CHAPTER 6
State Vocational Rehabilitation Agency Participation in Ticket to Work

SVRA dominance in TTW suggests that the program has prompted little change in the delivery of services to beneficiaries. SVRAs were virtually the only providers receiving SSA funding for employment support services before TTW, and they remain the dominant providers. In particular, over 90 percent of Ticket assignments have been made to SVRAs, which continue to rely on the traditional payment system for the overwhelming majority of clients. Thus, most beneficiaries participating in TTW are doing so under conditions that are essentially unchanged from before program rollout. In addition, most SVRAs we interviewed report that they are now serving beneficiaries who are similar to beneficiaries served in the past in terms of characteristics and backgrounds. Further, SVRAs do not appear to have changed the mix or intensity of services provided to beneficiaries. As explained in the initial evaluation report, SVRA officials tend to view TTW as a new payment system that imposes some additional administrative requirements but has little effect on current service delivery efforts.

There are, however, a few noteworthy changes. Some SVRAs report an increased recognition of the complexity of SSA’s program rules and work incentives and of the need to understand the difficult personal and financial decisions made by beneficiaries as they attempt to find a job. A number of SVRAs routinely refer beneficiaries to local BPAOs to ensure that they receive accurate information about the effect of employment on their financial and health care benefits. In addition, a few SVRAs are expanding their capacity to provide this information themselves or identifying outside individuals or organizations that can do so.

While SVRA participation in TTW remains strong, there is some evidence that SVRAs’ interest in TTW may have waned in recent months. SVRAs appear to have become less aggressive about obtaining assignments from their beneficiary clients. This is most evident in the Phase 2 states, where the beneficiary participation rate at SVRAs is well below the rate in Phase 1 states at the comparable point in the Phase 1 rollout. It also appears that Phase 1 SVRAs are obtaining fewer assignments than a year or so earlier. Our analysis of SVRA data on case closures suggests that the lower TTW participation rate is not related to the fact that SVRAs are serving fewer beneficiaries. It appears, instead, that SVRAs have reduced their efforts to obtain Ticket assignments from their clients who are SSA beneficiaries. Initially, SVRAs were concerned that many such clients would assign their Ticket to another EN after receiving extensive services from SVRA, leaving the latter unable to recoup its costs. As this concern has diminished over time, SVRAs have relaxed their efforts to obtain Ticket assignments.

Waning SVRA interest in TTW appears to have coincided with a general decline in the percentage of SSA beneficiaries whose cases were closed when they became competitively employed and stabilized in their position. This decline does not seem to be directly associated with the Ticket rollout because its timing was approximately the same across the country even though the program was phased in over three years. The reasons for the decline in closures due to employment are unclear. The slow economy during the observation period might explain the trend, but there was no comparable decline in case closures for SVRA clients who were not SSA beneficiaries. This finding, coupled with the reduction in payments to SVRAs under the traditional payment program during the same period, suggests that TTW has been fighting an uphill battle to promote improved employment outcomes among SSA beneficiary clients.

Our findings on SVRA participation are based on analyses of SSA and RSA administrative data, interviews with SVRAs chosen from Phase 1 and Phase 2 states (Connecticut, District of Columbia, Georgia, Massachusetts, Michigan, South Dakota, Vermont, and Wisconsin), interviews with staff from the Office of Employment Support Programs, and a review of 27 SVRA-EN agreements obtained from Phase 1 and Phase 2 states. Whenever appropriate, we have compared our current findings with those reported in both the initial evaluation report and the preliminary process evaluation report. Specifically, we compared the results of our interviews with 8 SVRAs conducted in 2004 and with the interviews with 13 Phase 1 SVRAs completed in 2002.

 

 

A. SVRA PROGRAMS AND THE PARTICIPATION OF SSA BENEFICIARIES

SVRAs operate with funding from the states and the U.S. Department of Education’s RSA). Under current legislation, federal funds pay for approximately 79 percent of VR activity, and the states fund the remaining 21 percent.1 Federal funding is distributed according to a formula that adjusts for a state’s population and per capita income. Since FY2000, total funding has remained fairly constant, ranging from $2.3 to $2.6 billion nationwide. The total $2.6 billion appropriation supports the total vocational rehabilitation program, including federal and state administrative costs, the national network of Centers for Independent Living, and other related programs. In addition to these administrative and other service functions, SVRAs use a large percentage of their state appropriation to purchase rehabilitation services for individual clients. For example, in FY2003, SVRAs spent approximately $1.34 billion to purchase services for their entire client population.

SVRAs use the funds to provide a mix of services intended to assist people with disabilities in identifying their vocational goals and securing employment. For example, assessment and evaluation services help individuals select a career area and set employment goals. Educational and medical services prepare individuals for employment in their chosen career area. Job placement, supported employment, and assistive technology services assist individuals in maintaining employment for extended periods and preparing for career advancement. SVRA services include basic counseling services delivered by a vocational rehabilitation counselor as well as specialized placement, training, and rehabilitation services specified in a client’s Individualized Plan for Employment that are purchased by the SVRA for a specific client from a statewide network of vendors.

 

Click for Figure VI.1. SSA Beneficiaries as a Percentage of All SVRA Case Closures FY1997–2003 (Opens in new window)

 

SVRAs serve a broad array of people with disabilities; in recent years, those receiving DI or SSI benefits have accounted for about one-fourth of all SVRA case closures (Figure VI.1). Another recent development includes a steady rise in the total number of SSA beneficiaries served by SVRAs, from 137,000 closed cases in FY1997 to 175,000 closed cases in FY2003.2

SSA payments to SVRAs under the TTW program primarily supplement the case service funds used by the agencies to purchase specific services for clients. While SSA disability beneficiaries account for about 25 percent of SVRAs’ case closures, funds from SSA account for less than 10 percent of SVRA case services monies. In FY2003, SSA reimbursements paid to SVRAs totaled approximately $80 million, roughly 6 percent of the total SVRA expenditures for purchased services of $1.34 billion. Thus, SVRAs have served disability beneficiaries through their primary funding sources with a small but nonetheless significant supplement provided by SSA TTW funds.

To a great extent, SSA payments are a far smaller fraction of total revenue than DI/SSI beneficiaries are of all people served by SVRAs because SVRAs have received SSA reimbursements for less than 10 percent of the SSA beneficiaries on their caseloads each year. SSA reimburses SVRAs (up to a limit) for the costs they incur to serve beneficiaries who earn at least the substantial gainful activity level (currently $830 per month for most beneficiaries) for nine months.3 Many beneficiaries who receive SVRA services do not earn at the substantial gainful level and so do not generate a payment from SSA.

Our initial evaluation report indicated that, at the beginning of the TTW program, SVRAs viewed TTW as a major threat to a funding stream that, albeit relatively small, had become increasingly important over the past two decades. Figure VI.2 provides historical information on the number and amount of SSA payments to SVRAs under the traditional payment program. During the early and mid-1990s, SVRAs were reimbursed for successfully serving about 5,600 to 7,300 individuals each year. As of the late 1990s, SVRAs began to serve a larger number of individuals. From 1998 to 2002, SVRAs received SSA reimbursements for an average of approximately 10,000 individuals each year, at an annual cost to SSA of over $100 million. Then, in FY2003, the number of reimbursements to states dropped significantly, to about 6,800.

Figure VI.3 presents another view of SSA expenditures on employment services, indicating the total payments made to SVRAs and ENs. Like Figure IV.2, Figure VI.3 also shows the decline in payments, from about $130 million in FY2002 to about $85 million in both FY2003 and FY2004. What is almost invisible are the payments to ENs in 2002–2004 (in 2004 those payments were $785,000, which is less than 1 percent of total payments).

This distribution of payments confirms the growing sense among SVRAs that shrinking payments from SSA are not a function of increased payments to ENs. The distribution also offers a second perspective on SVRAs’ dominance in the market to support employment efforts by disability beneficiaries.

 

Click for Figure VI.2. SSA Claims Allowed and SSA Payments to SVRAs Under the Traditional Payment Program, by Year (Opens in new window)

 

Click for Figure VI.3. Total SSA Payments to SVRAs and ENs (Opens in new window)

 

The reasons for the substantial decline in the number of traditional payment claims in both FY2003 and FY2004 are not completely clear. While probably not a major factor, the design of TTW could have reduced payments in the short term. In particular, while SSA made a single payment for eligible beneficiaries through the traditional payment system, milestone payments can occur over 12 months, and outcome payments are spread out over 60 or more months for beneficiaries who work enough to stop receiving cash benefits. Thus, efforts by TTW providers to help beneficiaries during the first years of TTW rollout would be expected to reduce revenue in the short term but increase it in following years. Such a rise in SSA payments will in fact be an important indication of TTW success.

Nevertheless, given that most Tickets have been assigned under the traditional payment system, the effect of delayed payments is not likely to be large. Furthermore, both the federal officials and SVRA representatives we spoke with said it is unlikely that TTW is responsible for the reduction in the traditional payment claims. Because SVRAs submit claims to SSA only after an individual has worked at SGA for nine consecutive months, payments in any given year largely reflect beneficiaries enrolled and served in previous years. For SVRA clients who receive SSI or DI and achieve a successful rehabilitation outcome, the mean length of time the client receives services is 25 months (Gilmore 2004). Therefore, it is likely that the bulk of claims submitted in FY2003 and FY2004 were for beneficiaries who began receiving services during FY2001 or 2002. Because TTW was first rolled out in February 2002 in only 13 states, it is unlikely that TTW alone could have had such a dramatic effect on the number of claims submitted by SVRAs and approved by SSA.

Both SSA and RSA officials have stated that the recent economic recession has affected payments made under the traditional payment system in two ways (Stafford 2004). First, the recession constricted the job market in many states, making it difficult for SVRAs to find jobs for SSA beneficiaries. Second, the recession put a heavy strain on state budgets and, by extension, reduced state funding to SVRAs. Faced with fewer resources, SVRAs could not offer services (or enough services) to everyone on their caseload, including disability beneficiaries. In fact, as of December 2004, 61 percent of SVRAs were rationing services to eligible people with disabilities (that is, they were operating on “order of selection”). The resulting decline in the number of disability beneficiaries who secured a job reduced SSA payments to SVRAs.

While it seems likely that the economy affected SSA payments to SVRAs, its effect on disability beneficiaries appears to differ from its effect on other SVRA clients. For example, RSA data on the rate at which SVRA clients are placed in competitive employment suggest that, while the rate fell for SSA beneficiaries, it did not fall for other SVRA clients (Figure VI.4). This difference may be an artifact of changes in how RSA data are collected.4 Alternatively, it could reflect the fact that disability beneficiaries have a steady source of income from SSA or that state fiscal pressures are leading SVRAs--either knowingly or unknowingly--to limit the amount of services provided to beneficiary clients. In our next report, we will examine this possibility by using RSA data that have been matched to SSA data.

Beneficiary participation in TTW through SVRAs will continue to be an important issue in future reports. The following discussion addresses various aspects of SVRA operations under TTW, revisiting some of the major issues documented in past reports.

 

 

B. TICKET ASSIGNMENT PRACTICES

SVRAs appear to be approaching Ticket assignment in a way that differs from their approach when TTW was first rolled out in February 2002. At that time, Phase 1 SVRAs prepared for what they expected to be an onslaught of new applicants by developing call centers and assigning new staff to handle such cases. When the response from new Ticket recipients was weaker than anticipated, SVRAs turned their attention to obtaining Ticket assignments from beneficiaries already on their caseloads, in large part to prevent them from assigning their Tickets to ENs (Kregel and Revell 2003). The Phase 2 SVRAs we interviewed, however, were less likely to establish call centers or extensive marketing programs. They also dedicated fewer resources to obtaining Ticket assignments from beneficiaries already on their caseloads, so-called “pipeline cases,” that receive their Ticket after signing an Individual Plan for Employment (IPE) with an SVRA. Their approach to Ticket holders—which may be correlated with the reduced participation rates in the Phase 2 states described in Chapter II—could be a result of at least three factors. First, these Phase 2 SVRAs may have learned from the experiences of the Phase 1 states, realizing that existing clients were unlikely to assign their Tickets elsewhere. Second, caseworkers may have come to see Ticket assignment merely as an administrative step that would not affect the services delivered to pipeline clients. Third, it could reflect longstanding (pre-TTW) differences in their approach to dealing with clients; one of the criteria for including states in Phases 1 and 3 was that they were more “market proactive,” thereby causing Phase 2 SVRAs to appear less active as compared with their Phase 1 counterparts.

 

Click for Figure VI.4. Percentage of Competitively Employed SSA Cases Versus non-SSA Cases, FY 1997–2003 (Opens in new window)

 

Recent interviews with eight Phase 1 and Phase 2 SVRAs also reveal that Ticket assignments from new clients—those who receive a Ticket before signing an IPE with an SVRA—continue to be a controversial issue. Transmittal 17 of the “Social Security Provider’s Handbook” (SSA 2002) allows SVRAs to submit a Ticket Assignment Form (Form 1365) without the beneficiary’s signature—that is, without his/her express consent—as long as the SVRA in question also submits the first and last pages of the IPE signed by both the beneficiary and an SVRA representative. Six of the eight SVRAs we interviewed indicated that they sometimes file Ticket assignment requests for new cases that have not signed Form 1365, with several SVRAs reporting that as many as 10 percent of all assignments may fall into this category.

SVRAs appear to be unsure what to do regarding unsigned Ticket assignment requests for new cases. Some say they are “not really comfortable” with this practice, and many indicate that they would strongly prefer that SSA forbid it. Yet, many SVRAs submit unsigned Ticket requests anyway because current SSA regulations require that they do so in order to recoup their costs under the traditional payment system and to prevent beneficiaries from assigning their Ticket to an EN without the SVRA’s knowledge.

Despite the fact that SVRAs have been seeking Ticket assignments for some new cases without the beneficiary’s signature, they believe that consumer choice is important, and they are doing their best to provide new clients—and others—with enough information on their rights and choices under the TTW and VR programs. SVRAs identified several practices designed to ensure choice in the context of current SSA procedures and regulations. Some SVRAs said they have trained their rehabilitation counselors to give clients information on both the consequences of signing an IPE and their rights and protections under TTW. To this end, four SVRAs reportedly modified their IPE forms. In addition, two SVRAs encouraged beneficiaries to meet with the local BPAO so that they would fully understand the effects of TTW participation and employment on their disability and health care benefits. One SVRA has worked with the Protection and Advocacy (P&A) program in its state to develop a consumer-oriented fact sheet on TTW that is used as an information guide for beneficiaries during their discussions with rehabilitation counselors about Ticket assignment.

 

 

C. USE OF NEW TTW PAYMENT OPTIONS

Although SVRAs can assign each Ticket under either the traditional payment system or one of the new payment systems, most SVRAs continue to rely almost exclusively on the former. As discussed in the initial evaluation report, only 4.5 percent of all Tickets assigned to SVRAs in Phase 1 states and 8.9 percent of Tickets assigned in Phase 2 states by the end of August 2003 were assigned under one of the new payment options. More recent data covering the period from initial rollout through March 2004 show that the percentage of Tickets assigned to SVRAs under the new systems continues to be low. Only 6 percent of all SVRA Ticket assignments nationwide were made under the new systems (Table VI.1). Phase 2 SVRAs continue to use these systems more often than Phase 1 SVRAs, but only 12 SVRAs have assigned more than 10 percent of their Tickets under one of the new systems.

 

Table VI.1. SVRA Ticket Assignments Made Under New TTW Payment Systems
State
Total Number of Tickets Assigned
Number Assigned Under New TTW Payment Systems
Percentage Assigned Under New TTW Payment Systems
Phase 1
New York
7,089
9
0.1
Colorado
335
1
0.3
Wisconsin
1,611
5
0.3
Florida
2,341
14
0.6
Illinois
4,175
29
0.7
South Carolina
1,240
9
0.7
Iowa
613
9
1.5
Arizona
380
7
1.8
Oregon
245
6
2.4
Delaware
435
37
8.5
Massachusetts
617
100
16.2
Vermont
409
98
24.0
Oklahoma
1,439
698
48.5
Subtotal
20,929
1,022
4.9
Phase 2
Alaska
55
0
0.0
Nevada
197
0
0.0
Virginia
512
1
0.2
Mississippi
204
1
0.5
MIchigan
2,642
18
0.7
Georgia
730
6
0.8
Tennessee
837
9
1.1
Kansas
197
3
1.5
Montana
127
2
1.6
Kentucky
289
11
3.8
Missouri
373
17
4.6
South Dakota
267
13
4.9
North Dakota
17
1
5.9
New Mexico
49
3
6.1
Arkansas
79
8
10.1
District of Columbia
56
9
16.1
New Jersey
347
64
18.4
New Hampshire
20
6
30.0
Louisiana
1,071
324
30.3
Indiana
270
89
33.0
Connecticut
439
173
39.4
Subtotal
8,778
758
8.6
Phase 3
Alabama
160
0
0.0
Hawaii
6
0
0.0
Maryland
50
0
0.0
Puerto Rico
1
0
0.0
Wyoming
5
0
0.0
Ohio
1,584
2
0.1
Washington
66
1
1.5
California
956
19
2.0
Utah
95
2
2.1
Nebraska
93
2
2.2
Maine
86
2
2.3
Idaho
121
5
4.1
Minnesota
76
4
5.3
Texas
167
10
6.0
Pennsylvania
404
60
14.9
West Virginia
44
9
20.5
North Carolina
228
126
55.3
Rhode Island
1
1
100.0
Subtotal
4,143
243
5.9

Grand Total
33,850
2,023
6.0

Source: Ticket Research File Data on Beneficiaries with Assigned Tickets, March 2004.

 

Recent interviews with eight SVRAs shed light on Ticket assignment patterns. In general, these SVRAs and those interviewed for the preliminary process evaluation offered the same explanation for their behavior. They were concerned not only about the potential effect of the new options on agency revenue but also about potential increases in administrative costs associated with modifying data reporting systems, tracking Ticket assignments and communicating with the Program Manager, and training counselors in making decisions regarding the new payment systems. Although some SVRAs said that they would be willing to reexamine their payment choice in the future, they will remain cautious until it is empirically demonstrated that the new options will lead to increased payments and, by extension, to revenues that are higher than what they would expect to collect under the traditional system. One SVRA reported that some of its staff members have been encouraging the use of the new payment options in a small pilot test.

Three SVRAs (in Connecticut, Vermont, and Massachusetts) have been serving a significant share of TTW participants (about 16 to 39 percent) through either the outcome-only or milestone-outcome system. The circumstances that prompted them to choose either the traditional system or one of the new systems include the following:

  • In Connecticut, counselors use a “decision tree” to choose a payment option for a specific beneficiary. If a beneficiary is receiving SSI or SSI and DI, the counselor selects the traditional payment system. If the individual is receiving DI and is under age 55 and the agency expects to spend less than $10,000 on the case, the counselor selects the outcome-only option. Staff had determined that $10,000 is the average cost reimbursement.

  • In Vermont, SVRA staff select the outcome-only system for beneficiaries who are on DI, under age 55, and will likely require less than $10,000 in services. In addition, the agency attempts to clinically appraise the likelihood that the individual is capable of working above the SGA for some period that will generate enough payments for the agency to recoup its service costs.

  • In Massachusetts, SVRA staff select the milestone-outcome payment system for clients served exclusively through state funds. The Massachusetts legislature supplements the SVRA’s federal case service monies with funds beyond the required match. One official indicated that SSA could not reimburse the agency for these additional state funds because the traditional payment system applies only to cases served through federal/state matched monies.

 

 

D. SVRA-EN RELATIONSHIPS

In our initial evaluation report, we made the point that, while TTW regulations allow each EN to negotiate an individualized agreement with an SVRA, most SVRAs have simply developed a standard agreement for use with all ENs. Furthermore, because SVRAs and RSA have interpreted TTW as a “comparable benefit,”5 SVRAs have typically crafted agreements requiring ENs to reimburse them for most or all services provided by SVRAs to a beneficiary whose Ticket was assigned to an EN. If a resource is identified as a comparable benefit, the SVRA views that resource as a “first dollar” expenditure, meaning that the comparable benefit funds (i.e., the Ticket) are applied first before accessing SVRA funds. Unfortunately, in crafting SVRA-EN agreements, SVRAs have interpreted the notion of comparable benefit broadly. If an EN indicated that it could provide a specific service in its application to the PM, then that service was viewed as a comparable benefit for all Ticket holders, and the agreement required the EN to reimburse the SVRA for the service. Informal guidance from RSA (Stafford 2003) has directed SVRAs to apply the concept of comparable benefits at the level of the individual consumer. If a specific service matches a service in an individual’s IPE and is available in a timely manner, then the service should be considered a comparable benefit. If the service is not in the individual’s IPE or not readily available at the time the individual requires it, the service should not be considered a comparable benefit. The latter approach to interpreting comparable benefits would require ENs to reimburse SVRAs for services much less frequently.

The findings described above were based on an analysis of SVRA-EN agreements obtained during site visits conducted in 2002 as a part of the preliminary process evaluation. To determine whether the agreements changed as TTW was rolled out, we analyzed 27 agreements obtained in 2004 from the 34 Phase 1 and 2 SVRAs (not all states had developed agreements at the time of the analysis). We also supplemented the analysis with data from interviews we conducted for this report with the 8 SVRAs.

We found that little had changed. SVRA-EN agreements still generally require ENs to reimburse SVRAs for most or all of the services provided by the latter to beneficiaries who have assigned their Ticket to an EN. In many states, it appears that few ENs are signing agreements. This section reviews the core components of SVRA-EN agreements, describes the status of RSA guidance, and details why, in the eight states we examined, few individuals are jointly served under the terms of an agreement.

1. Core Components of SVRA-EN Agreements

SVRA-EN agreements describe the terms and conditions under which the SVRA will provide services to a beneficiary referred by an EN. For instance, the agreements cover issues such as referral and information-sharing procedures, the financial responsibilities of both parties, the terms under which the EN will reimburse the SVRA for services provided, and dispute resolution procedures. Below, we discuss how agreements vary with respect to their core components: how reimbursable services are defined, conditions under which ENs are expected to reimburse SVRAs, SVRA incentive payments, and the sharing of SSA reimbursements.

Definition of Reimbursable Services. In most of the 27 agreements we reviewed, ENs are required to reimburse the SVRA only for direct services such as assessment, placement, or job-accommodation services. In 5 of the agreements, however, SVRAs require ENs to reimburse the SVRA for administrative and counseling/guidance services. In addition, nearly half of the agreements stipulate that SVRAs will not provide or pay for services that the EN has indicated it can provide in its application to the Program Manager and/or on the beneficiary’s IWP.

Conditions Under Which ENs Will Reimburse the SVRA. The conditions can vary considerably depending on the agreement.

  • Of the 27 agreements, 24 do not require the EN to reimburse the SVRA for services until the beneficiary is employed at a level that will bring in milestone or outcome payments. However, 3 agreements require the EN to reimburse the SVRA immediately after services are provided regardless of whether the EN has begun to receive payments from SSA.

  • While most agreements allow the EN to retain a portion of payments received from SSA beginning with the first payment, six of the agreements require the EN to reimburse the SVRA completely before the EN is allowed to keep any portion of the payment from SSA.

  • Most of the agreements require the EN to reimburse the SVRA only for the costs of services provided. However, five agreements entitle the SVRA to a share of the EN’s payments even after the SVRA has been completely reimbursed for its expenditures.

SVRA Incentive Payments. For Tickets assigned to an SVRA, a small number of agreements define situations in which the SVRA will make “incentive payments” to a partner EN for support services provided to help a beneficiary successfully maintain earnings above SGA. Five of the 27 SVRA-EN agreements identify some type of incentive payment, generally in the form of a lump-sum payment to the EN for services such as ongoing support to employed beneficiaries.

Payment Sharing. Just three agreements call for an SVRA and an EN to share SSA payments in cases where the Ticket has been assigned to the SVRA. The intent of these agreements is to allow ENs to receive reimbursement beyond the direct cost of purchase of service agreements previously negotiated with the SVRA for specific services. These provisions are intended to balance out the provisions in the SVRA-EN agreements under which the ENs pay the SVRA in situations where the EN holds the Ticket and reimburses the SVRA for services provided. The result is a reciprocal arrangement in which the SVRA shares its payments with ENs (instead of the one-way agreements typical of most states, whereby only the EN shares its payments with the SVRA). From the perspective of SVRAs, this procedure is designed to increase ENs’ willingness to serve SSA beneficiaries.

2. RSA Guidance on Comparable Benefits

Several SVRAs have criticized RSA for not providing clear guidance related to comparable benefits. To date, RSA has not issued definitive written guidance on how SVRAs should address comparable benefits in their agreements with ENs. In early January 2005, RSA began circulating a draft information memorandum for comment. However, as of this writing, RSA has not finalized and transmitted the memorandum, entitled “Principles and Promising Practices for Effective Cooperative Agreements between State Vocational Rehabilitation Agencies and Employment Networks under the Ticket to Work Program.” Presentations by RSA staff (Stafford 2004) indicate that the question of whether services provided under TTW constitute a comparable benefit is something that must be considered for each beneficiary rather than solely on the basis of the service-related information specified in an EN’s application to SSA.

3. Extent to Which SVRAs and ENs Jointly Serve Beneficiaries Under the Terms of SVRA Agreements

Although many SVRAs have drawn up agreements with ENs, many ENs in a state may not have signed the documents. Moreover, the fact that SVRAs may have signed agreements with several ENs does not ensure that large numbers of beneficiaries are jointly served under the terms of the agreements. For example, among the eight SVRAs we interviewed:

  • Two have yet to finalize an agreement with ENs

  • Three drew up agreements that have been signed by several ENs but do not jointly serve any beneficiaries under the agreement

  • Three have developed agreements and jointly serve beneficiaries under the terms of the agreement (although one reported jointly serving just one beneficiary)

The extent to which the above experiences mirror those of other SVRAs is unknown. However, the fact that over 85 percent of all Tickets have been assigned to SVRAs, coupled with the reality that SVRAs assign over 90 percent of all Tickets under the traditional payment system, strongly suggests that relatively few beneficiaries are served under the terms of SVRA-EN agreements. This is significant because, as reported in Chapter V, some ENs are not accepting Tickets from individuals with any connection to the SVRA system; these ENs believe that the acceptance of a Ticket assignment is financially unwise under the SVRA-EN agreement.

 

 

E. EFFECT OF TTW ON SVRAS AND THE TRADITIONAL VR REIMBURSEMENT PROGRAM

Overall, TTW’s effects on SVRAs range from positive, to neutral, and even to negative. This section discusses some of the important ways in which TTW has affected the eight SVRAs we interviewed.

1. Deeper Insight into the Employment Support Needs of SSA Beneficiaries

Although TTW may not have changed the amount or type of services SVRAs provide to beneficiaries, five of the eight SVRAs interviewed in 2004 reported that TTW has changed how their staff—from central office officials to local rehabilitation counselors—see the service needs of SSA beneficiaries. Some SVRAs have concluded that local counselors did not fully understand the employment obstacles unique to SSA beneficiaries. In particular, by making payments to ENs conditional on the beneficiary’s cash benefit reaching zero, TTW has caused some SVRAs to undertake a critical examination of their program goals related to SSA beneficiaries. One respondent said, “The TTW program raised the level of discourse in the agency about clients’ values and goals, the agency’s values and goals, and return-to-work issues. People are thinking and talking more about what is the best thing to do in different situations, for different people, and that involves considering potentially different values.”

2. Staff Development and Outreach

Several SVRAs now understand that local rehabilitation counselors, service vendors, and beneficiaries do not completely comprehend the effect of employment and earned income on disability benefit status and access to health care among SSA beneficiaries. This realization has prompted SVRAs to step up their efforts to educate staff in the employment needs of SSA beneficiaries and, in some cases, to tailor outreach efforts to the specific needs of clients.

Training for Rehabilitation Counselors. All SVRAs have implemented statewide training programs for local rehabilitation counselors to broaden counselors’ understanding of TTW. Training activities have focused on areas such as basic SSA disability program provisions, TTW provisions designed to eliminate specific disincentives to employment (e.g., CDR protections, Medicaid Buy-In programs, expedited reinstatement, and so forth), strategies for encouraging beneficiaries to assign their Ticket to the SVRA, and procedures for administering Ticket assignments within the SVRA.

Training for Local Service Providers. Three SVRAs initiated or participated in efforts to explain the several components of the Ticket legislation to local service providers and vendors; the SVRAs’ goal was to involve providers/vendors in TTW, Medicaid Buy-In programs, and other state initiatives. The South Dakota SVRA, for example, has conducted extensive training at conferences sponsored by the Association for Persons in Supported Employment (APSE). Similarly, the Georgia SVRA hosted “partners meetings” for community organizations and individuals interested in joining the SVRA as a partner. The SVRA brought in a consultant to facilitate the meetings, prompting several organizations to apply for EN status.

Outreach to SSA Beneficiaries. Two SVRAs initiated orientation sessions to explain not only the TTW program to beneficiaries but also the services and supports available through the SVRA. The Michigan SVRA, for example, works with a benefits planner to host special orientation sessions for SSA beneficiaries. Some of the SVRA’s partners, including ENs, send clients to the orientation sessions.

3. More Reliance on Benefits Planning and Assistance

Seven of the eight SVRAs indicated that the availability of the BPAO program has changed the way they work with beneficiaries. The SVRAs in four states—Connecticut, Georgia, Massachusetts, and Vermont—operate a BPAO program though a cooperative agreement with SSA. Two SVRAs are using funds received through the traditional program to support benefit specialist positions, and two other SVRAs are considering this option for the future.

4. Traditional Payment Program As a Funding Source

The eight SVRAs generally see SSA’s traditional cost reimbursement program as a particularly important source of revenue. Most continue to believe that TTW will have a negative effect on cost reimbursement revenue, thereby threatening the states’ ability to provide case services. This perception is significant because SVRA revenues from the traditional payment system had begun to decline before TTW’s launch.

5. Elimination of the DDS Referral Program

The eight SVRAs differ in terms of how they feel about the extent to which the elimination of the DDS referral program, a consequence of the TTW legislation, has affected referrals to them. Two states have examined the traditional program, in which DDS offices referred individuals directly to the SVRA, and determined that few individuals referred from DDS (only 4 percent, according to one state) ultimately became SVRA clients. Two states indicated that the previous link with the DDS program was not only extremely valuable but also a primary source of referrals, noting that the elimination of the DDS referral program has led to small but significant decreases in referrals to the agency. The remaining four states indicated that it was too early to assess the effect of eliminating the referral program.

6. Administrative Burden

The eight SVRAs all reported that TTW has increased their administrative burden under the traditional payment system; as a result, their costs have risen as well. Respondents indicated that central office staff and local rehabilitation counselors spend a substantial amount of time explaining the program to beneficiaries, encouraging them to assign their Tickets to the SVRA, and trying to ensure that beneficiaries exercise informed choice in assigning their Ticket. TTW’s administrative burden is a significant concern because any increase in SVRA administrative costs will reduce net revenues.

 

F. SUMMARY AND CONCLUSION

SVRAs continue to play a major role in TTW simply because they are the dominant providers of employment services for people with disabilities. To date, over 90 percent of Ticket assignments have gone to SVRAs, a trend that has remained steady since program launch. While TTW has changed SVRA operations in some respects, the number and type of core services provided to SSA beneficiaries appear to have remained the same. Furthermore, SVRAs choose the traditional payment system for almost all their Tickets as opposed to one of the two new payment systems. Together, these findings suggest that most beneficiaries participating in TTW are doing so under virtually the conditions that would have been in place before TTW was created.

SVRA officials remain unconvinced that the new payment options will be as lucrative as the traditional system, and they are not alone. As documented in Chapter V, some ENs would rather operate as vendors to SVRAs under cost reimbursement than as independent entities waiting to collect milestone or outcome payments. SVRAs also remain concerned about the potential impact of lost cost reimbursement payments.

SVRA-EN agreements do not appear to foster a positive relationship between the two types of providers. Influenced by the current interpretation of comparable benefits, most SVRAs have drafted agreements that create significant financial risks for ENs. It is not surprising, therefore, that many ENs have shied away from the agreements.

Employment Outcomes for SVRA Clients. The share of SSA beneficiaries that have assigned their Ticket to an SVRA and met the employment criteria for generating a payment to the SVRA under the traditional payment system has recently declined. At the same time, the share of TTW participants whose cases have been closed as competitively employed has declined.

These declines, which started in the same year as the Phase 1 TTW rollout, raise concerns over whether they were related to TTW in some way. In general, it seems unlikely that TTW caused the overall reduction in employment outcomes because the decline has been consistent across all three groups of states (Phase 1, 2, and 3). The downturn in the economy might explain the decline, but the pattern does not hold for other SVRA clients. If the economic downturn is to blame, the fact that the decline is not observed for non-beneficiary SVRA clients suggests that the slowing economy had a much greater impact on beneficiary clients, perhaps because they have an alternative source of income (i.e., DI or SSI benefits) or because they have more challenging physical and medical conditions. Whatever the cause, the trend toward decreased employment outcomes for SSA beneficiaries served through SVRAs is disturbing. Future analyses will examine whether these trends continue and, if they do, will identify the underlying causes.


1 The information in this paragraph is from the Institute for Community Inclusion (2005). Return to Text.

2 The percentages identified in Figure VI.1 include both successful and unsuccessful case closures. Successful case closures are those in which the participant achieves competitive employment in an integrated setting that is consistent with the participant’s strengths, resources, priorities, concerns, abilities, capabilities, and informed choice. An individual may achieve a successful closure yet not meet the SGA earnings level in any given month. An unsuccessful closure occurs when an individual leaves the SVRA service rolls before achieving an employment outcome. Return to Text.

3 Since 1981, SSA reimbursed SVRAs for services provided to SSA beneficiaries that result in specified employment outcomes. Despite considerable state-to-state variation under the SSA VR Reimbursement Program (the traditional payment program), the state Disability Determination Services (DDS) Program generally referred to SVRA new beneficiaries who appeared to be possible candidates for rehabilitation. If the SVRA was able to assist the beneficiary in achieving employment at or above SGA for 9 months in a 12-month period, SSA reimbursed SVRA for the “reasonable and necessary” costs of providing rehabilitation services to an eligible beneficiary. With the inception of the TTW program, the DDS referral program was eliminated, but SSA continues to reimburse SVRAs for individuals who meet the specified employment criteria. Return to Text.

4 Before FY2002, SVRAs were required to report only if clients received SSA benefits at any point during their receipt of RSA services. From FY2002 forward, they were required to report receipt separately at both client application for SVRA services and closure. Hence, our method for identification of SSA beneficiary clients in FY2002 and FY2003 (any client who is reported to receive benefits at application or closure) differs from our method for earlier years (any client reported to have received benefits at any time during the service delivery period). Note that the divergence in competitive employment trends for beneficiary and nonbeneficiary clients begins in FY2002, which would be consistent with the possibility that a change in reporting is the cause. It is not apparent, however, why the particular change would have the observed effect. Return to Text.

5 Comparable services and benefits are defined in the Rehabilitation Act of 1973 as amended by the Workforce Investment Act of 1998 as follows: “(A) Services and benefits that are provided or paid for, in whole or in part, by other Federal, State, or local public agencies, by health insurance, or by employee benefits; (B) Available to the individual at the time needed to ensure the progress of the individual toward achieving the employment outcome in the individual’s individualized plan for employment; and (C) Commensurate to the services that the individual would otherwise receive from the designated State vocational rehabilitation agency.” Section 101 (a) (8), 34 CFR Part 361.5. Return to Text.