both in Congress and from the Bush and Clinton Administrations as a major step forward in addressing the very high unemployment rate among Americans with severe disabilities, including adults with severe mental illnesses (estimated as high as 85%).
The "Ticket" program is a major feature of TWWIIA and is intended to offer Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) recipients a voucher that can be used to obtain employment, training or vocational services from the provider of the consumer's choice. The basic idea of the "Ticket" program is to maximize consumer choice by allowing beneficiariesto select their own employment or rehabilitation provider. That provider is then paid based only on a successful outcome - defined in the law as successfully getting people in a job and off of SSI and/or SSDI cash benefits.
By paying employment providers only for successful ongoing job placements, the program is designed to place greater emphasis on ongoing workplace supports (for a period of up to 5 years), rather than pre-employment assessments with no ongoing post-placement support. Research on successful employment interventions for adults with severe mental illnesses has demonstrated that ongoing job-related supports are much more effective than pre-employment services or job search assistance.
SSA's final rules appear to retain a number of provisions the draft Notice of Proposed Rulemaking (NPRM) published in December 2000 that are likely to make it difficult for many SSI and SSDI beneficiaries with severe mental illnesses to effectively use the Ticket program. For example, the final regulations retain a restriction that prevents a beneficiary classified as "medical improvement expected" (MIE) from receiving a Ticket until after their first continuing disability review (CDR). SSA also retained provisions limiting beneficiaries to one Ticket per period of eligibility for SSI and SSDI - thereby forcing many consumers into having to get off benefits and initiate a new application in order to get another Ticket.
Beginning on February 8, SSA will begin to send out notices to eligible SSI and SSDI beneficiaries in 13 pilot states that Tickets are available to them. These 13 pilot states are: Arizona, Colorado, Delaware, Florida, Illinois, Iowa, Massachusetts, New York, Oklahoma, Oregon, South Carolina, Vermont and Wisconsin. In addition, the national Program Manager for the Ticket program, MAXIMUS Corporation, has already begun recruiting Employment Networks in these 13 states. It is these Employment Networks that will directly serve Ticketholders. Despite the efforts of SSA and MAXIMUS to reach out to private and non-profit employment and vocational providers to sign up as Employment Networks, there is growing concern that too few have been recruited in these 13 states to result in meaningful consumer choice. This is especially the case with respect to private and non-profit agencies serving adults with severe mental illnesses, i.e. psychosocial rehabilitation programs, clubhouses, CMHCs and consumer-run programs. NAMI affiliates in these 13 pilot states are therefore urged to reach out to agencies and programs in your area to encourage them to consider signing up as an Employment Network. More information on how providers can sign up to be an Employment Network is available at through the MAXIMUS toll-free number (1-866-968-7842) or through SSA's Employment Support programs website at: www.ssa.gov/work/ResourcesToolkit/networks2.html.
NAMI will continue to monitor both SSA's implementation of the final Ticket regulations and efforts in the 13 pilot states to make Tickets available to SSI and SSDI beneficiaries and recruit Employment Networks. A listing of providers that have already signed up to be Employment Networks in the 13 pilot states is available at: www.ssa.gov/work/ServiceProviders/endirectory.html.
Below is a brief analysis of provisions in the final regulations of concern to SSI and SSDI beneficiaries with severe mental illnesses. The full text of SSA's final regulations can be viewed at: www.ssa.gov/work/ResourcesToolkit/FinalRegs2002.html. NAMI's comments on the draft Ticket regulations can be viewed at: www.nami.org/update/20010227.html
This is particularly troubling to NAMI for several reasons. First, a high proportion of SSI and SSDI beneficiaries classified as MIE have severe mentalillness as the primary basis for their successful disability claim. Second, historically, SSA has had a tremendous backlog in completing CDRs, resulting in significant delays until these mandated reviews are completed. SSA decision is certain to result in significant delays in beneficiaries with severe mental illnesses in getting Tickets. This runs counter research indicating that early employment and rehabilitation interventions are more effective in serving most consumers.
This one Ticket per eligibility period limit is especially troubling for SSI beneficiaries participating 1619 programs allow for extended health and cash benefits for beneficiaries entering the workforce. These SSI beneficiaries often retain "eligibility" for benefits under 1619(b) even though they are not receiving any cash benefits. For these individuals, the Ticket could be fully paid out and the person would come back into payment status and not be able to get another Ticket because they are still considered to be in the same "period of disability."
In addition, some individuals with high upfront rehabilitation costs who are served by their state vocational rehabilitation (VR) agency will see their chance to fully benefit from a Ticket limited. In many cases, VR agencies are reimbursed for the full costs of services, even if the cost is higher than the total value of the Ticket, so long as a person achieves nine months of Substantial Gainful Activity (SGA). Since nine months of SGA still leaves a person eligible to receive SSI or SSDI, the person will still be on the rolls, not having achieved full independence. However, these individuals will no longer have access to services because they will not have a Ticket. This will be particularly unjust in the rehabilitation of individuals with severe mental illness, since state VR agencies have generally done a strikingly poor job of tailoring VR programs to the needs of persons with severe mental illness.
In the final regulations, SSA did make an important change in the "one Ticket per entitlement period" restriction to accommodate "Expedited Reinstatement" section of TWWIIA. TWWIIA provides for a 60-month Expedited Reinstatement that follows the termination of benefits due to work. Expedited Reinstatement allows an individual actively using a Ticket to be automatically reinstated to cash benefits (pending a CDR after six months) in the case of a recurrence of acute symptoms or impairment (e.g. a psychiatric episode or break). The final rules clarify that individuals reinstated to benefits through Expedited Reentry can receive another Ticket in the first month of entitlement or eligibility.
SSA appears to have retained a provision that would allow placement of a Ticket in inactive status only during the first 24-month period of use. SSA notes that they will still permit intermittent employment in the subsequent progress review periods. Presumably then, if a beneficiary stops pursuing an employment plan after the first 24 months, then they would have to request expedited reentry and could be subject to a CDR (Section 411.220(a)).
SSA made four changes to the outcome-milestone payment system in partial response to comments from advocacy groups, including NAMI. SSA rejected as administratively impractical suggestions that a graduated fee system be adopted, that individual fees be set or that the Program Manager negotiate fees with ENs. SSA also chose not to narrow the gap between the outcome and outcome-milestone payment systems out of cost considerations and to maintain "incentives" to ENs to choose the outcome payment system. SSA also rejected suggestions that pre-employment milestones be paid given projections that a "significant number of beneficiaries who would achieve them would not eventually leave the disability rolls because of work or earnings."
SSA had originally proposed that ENs submit with their requests for outcome payments a beneficiary-completed "Work Activity Report" that would include information about their use of PASS plans, IRWEs and other work incentives. In NAMI's view, this requirement had significant potential to create an adversarial relationship between beneficiaries and ENs. By requiring Ticketholders to alert ENs as to incentives they are concurrently using, it would almost certainly increase the time it takes for the EN to get paid, thereby discouraging many ENs from serving some beneficiaries. SSA is instead now suggesting that beneficiaries get the proper forms from their SSA field offices and complete these with the assistance of the SSA personnel, not ENs (Section 411.575(b)).
Disabled Adult Children (DACs)
SSA did use the final rules to respond to comments submitted about DACs - by NAMI and other disability advocacy organizations - regarding the ability to move on and off SSDI cash benefits to the same extent as other beneficiaries. SSA claims that under section 202[d] of "the Act" (presumably Social Security) "an individual whose entitlement to child's insurance benefits based on disability has terminated may again become entitled to such benefits if he or she has not married and he or she is under a disability which began before the end of the 84th month following the month in which his or her most recent entitlement to child's insurance benefits terminated because he or she ceased to be under a disability." It appears that SSA is claiming that existing law addresses the concerns about DACs and their ability to take advantage of TWWIIA without losing access to their childhood level of benefits if necessary.
SSA Awards Benefit Planning and Assistance and Outreach Grants
In addition to issuing final regulations on the Ticket program on December 28, SSA has also been releasing funds for a separate program authorized by TWWIIA - the Benefit Planning, Assistance and Outreach (BPAO) program. NAMI strongly supported the inclusion of the BPAO program in TWWIIA. One of the most daunting obstacles to employment for SSI and SSDI beneficiaries with severe mental illnesses is the fear associated with losing cash benefits and health care coverage through Medicare and Medicaid.
While TWWIIA and other SSA work incentive programs are intended to help ease the transition from dependence on public benefits to employment, the complicated eligibility rules and restrictions are troubling. Further, the severe penalties associated with violating these very complicated rules, i.e. complete loss of cash and health care coverage, makes many beneficiaries reluctant to even attempt work when they are otherwise clinically and functionally able to do so. This is especially the case with beneficiaries that have attempted work in the past, only to later be faced with the severe financial penalties associated with an overpayment of cash benefits.
The BPAO program is intended to provide assistance to SSI and SSDI beneficiaries with reliable, independent and accurate information about the consequences of work - how much can be earned without penalty, how to access extended Medicare and Medicaid coverage, how to access the Ticket program, how to develop a PASS plan, etc. BPAO grants have thus far been allocated to 117 separate projects in every state. These BPAO programs operate independent of national and SSA field offices. In many states, SSA has awarded BPAO grants to state and local Centers for Independent Living (CIL) - agencies that have traditionally served individuals with physical disabilities. To inquire about which agency in your state or community was awarded the BPAO grant in your area, contact your local SSA field office, or visit: www.ssa.gov/work/ServiceProviders/statebystate.html.
Finally, SSA has also awarded grants under the new Protection and Advocacy (P&A) program that Congress authorized as part of TWWIIA to assist SSI and SSDI beneficiaries in accessing employment and vocational services. This new PABSS program is intended to assist all SSI and SSDI beneficiaries in both obtaining services and resolving disputes with state VR agencies and ENs. PABSS grants have thus far been awarded to most of the designated P&A agencies across the country. More information on this program is available at:www.ssa.gov/work/ServiceProviders/pa.html
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