SSA s Ticket to Work Program

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1 Medicaid Infrastructure Grants & SSA s Ticket to Work Program June 8, 2010 June 8, 2010 John Coburn, Health & Disability Advocates

2 The Role of MIGS and Healthcare Development The Healthcare Picture MIGs and the Ticket to Work Program New news guidance to states on Ticket to Work Payment and Medicaid funded employment services under 1915 (c ) waivers Opportunities for braiding & blending funding for the Ticket to Work Program

3 43 States have Medicaid Infrastructure Grants. Usually housed in Medicaid office, VR, or a University. Created as part of Ticket Act to do the planning and building of an environment where all the pieces work together to support employment. Purposefully flexibility so a lot of different work going on.

4 A big role of the MIGs in many states has been development and implementation of Medicaid Buy In Programs. Medicaid Buy In Programs now in 42 states, sometimes in various stages of development. Medicaid Buy In Programs vary from state to state so it is very important that you understand how your state program works. Medicaid Buy Ins can complete the healthcare puzzle.

5 Loss of healthcare was a big barrier to individuals working in the past. Fear of loss of healthcare STILL IS a barrier, whether it is true or not. Some of this was fixed on the federal level by creating a special program for all SSI beneficiaries and continuing Medicare for SSDI individuals. One piece of the puzzle was left to the states, with the option to create Medicaid Buy In.

6 SSI beneficiaries are automatically eligible for Medicaid id in most states. t With some state variation for states called 209(b) states, $1 SSI means Medicaid. In ALL states, if you stop receiving SSI due to work, a provision called 1619(b) allows Medicaid id to continue up to a state t specific threshold as long as you meet other SSI requirements. Even that state specific threshold can be higher through an individual threshold.

7 Julie gets a job and earns $1000 in income and gets a smaller SSI check. In most states, she still gets Medicaid because she still gets SSI. Julie starts earning $1600 per month and SSI Julie starts earning $1600 per month and SSI is reduced to $0. Julie still gets Medicaid for free under 1619(b) presuming she is under her state threshold or an individual threshold.

8 SSDI beneficiaries receive Medicare after a 24 month waiting period. After waiting period ends, you get an SSDI check, you get Medicare. Simple. If you stop receiving SSDI due to earnings, Medicare still continues under a complicated time frame calculation, l but for several years with the option to purchase afterward. Increased income may impact eligibility for state programs called Medicare Savings Programs that help pay Medicare costs.

9 Jim receives SSDI and gets a part-time job at $700 per month. Jim still gets SSDI. Jim still gets Medicare. Impact on Medicare Savings Program? Jim receives SSDI and works at $1400 per month, stopping his check after the Trial Work Period and Grace Period. Jim still gets Medicare under the extended Medicare provisions even though SSDI has stopped. Impact on Medicare Savings Program?

10 Some but not all SSDI beneficiaries can qualify for Medicaid. They meet the definition of disability and their income and assets are low enough. They meet the definition of disability and, in certain states, can get Medicaid with a spenddown or incurment or share of cost. They meet the definition of disability and are working.

11 About 85% of those on Buy-In are SSDI beneficiaries. i i SSDI beneficiaries use Buy In to maintain or obtain Medicaid when they would otherwise income out of the program. Prior to Buy Ins, if an SSDI beneficiary worked and earned too much, they would be dropped d from Medicaid or get a huge spenddown. Medicaid Buy In is also used to decrease the cost of Medicare Part D prescription drugs because the person gets extra help.

12 Harry receives $700 per month in SSDI and this allows him to also qualify for Medicaid id in his state. Before the Buy In was implemented, Harry was offered a job at $700 per month but would not take it because his Medicaid caseworker said his spenddown would be about $500 per month. After Buy In, same job, Harry can take that job and get Medicaid for a small premium every month.

13 How are SSI and Medicaid related in your state? What is the 1619(b) threshold for SSI beneficiaries in your state? Medicare is federal so same everywhere, but how do earnings impact eligibility for Medicare Savings Programs? Does your state have a Buy In Program? What is your Buy-In eligibility and who would need to enroll in Buy In and when?

14 SSI beneficiaries can work and earn up to the state threshold and maybe beyond and keep Medicaid but check state variation if 209(b). Get an SSDI check, get Medicare (after waiting period). Continue to get Medicare even if SSDI stops for a period of time. Costs may change with added income. Some SSDI beneficiaries get Medicaid. Medicaid can continue at low cost through Buy In programs when people work up to the income and asset thresholds Get the message out: HEALTHCARE IS NOT A BARRIER!

15 SSI beneficiaries can work and earn up to the state threshold and maybe beyond and keep Medicaid but check state variation if 209(b). Get an SSDI check, get Medicare (after waiting period). Continue to get Medicare even if SSDI stops for a period of time. Costs may change with added income. Some SSDI beneficiaries get Medicaid. Medicaid can continue at low cost through Buy In programs when people work up to the income and asset thresholds. But be careful since this program may be limited! Get the message out: HEALTHCARE IS NOT A BARRIER FOR MANY!

16 SSI beneficiaries can work and earn up to the state t threshold h and maybe beyond and keep Medicaid but check state variation if 209(b). Get an SSDI check, get Medicare (after waiting period). Continue to get Medicare even if SSDI stops for a period of time. Costs may change with added income. Some SSDI beneficiaries get Medicaid. Earned income may cause loss of Medicaid. Message: ROBUST BUY IN STILL NEEEDED TO COMPLETE THE PICTURE.

17 Healthcare reform s general purpose was to cover the uninsured, make some enhancements, and regulate private insurance. In general, it was not intended to offer something new to people who already had something. Healthcare reform did not change the picture for those on SSI and SSDI in general in how they get healthcare, although introducing anything new always has effects. Example: Buying Medicare. New opportunities in home and community based services, CLASS Act, etc.

18 Convener Facilitator Evaluation & Data Analysis Training & Technical Support Capacity Building

19 Convene state VR with Community Rehabilitation Providers (CRPs) to create a common agenda for the Ticket to Work Examples: New Hampshire, Maine Convene CRPs to identify program opportunities to build policy to promote employment at or above SGA Example: West Virginia

20 MIG has played a key role in facilitating relationships important to building infrastructure around the Ticket to Work program Facilitates bringing together different components of the employment system Example: AZ and the One-Stop Systems; New Hampshire and the Community Mental Health Providers

21 MIG providing resources and supports for CRPs and state agency partners to use data on successful closures to determine how using an outcome or milestone payment model would have worked Example: Oregon

22 MIG is able to use considerable funding for providing training and technical support to CRPs and other employment & training providers on how to be utilized SSA work incentives programs and the Ticket to Work program Examples: Arizona, Arkansas, Maine, Montana, Nebraska

23 VR Contracts and Partnership Plus Medicaid Dollars Taking Ticket on your Own Utilizing Resources, Services in the One Stop Other Grants

24 Flexible, Flexible Flexible SSA does not care about other funding streams. All it cares about is outcomes. Ticket monies can be used for anything. No requirement that you account for the money. Meet the benchmark, get paid, with very minimal requirements on what must be in place to get that money.

25 There has been widespread concern that taking Ticket money on a customer for whom you have billed services under Medicaid would be double dipping. Medicaid pays for particular services, while Ticket pays for outcomes. Most service providers agree that there were many services NOT billed to Medicaid that are delivered to get or maintain that job.

26 Ticket Outcome and Milestone payments do not conflict with regulatory requirements and do not constitute an overpayment of Federal dollars for services provided since EN payments are payment for an outcome, rather than for a Medicaid service rendered. Furthermore, State agencies and/or providers interested in participating in the Ticket to Work program as ENs are encouraged to do so. However, it is important for State agencies acting as ENs to keep ticket payment funding separate from resources used by the State to comprise the State s Medicaid share, in accordance with applicable Federal regulations at 42 CFR

27 Accurate accounting for Medicaid funded employment services and supports is important Opportunity continue billing Medicaid for services already provided, put Ticket to Work payments in a separate account to pay for services 1915 (c) can t cover. Bottom Line: You can braid Ticket and Medicaid funding to serve your customers

28 Passive Partnership Plus Semi-Facilitated Partnership Plus Actively Facilitated Partnership Plus VR Competes as EN VR/EN Split Ticket VR/EN agreement or enhanced payment Intelligent Assignment Coupled with Reinvestment Strategy

29 Where do our current placements fall in the Ticket payment system? Do we find people jobs or could we find people jobs where they would feel comfortable leaving the SSA roles? What are the current placements by VR in our state? If we participate in the Partnership Plus model with VR, how long will it be before revenue starts coming in on the average customer?

30 What funding do we currently have? How is our VR working with Ticket? Have we set up mechanism to take Ticket and Medicaid billing on same person? Can ticket be braided and blended with more and better services? Can Ticket money be used to support a more effective program that brings in even more revenue?

31 Get the healthcare picture: Is it an issue in my state that will impede my efforts to find people better paying jobs? How can we access the better paying jobs? Other barriers? Is there work going on in my state on barriers to better paying jobs? Am I involved in those discussions?