New York Makes Work Pay Developing a path to employment for New Yorkers with disabilities www.NYMakesWorkPay.org Policy to Practice Brief #5 Enhancing the Peer Support Model Using the Ticket to Work to Expand Employment Services to SSI and DI Beneficiaries Thomas P. Golden Employment and Disability Institute John Allen New York State Office of Mental Health About Policy-to-Practice Briefs This document is one of a series of policy-to-practice briefs published as part of the New York Makes Work Pay Project, a Comprehensive Employment Services Medicaid Infrastructure Grant funded by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) to the New York State Office of Mental Health (OMH) and its management partners the Blatt Institute at Syracuse University and the Employment and Disability Institute (EDI) at Cornell University. The New York Makes Work Pay Initiative is currently funded for calendar years 2009 and 2010 and will provide an array of services to individuals with disabilities and the agencies and advocates that serve them, helping to remove obstacles to work and pave the way to self-supporting employment.(Footnote Reference 1) Footnote 1: A detailed description of the New York Makes Work Pay Project and its services can be found at http://www.NYMakesWorkPay.org This brief is based, in part, on a similar document last updated by the authors in 2003 and originally published by the Work Incentives Support Center in the Employment and Disability Institute at Cornell. Materials were reviewed for accuracy by the Social Security Administration (SSA), Office of Employment Support Programs. However, the thoughts and opinions expressed in these materials are those of the authors and do not necessarily reflect the viewpoints or official policy positions of the SSA, CMS, or OMH. The information, materials and technical assistance are intended solely as information guidance and are neither a determination of legal rights or responsibilities, nor binding on any agency implementation and/or administrative responsibilities. This publication is based on federal Social Security and Supplemental Security Income (SSI) laws, regulations and policy. However, unlike earlier versions, the current version is specifically targeted to New Yorkers with disabilities and, as such, will use New York’s SSI rates in all its examples. Also, as relevant, we will specifically mention New York agencies by name and reference any New York-specific supports which may be able to assist New Yorkers with disabilities achieve their work goals when used in combination with SSI’s Plan for Achieving Self Support. Notwithstanding this focus on New York, this publication will include extensive references to SSI policy and will be a valuable reference throughout the nation. Contents I. Introduction II. The Peer Support Model III. Peer Support Services A. Social Interaction and Educational Services B. Health, Wellness and Crisis Services C. Community and Daily Living Supports D. Protection and Advocacy E. Employment Services and Supports IV. The Ticket to Work and Self-Sufficiency Program A. Ticket to Work Eligibility B. How the Ticket To Work Program Actually Works C. Can Peer Support Groups Serve as Qualified Employment Networks? D. How The Ticket To Work Program Can Expand Program Revenue E. The Payment Systems 1. Payments Under the “Outcome Payment System” 2. Payments Under the “Outcome Milestone Payment System” 3. Assessment of Prior Work Activity and Milestone Payments 4. Payment Rates under the Outcome Milestone Payment System F. Reporting and Processing Payments G. What Is the Benefit of Participating in This Program for Our Support Group And Our Constituents? V. Enhancing Service Options for Peer Support Groups VI. The Operations Support Manager and the Program Manager for Recruitment and Outreach VII. Summary I. Introduction This paper was developed to create a framework for government and individuals to support the expansion of peer support groups to offer vocational rehabilitation, employment services, and/or other supports that enhance the employment outcomes of beneficiaries of Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) who are or have been in the mental health system. Typically peer support groups offer a myriad of customized services and supports from a standardized menu of service offerings to create a service model that best meets the needs of the constituents they are serving. Often this menu of services can become the basis of a government contract or funding as a complimentary augmentation of the traditional mental health service array. This paper describes a model of the typical service approach provided by existing peer support groups throughout the United States (US). Peer support groups targeting individuals who are or have been in the mental health system are a rapidly growing market segment in the US, and SSI and SSDI beneficiaries make up a large percentage of constituents served by these support groups. In the Annual Statistical Report on the Social Security Disability Insurance Program (SSA, 2008), one-third of beneficiaries receiving SSI and SSDI in the US have a mental disorder other than mental retardation—representing over three million beneficiaries nationwide. Of those three million beneficiaries, only 37, 711 receiving SSDI in 2008 successfully returned to work.(Footnote Reference 2) The disparity between these two figures represent the vast numbers of individuals with mental illness who potentially could benefit from access to peer-run vocational rehabilitation, employment services, and/or other services and supports. Footnote 2: Social Security Administration. (2009). Annual Statistical Report on the Social Security Disability Insurance Program, 2008. Washington, DC: Office of Policy, Office of Research, Statistics and Evaluation. Table 53. Distribution of workers with benefits terminated because of successful return to work, by diagnostic group and age, 2005. This paper models how peer support groups can expand their current approach through participation in the Ticket to Work and Self-Sufficiency Program. Discussed is how participation as an Employment Network (EN) can broaden and deepen services provided while at the same time creating revenue to support additional enhancement of services and supports that could be available. II. The Peer Support Model Self-help, mutual or peer support, and peer-run organizations exist on a continuum from doing things for one-self to large multi-faceted organizations. Since many use the term “self-help” when referring to mutual support groups, we begin with definitions that we will use consistently in order to promote understanding. Self-help refers to methods that individuals use to help or improve oneself without assistance from others. Mutual or peer support refers to groups of people who share a common experience who come together in order to provide each other with moral support, information, and advice. The term peer-run organization refers to those organizations (including mutual or peer support groups) that are member-run, in which the majority of staff and a majority of the board are made up of people who would qualify for membership (i.e. individuals who have used mental health services or been psychiatrically labeled). Many peer support groups, peer run organizations and some traditional mental health providers provide information on self-help but have come to use the term in ways that refer to the “industry” of peer support or peer-run organizations. There are four characteristics which make up a peer support or mutual help group as cited by the American Self-Help Group Clearinghouse (White & Madara, 2007). They are: *Mutual Help — This is the primary dynamic process that takes place within the group — it’s people helping one another and helping themselves in the process. Experiences are shared, knowledge is pooled, options are multiplied, hopes are reinforced, and efforts are joined as members strive to help one another. *Member-Run — Member run and “owned.” Providing a sense of belonging and reflecting members’ felt needs. They are not professionally run groups. If professionals are involved (and in many cases they are) they serve in ancillary supportive roles, i.e., they are “on tap, not on top” as some groups describe it. *Composed of Peers — members share the same problem/experience, providing a powerful sense of understanding and not being alone, which can often lead to an almost instant sense of community at the first meeting. *Voluntary Non-Profit organization — volunteer-run or at a minimum voluntary participation, no fees; dues, if any, are minimal. They are, as described by A. Tofler in his 1980 book, The Third Wave, prosumers, rather than consumers. Peer support groups often begin with a single individual or small group wanting to meet their own specific need for support. Peer-run organizations are the outgrowth of these groups as they grow and develop creating more groups to address identified need. This document, in addition to providing government with a potential framework for contracting, can provide developing groups with ideas and methods to address need. III. Peer Support Services Peer support services vary in the types and breadth of services they offer. Often even when peer support groups offer similar services, the depth and breadth of those services may vary greatly. Below is a breakdown of typical services and supports available. A. Social Interaction and Educational Services Peer support groups offer an array of services to support social interaction and relationship building. In addition, they provide educational services to assist their constituents in understanding themselves, their environment and how to self-manage aspects of daily living. Drop-In Centers - Many groups begin in a more formalized way with the creation of a drop-in center. This is a place where people can stop by at any time to enjoy a cup of coffee, socialize or just hang out in a low stress, low demand environment. Centers are typically staffed at first with volunteers who insure a safe, comfortable and friendly atmosphere. The drop-in center becomes a focal point from which to offer other services. A drop-in center is often used as an engagement strategy attracting those not interested in participating in traditional mental health service offerings. Many centers begin operation in donated space such as part of a church or sometimes a formal mental health center. Hours of operation vary from a few hours one day a week (typical in donated space), to evening and week-end hours for those complementing traditional service providers, to 24 hours a day / 7 days a week for those providing homeless support services. Peer Support - Whether part of the formal process or simply as a matter of people building relationships in peer support groups, the notion of one-to-one peer support is central. As groups grow, they will often provide training for volunteers who are willing to provide support to other members. Some groups create mechanisms to visit sick members, paying particular attention to those who are hospitalized, to help them maintain a connection with the community. In other areas, peer support groups contract to provide peer bridger services, which help those individuals who are in psychiatric hospitals make the transition to community life. This is an especially valuable service assisting long term residents of psychiatric hospitals in overcoming the fears related to leaving a facility. Social Recreation Events - As groups grow and people form natural relationships within the peer support group, the desire to social recreation activities expands. Many peer support groups offer social recreation opportunities both to meet member needs, and also to create marketing for new members. Social recreation provides opportunities for members to continue to build their own natural support networks as well as simply have fun. Many groups plan dances, movie outings, picnics, softball games, bowling leagues and other events based on member preferences. Support Groups - Many peer support groups identify other needs as individuals come together for support. This results in many groups developing other support groups as part of their overall efforts such as: art activities; Depression and Related Affective Disorders Association (DRADA); Emotions Anonymous (EA); groups for individuals who are Lesbian, Bi, Gay, Transgendered (LBGT); men’s groups; music groups; Recovery Inc.; and women’s groups. Psycho-Education / Self-Management Education - Many peer organizations provide a variety of educational programs to support their member’s recovery. A number of peer support groups have explored a variety of methods to increase available funding to support their activities including the use of Medicaid. Offering psycho-education and groups to educated individuals on self-management strategies is something that a number of states have now adopted as a Medicaid billable peer provided service. Newsletters - Almost all peer support groups develop a newsletter as a way of keeping their members informed of events and activities. These newsletters also create volunteer opportunities for members to become involved with the variety of production activities from writing to layout. Some newsletters publish member poetry, art, short stories, recipes, book and travel reviews in addition to center news. Newsletters are an excellent method of marketing the peer support group as well as disseminating valuable information to members. Speakers’ Bureau - Peer support groups frequently develop Speakers’ Bureaus for a variety of reasons. The most common are to enhance their efforts to attract new members, to provide public education regarding recovery and stigma, and to support their fund-raising efforts. Speakers’ Bureaus provide members with a variety of opportunities for personal growth and development in addition to de-stigmatizing mental health in the community. Some groups partner with organizations like Toastmasters International to assist members with public speaking skills. B. Health, Wellness and Crisis Services Peer support groups recognize the importance of holistic services and supports that meet the need of the entire person. Many groups offer services specifically targeted to enhance or maintain health and wellness while at the same time serving as a critical crisis support vehicle. Substance Abuse Recovery Supports - Individuals who have used mental health services often identify co-occurring substance use as an issue they would like help with. For this reason, many peer support groups and drop-in centers offer or support substance abuse groups like Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or Double Trouble and Recovery (DTR) by holding meetings at their locations. Specialized groups like DTR address the concerns of people who use psychotropic medications in ways that some typical AA meetings can’t (some groups require no drugs of any kind including prescriptions). Groups often begin by partnering with a AA , NA or DTR group offering space and refreshments. Some drop-in centers have volunteers and or staff with training and backgrounds specific to facilitating a group. Advanced Directives / Wellness Recovery Action Plans - As groups develop and members gain more experience in their personal recovery journeys, helping members find ways to insure their treatment preferences are respected and followed is a natural development. Advanced directive training and support follows with groups providing information, education and some offering workshops. Some groups take the legal concept of advanced directives to incorporate treatment preference planning beyond just a crisis plan. Most places that provide workshops recommend that an advanced directive be developed over a period of time in discussions with the supports that an individual desires. In this way, the people providing support know the exact preferences of the individual they are supporting and under what circumstances they should take action. This service, provided by a peer support group in a traditional provider setting, can create opportunities for traditional mental health staff to move beyond simply understanding the preferences of their clients, allowing them to create service options that actually promote recovery. Wellness Recovery Action Plans (WRAP) is a process many peer organizations endorse, which supports each individual in creating a plan for themselves through structured discussions and activities. Many peer groups offer members, volunteers and staff the opportunity to attending WRAP facilitator training so that they are credentialed to run WRAP groups. Crisis Support / Warm Lines - As peer support groups grow, many begin to provide a variety of crisis supports, usually beginning with volunteer in-home peer support during crises. Some groups expand that concept to a more formal crisis option, with some establishing crisis emergency residences under contract with local government as peer-staffed hospital diversions. Many also begin telephone support trees in which members provide informal support to each other. In a number of instances, these have grown to more formal warm lines staffed by peers to provide telephone support. C. Community and Daily Living Supports At some point in everyone’s life the need for supports to manage everyday life arise. Most peer support groups offer a broad segment of services in this area. Clothes Closet - Depending on the needs of members, some peer support groups working with other community organizations provide a Clothes Closet, enabling members to find warm clothing in the winter when they lack financial resources, for example. Often these are as simple as a closet in the drop-in center, where people place clothing they no longer want that others can use. In some peer support groups this activity has grown to the point of an agency run thrift shop that generates both employment opportunity for members as well as income for the group. Community Meals / Kitchen - An easy way to entice new members when starting a peer support group is to provide food. Many peer support groups offer community meals as a way also of addressing members’ issues in making limited financial resources stretch. Peer support groups that provide homeless services find that meals become a necessity to meet their members’ needs. No matter the reason that a peer support group provides meals, they become an attraction and engagement tool for attracting new members and building a true community of support for existing members. Meals are frequently begun as pot-luck suppers, where each member agrees to bring an item to share. Working with food pantries and extension agents, community meals can provide opportunities to provide meal planning and preparation and nutrition education to members, enabling them to get the most from their limited food budgets. Food Pantry / Nutritional Assistance - Many groups, particularly those that have established community meals, begin to explore creating food pantries in collaboration with local food banks. These pantries provide members with low cost or emergency food options that enable individuals living on the fixed income from disability to be able to maintain a healthy diet. Some programs also work with local cooperative extension or homemaker services to provide education on meal planning and preparation as part of their service. Housing - Some of the earliest peer support groups created a variety of informal housing options in which members shared resources in the same way that non-disabled individuals room together. This has led to the creation of a variety of housing options including peer support groups operating HUD section 8 housing programs, providing McKinney Homeless housing services and building Habitat for Humanities housing. Working with local NAMI, Mental Health Associations and local Habitat for Housing, some peer support groups build on a program started in Georgia called “Jerome’s Home” to create home ownership opportunities for individuals in the mental health system. Parenting Support - The least provided service in traditional mental health systems is support for individuals who receive services who are parents. In this area, peer support groups have created a variety of support mechanisms including parenting education, support groups and even in a few places respite babysitting services. Other groups have focused on advocacy in parental rights, often with child custody issues taking the forefront. Laundry - As groups grow and established permanent drop-in centers, some provide opportunities for members to meet their laundry and cleaning needs. This is especially true for groups that provide support to individuals who are experiencing homelessness. Although laundries do exist, many individuals who are homeless find that they are not welcome at those establishments, so peer support groups become their only option. Lending Library - Although public libraries can often address the need for information on recovery, many peer support groups maintain literature and publications on everything from medication to legal rights. These libraries of information are often used by the groups as part of their member educational efforts. Mail Service - Peer support groups that have a number of members who experience homelessness or live in transitional housing will sometimes create mail services. This sometimes looks like a post office with locked mail boxes for each individual and is sometimes as simple as acting as the address for those that lack stable housing enabling them to receive mail. D. Protection and Advocacy Throughout an individual’s life the need for certain levels of protection and advocacy may be needed. An individual who receives a benefits overpayment may need assistance navigating the appeals process. An individual being discriminated against on the basis of their disability may need legal representation or advocacy support. Peer support groups, working in conjunction with federally-mandated protection and advocacy programs, ensures their constituents needs are met in this area. Advocacy / Advocacy Training - Most mutual support groups for mental health recipients in the past were started as a way to change the system. Individual and systemic advocacy is a service that many peer support groups still perform, both as a way of assisting members in addressing issues, and as a method of engagement of new members. Advocacy has also taken new directions, as some jurisdictions employ peer support groups to gather input into governmental processes. Other groups provide individual advocacy training to enable members to become better self-advocates. There are peer support groups that work with both the federal Protection and Advocacy for Individuals with Mental Illness (PAIMI) and Protection and Advocacy for Beneficiaries of Social Security (PABSS) agencies to act as lay advocates and provide legal representation. Some service systems provide advocates contracted from peer support groups to assist individuals in navigating complaint and grievance processes or other part of the system. Forensic Support / Jail Diversion - In some areas, peer support groups who have members involved in the criminal justice system provide a variety of support activities specifically aimed to help re-integration and maintenance of positive community involvement. As groups have provided training and support to local law enforcement, some groups have developed a variety of formal and informal mechanisms to assist with diversion activities. These typically involve crisis support for individuals whom police are called as a result of unusual behavior. Representative Payee Services/Budgeting and Money Management - Many individuals on Social Security benefits have the need for assistance in managing their funds through a representative payee. In some cases, individuals are mandated to have a payee because of prior money management or chemical addictions. Since it is often difficult to find someone willing to accept responsibility as a payee given the lack of funding for this service, peer support groups in many areas have provided training and staff to assist members as a representative payee. In some instances, peer support groups have expanded their efforts to help members learn better money management skills. Some have a member who is an accountant can assist with tax return preparation. E. Employment Services and Supports While relatively new to the menu of peer support services, employment services and supports are a rapidly growing segment. Many people prefer to receive vocational and employment support from peers who share a common experience —with whom they have trust. This basic element of human nature provides a solid springboard for peer support groups to begin expanding their service offerings if they are not already engaged in career development and employment services. Computers / Internet Access - Once a peer support group grows, having a computer to keep records and write the reports required by funding sources becomes critical. Groups have found that they can address members’ needs by making that same computer available to members to aid in resume writing, and job searches. Some groups augment their single computer by seeking donations from companies that regularly upgrade and replace their equipment. This has created an opportunity for these peer support groups to establish computer training programs, which in some cases include industry standard certifications recognized by Microsoft and Novell. Internet access is frequently available at free or reduced rates from local internet providers once the group has its non-profit status. This allows the group’s members to conduct their own research and education on topics such as medications, diagnosis, wellness self management, or other topics of interest. Some peer support groups serve as pre-vocation sites and even vocational employment training sites for the traditional service system. Literacy Training / Education Support - Depending on the community and its members, some peer support groups collaborate with basic literacy education programs to assist members with basic reading skills or attainment of G.E.D. diplomas. Other groups augment disability services frequently available on college campuses to support members who are furthering their education through college or vocational classes. Volunteer Referral - As peer support groups grow, providing members linkage with volunteer opportunities is almost a standard offering. Few groups begin without the ability to recruit, mobilize and manage volunteers. Some groups working with volunteer clearinghouses co-host opportunities to explore volunteering. Other groups provide information and support to members who are interested in volunteering. Work Incentives and Benefits Planning and Assistance - New people receiving mental health services and individuals who have been in the system who desire to work, often seek guidance from peers on benefit and entitlement issues. Many peer support groups provide work incentives and benefits planning and assistance, ranging from supports pertaining to SSI, SSDI, Medicaid, Medicare, and other federal entitlements and benefits (i.e. Temporary Assistance for Needy Families, Housing and Urban Development, etc.), to state and local assistance like emergency energy assistance. With turnover rates for mental health workers being high, individuals who have been in the system are often the best source of practical information on benefits. Work incentives and benefits planning and assistance are commonly occurring services within peer support networks, and a critical foundation upon which to participate in the Ticket to Work Program and begin offering vocational rehabilitation, employment services and/or other supports leading to employment and greater economic self-sufficiency of beneficiaries. This will be discussed in greater depth in the next section. Career Club / Employment - As peer support groups grow in membership, issues of recovery often begin to focus on employment. To supplement the work incentives and benefits planning and assistance that is critical when considering work, peer support groups have created job/career clubs to provide mutual support for members seeking employment and struggling with returning to work. Coupled with traditional employment or job coaching services, this mutual support activity provides a unique assistance to aid individuals in transitioning from an individual identity of a disabled person to that of productive employee. Some peer support groups have created agency run business enterprises as a way of creating supportive job opportunities for members. Career development and employment services, coupled with benefits and work incentives planning and assistance, are the essential elements to success under the Ticket to Work Program. Peer support groups serving individuals with mental illness typically report high percentages of constituents receiving either SSI, SSDI, or both. These individuals are more than likely Ticket holders under the Ticket to Work program and potentially looking for ENs to assist and support them in achieving their vocational and work goals—an already established referral network within the peer support group. IV. The Ticket to Work and Self-Sufficiency Program With the passage of the Ticket to Work and Work Incentives Improvement Act(P.L. 106-170) (Ticket to Work Act) came several enhancements to individualized assistance and case management in the United States for beneficiaries of SSI and DI to support employment outcomes. Title I, subtitle A of the law established the Ticket to Work and Self-Sufficiency Program (Ticket to Work Program) to allow individuals with disabilities to seek the services and supports they need to obtain and retain employment and reduce their dependency on cash benefit programs (Bruyere, Golden & Zeitzer, 2003). One of the primary purposes of the Ticket to Work Act was to expand the universe of providers available to provide beneficiaries with disabilities who receive SSI and SSDI access to vocational rehabilitation, employment service, and/or other supports needed to achieve an employment outcome (Golden, 2003). Part of that potential universe of providers should be peer support groups. The Ticket to Work Program is operated through a national network of service providers referred to as “Employment Networks” or “ENs” and State Vocational Rehabilitation Agencies who are recruited, approved and contracted with for providing services by the Social Security Administration (SSA) through the program manager, MAXIMUS, Inc.(Footnote Reference 3) To serve as an EN, a peer support group would need to complete the application process and this is discussed in greater detail later in this paper. Footnote 3: More comprehensive information pertaining to the administration, management reporting requirements, and interplay of other SSA programs on the Ticket to Work and Self-Sufficiency Program is available in The Ticket to Work and Self-Sufficiency Program: The Changing Landscape of Vocational Rehabilitation for Beneficiaries of Social Security Administration Disability Benefit Programs a free Policy to Practice Brief prepared by Cornell University’s Employment and Disability Institute. This is available on-line in both pdf and text at http://www.ilr.cornell.edu/edi/s-PPBriefs.cfm (brief #6). The initial regulations to implement the Ticket program were published in the Federal Register on December 28, 2001(Footnote Reference 4) and became effective on January 28, 2002. In February 2002, SSA issued new Ticket to Work procedures in its Program Operations Manual Systems (POMS), used by SSA staff to implement the Ticket provisions. (Footnote Reference 5) Footnote 4: 20 CFR. Part 411, published as final regulations at 66 Fed. Reg. 67370 - 67442 (Dec. 28, 2001). Footnote 5: POMS DI 55001.000 et seq. In several reports over the course of the first six years ofimplementation of the Ticket to Work program, the Ticket to Work and Work Incentives Advisory Panel cited the inadequacy of program performance. The Crisis in EN Participation: A Blueprint for Action(Footnote Reference 6) clearly delineated the shortcomings in the structure of the program, stating that the Ticket to Work Act, specifically the Ticket to Work program, had failed to recognize its full potential in expanding employment opportunities for people on the SSA disability roles. Further, the report observed that the program had failed to recruit the anticipated numbers of ENs and that only a small fraction of beneficiaries were currently being served by the program. While the report showed that over 1,000 providers had enrolled as ENs, only about one-third of those operating had accepted Tickets. Reasons cited for this poor performance included the reality that State VR Agencies were more advantaged under the VR Cost Reimbursement Program and that payment schemes under the Ticket program were inadequate to provide enough incentive to entice ENs. Footnote 6: The Crisis in EN Participation: A Blueprint for Action. (2004). Advice Report to Congress and the Commissioner of the Social Security Administration. SSA: Baltimore, MD. An earlier report issued by the Panel in 2002 had already discussed the inadequacy of financial incentives for ENs and explained that beneficiaries requiring long-term supports, high cost accommodations, earning sub-minimum wage, and individuals who work and receive a partial cash benefit would not be served under the initial regulations promulgated by the Administration.(Footnote Reference 7) This was reinforced by a later work group which was established by the SSA in response to a Panel recommendation, specifically charged with developing an alternative payment scheme that addressed the adequacy of incentives for the four targeted groups identified in the initial legislation. In response to the growing national discontent with the initial regulations and the reality that the Ticket program had yet to recognize its full potential, the Commissioner of the SSA issued subsequent regulations concerning the Ticket to Work program.(Footnote Reference 8) These final Ticket regulations are based on Notices of Proposed Rulemaking published in the Federal Register on September 30, 2005 and August 13, 2007. The revised regulations incorporate SSA’s vision of the future direction of the Ticket to Work Program and are based on lessons learned and issues arising from SSA’s experience in implementing the prior regulations. In the preamble to the regulations SSA stated… Footnote 7: Design Issues Relating to the Adequacy of Incentives Study.(2002). Advice Report to the Commissioner of the Social Security Administration. SSA: Baltimore, MD. Footnote 8: 20 CFR Part 411, published as final regulations at 73 Federal Register 29324-29335 (May 20, 2008). “We are revising our prior rules to improve the overall effectiveness of the program to maximize the economic self-sufficiency of beneficiaries through work opportunities. We have based these revisions on our projections of the future direction of the Ticket to Work program, our experience using the prior rules, and the recommendations made by commenters on the program.” The new, long-awaited regulations became effective on July 21, 2008. The regulations laid out a new payment scheme to address adequacy of financial incentives for ENs, expand eligibility criteria, modify certain procedural rules regarding beneficiaries making timely progress toward their individual work plans, and allow the VR Cost Reimbursement Program to operate parallel to the Ticket to Work program, affording availability of longer-term supports for beneficiaries that require intensive VR services and supports. (Footnote Reference 9) Footnote 9: Id. 20 CFR Part 411. A. Ticket to Work Eligibility To be eligible to participate in the program an individual must be entitled to Title II disability benefits or Title XVI (SSI) disability or blindness benefits. The individual must also meet several additional criteria to be eligible for a Ticket: *be 18 and not attained age 65 years of age; *if an SSI recipient, be eligible for benefits under the adult disability standard; *be receiving a federal cash benefit from Social Security. A person is not eligible to participate in the Ticket program if they are receiving: “Section 301” payments, i.e., continued SSDI or SSI benefits following a determination of medical improvement because they are participating in an approved VR program;(Footnote Reference 10) continued benefits while appealing a cessation of benefits based on a finding of medical improvement; provisional cash benefits while SSA is considering a request for expedited reinstatement of SSDI or SSI; or presumptive disability payments while awaiting a final decision on an application for benefits. Footnote 10: See 20 CFR 404.316(c), 416.1338; POMS DI 13515.001 et seq. SSI beneficiaries who are 18 years old and received SSI as children will not automatically be provided a Ticket upon turning 18. However, they will qualify for a Ticket later if SSA finds them disabled based on the adult standard after conducting an age 18 redetermination.(Footnote Reference 11) Footnote 11: POMS DI 55002.005 C.5. An individual is eligible for only one Ticket during a period of entitlement to SSDI or SSI based on disability. However, if entitlement to SSDI or SSI ends or is terminated, and is later reinstated, a new Ticket will be issued.(Footnote Reference 12) There is no limit to the number of new Tickets an individual could receive. Footnote 12: 20 CFR 411.125(b) and (c). B. How the Ticket To Work Program Actually Works The Ticket to Work program is strictly voluntary in nature and beneficiaries are not required to participate. A beneficiary’s Ticket never expires, so while a beneficiary may choose to not use their Ticket when it is received, they can utilize it at any point in the future when they feel they are interested and ready to pursue work. Once a beneficiary has made a positive choice to use their Ticket, they can assign it to any EN or State Vocational Rehabilitation Agency (SVRA) of their choosing. Keeping with the voluntary nature of the program, an EN or SVRA can choose to not accept a Ticket if they feel the individual may not benefit from their services — resulting in the beneficiary’s achievement of their vocational goals. In that case, a beneficiary can continue to shop for an EN until they find one where both parties mutually agree to assign the Ticket. MAXIMUS, Inc maintains a directory of available ENs across the US on their website at http://www.yourtickettowork.com. A Ticket cannot be assigned to more than one EN at any given time however, should a beneficiary become unsatisfied with the services and supports being provided by an EN they can take their Ticket out of assignment and reassign it to a new EN. Again, keeping with the voluntary nature of the program, an EN can also decide to take a Ticket out of assignment if they feel a beneficiary is not progressing toward their agreed upon goals at any time. A Ticket being assigned is the beginning of an exciting and often interesting journey toward employment. Following Ticket assignment, the EN and beneficiary will begin a dialogue regarding the individual’s employment goals, needs for services and supports, and level of earnings a beneficiary may need to offset the potential and future decrease in or loss of cash benefits. This discussion leads to the development of an Individualized Work Plan (IWP). The plan basically details specific services and supports the EN will provide to assist the beneficiary in reaching their stated work goals. The EN and beneficiary will develop the IWP together and both sign it as a form of agreement as to expectations regarding performance. Once agreed to, the EN and beneficiary will begin working together on achieving the plan. As the beneficiary makes progress toward their stated work goals and is meeting specific employment criteria, the EN is paid a portion of the savings to the SSA for having supported the beneficiary in achieving their goal. ENs are not paid for services rendered but rather for outcomes achieved by the beneficiary. For a peer support group, this revenue can offset the cost of offering specific services and supports not covered by existing funding sources. In addition, these revenues could be used to offer financial incentives to beneficiaries to provide incentive for them to make progress toward their individual goals. For example, an EN may want to consider offering a post-employment cash benefit to beneficiaries they serve that obtain a certain outcome. Once a beneficiary is no longer receiving a cash benefit from the SSA, to alleviate the potential stress associated with this loss of income, the EN may pay the beneficiary a percentage of the Ticket payment they receive as an incentive to stay employed. Another example might be where an EN uses a small portion of their Ticket payment to pay a stipend to the beneficiary for reporting weekly earnings (Golden, 2003). C. Can Peer Support Groups Serve as Qualified Employment Networks? The simple answer is yes. Any agency, instrument of a state (or political subdivision), or a private entity that takes responsibility for the coordination or the actual delivery of services is eligible to apply to be an EN. An EN can be a single entity or a collaborative made up of several entities who choose to combine resources to serve Ticket holders. A peer support group would just need to provide evidence that they are qualified to provide the specific services and supports they say they are going to provide to beneficiaries in the application they submit to SSA. Additional information and the application for becoming an EN is available online at http://www.yourtickettowork.com. D. How The Ticket To Work Program Can Expand Program Revenue The very purpose of the Ticket to Work Program is to pay ENs based on their ability to assist beneficiaries in achieving certain employment criteria. Payments to an EN are based on work activity that result in savings to the SSA as a result of decreased or cessation of SSI or SSDI cash benefits. Under the new regulations governing the Ticket to Work Program, ENs have an option to be paid under one of two payment systems – the Outcome Payment System or the Milestone Outcome Payment System. Payments to ENs are dependent on several factors: the type of benefit received by the beneficiary; the type of payment system selected; and, how quickly the beneficiary achieves the required work outcomes for the payment system selected. An EN will select their preferred payment system when entering into agreement with the SSA although opportunity does exist to modify this choice at a later time based on a schedule established by the SSA. E. The Payment Systems The underlying premise of the Ticket to Work program is to pay ENs based on the satisfactory employment (or self-employment) outcomes of the SSDI or SSI beneficiary. With the exception of the Phase I milestone payments and Phase II outcome payments available under the Outcome-Milestone Payment options, and the separate option for State VR Agencies to be paid under the longstanding cost reimbursement payment system, all payments to an EN occur based on work activity that results in the beneficiary’s loss of SSDI benefits and disability-based federal cash SSI benefits. ENs (including a State VR Agency acting as an EN) may elect to be paid under one of two EN payment systems - the Outcome Payment System or the Outcome-Milestone Payment System. Payments under the new EN payment systems differ, depending on the option chosen and the types of benefits received by the beneficiary. The pace of payments to an EN will also depend on how quickly the beneficiary achieves the required work outcomes. An EN elects one of the two payment systems when it enters into an agreement with SSA to serve as an EN. After first electing a payment system, the EN can then make one change in its chosen payment system during each calendar year. (Footnote Reference 13) Footnote 13: 20 CFR 411.515. Each calendar year, SSA bases the payments for both EN payment systems, described below, on something called the Payment Calculation Base. One of two Payment Calculation Bases is used, depending on whether the individual served is an SSDI or SSI beneficiary. For SSDI beneficiaries (including concurrent SSDI/SSI beneficiaries), the Payment Calculation Base will be the average monthly disability insurance benefit payable for the months during the preceding calendar year to all disabled worker beneficiaries who are in current pay status for the month in which the benefit is payable. For SSI beneficiaries (who are not concurrently SSDI beneficiaries), the Payment Calculation Base will be the average monthly federal SSI payment based on disability payable for the months during the preceding calendar year to all beneficiaries who: i) have attained age 18 but not age 65; ii) are not concurrent SSDI/SSI beneficiaries; and iii) are in current pay status for the month in which the payment is made. (Footnote Reference 14) Footnote 14: 20 CFR 411.500(a). 1. Payments Under the “Outcome Payment System” (Footnote Reference 15) SSA can make up to 36 outcome payments to the EN (or State VR agency acting as an EN) for a Title II disability beneficiary (including a concurrent Title II/Title XVI disability beneficiary). SSA can pay up to 60 outcome payments to the EN (or State VR agency acting as an EN) for a Title XVI disability beneficiary who is not concurrently a title II disability beneficiary. For each month during the beneficiary’s outcome payment period for which Social Security disability benefits and federal SSI cash benefits are not payable to the beneficiary because of the performance of SGA or by reason of earnings from work activity, the EN (or the State VR agency acting as an EN) is eligible for a monthly outcome payment. Payment for an outcome payment month under the outcome payment system is equal to 67% of the payment calculation base for the calendar year in which such month occurs, rounded to the nearest whole dollar. Footnote 15: 20 CFR 411.525 2. Payments Under the “Outcome Milestone Payment System”(Footnote Reference 16) Footnote 16: 20 CFR 411.535 SSA can pay the EN (or State VR agency acting as an EN) for up to four Phase One milestones attained within the required earnings period for a Title II or Title XVI disability beneficiary who has assigned his or her ticket to the EN (or State VR agency acting as an EN). • First Phase One Milestone: When a beneficiary has worked in a month and earned at least 50% of the amount of earnings considered to represent a trial work period service month. • Second Phase One Milestone: When a beneficiary has worked for three months within a six-month period and has gross earnings in each of those three months equal to or greater than a trial work period service amount. • Third Phase One Milestone: When a beneficiary has worked for a total of six months within a twelve-month period and had gross earnings in each of those six months equal to a trial work period service amount. • Fourth Phase One Milestone: When a beneficiary has worked a total of nine months within an 18-month period and had gross earnings in each of those nine months equal to a trial work period service amount and the EN has substantially completed the services agreed to in the IWP/IPE, including any amendments. Earnings used to meet the first, second or third Phase One milestones may be counted again when determining if a later Phase One milestone is met, provided the earlier earnings fall within the relevant time period for meeting the later milestone. SSA can also pay the EN (or State VR agency acting as an EN) up to 11 Phase Two milestones achieved by a Title II disability beneficiary (including a concurrent Title II/Title XVI disability beneficiary) or up to 18 Phase Two milestones achieved by a Title XVI disability beneficiary (who is not concurrently a Title II disability beneficiary) who has assigned his or her ticket to the EN (or State VR agency acting as an EN). A Phase Two milestone is met for each calendar month in which the beneficiary has worked and has gross earnings from employment (or net earnings from self-employment) in that month that are more than the SGA threshold amount (before any deductions for work incentives). SSA pays available milestone payments in sequence except when the beneficiary’s outcome period begins before the beneficiary has achieved all Phase One and Phase Two milestones. In addition to the milestone payments, monthly outcome payments can be paid to the EN (or State VR agency acting as an EN) during the outcome payment period. These outcome payments are paid under the same terms (i.e., SSDI not payable due to SGA and/or SSI not payable due to earnings), but at a lower payment rate than available under the outcome payment systems. The outcome-milestone payment system is designed so that the total payments to the EN (or the State VR agency acting as an EN) for a beneficiary are less than the total amount that would have been paid if the EN were paid under the outcome payment system. Under the outcome-milestone payment system, the total payment to the EN (or the State VR agency acting as an EN) is about 90% of the total that would have been potentially payable under the outcome payment system for the same beneficiary. 3. Assessment of Prior Work Activity and Milestone Payments Significant work activity prior to ticket assignment will limit the availability of Phase One milestone payments. The OSM will make this assessment of work activity prior to the first ticket assignment on each ticket, irrespective of the EN’s chosen payment system, in order to determine how many milestone payments may be available for serving an individual in the Ticket to Work program. The first Phase One milestone payment is not available to be made to an EN if the beneficiary has worked above the trial work level in the calendar month prior to the first ticket assignment on each ticket in the Ticket to Work program. The second Phase One milestone payment is not available if the beneficiary has worked above the trial work level in three of the six months prior to the first ticket assignment on each ticket in the Ticket to Work program. The third Phase One milestone is not available if the beneficiary has worked above the trial work level in six of the twelve months prior to the first ticket assignment on each ticket in the Ticket to Work program. The fourth Phase 1 milestone is not available if the beneficiary has worked above the trial work level in nine of the 18 months prior to the first ticket assignment on each ticket in the Ticket to Work program. 4. Payment Rates under the Outcome Milestone Payment System The following chart summarizes the Phase One payment rates for calendar year 2009, based on the type of benefit received. Phase 1 -- Potential Type: Milestone 1 Earnings: $350/mo for 1 months SSDI: $1,211 SSI $1,211 Phase 1 -- Potential Type: Milestone 2 (M1+2 mo.) Earnings: $700/mo for 3 months SSDI: $1,211 SSI: $1,211 Phase 1 -- Potential Type: Milestone 3 (M2+3 mo.) Earnings: $700/mo for 6 months SSDI: $1,211 SSI: $1,211 Phase 1 -- Potential Type: Milestone 4(M3+3 mo.) Earnings: $700/mo for 9 months SSDI: $1,211 SSI: $1,211 Phase 1 -- Potential Type: Total Potential Phase I SSDI: $4,844 SSI: $4,844 The following chart summarizes the Phase II payment rates for calendar year 2009, based on the type of benefit received. Type: Phase 2 Earnings: Gross > SGA ($980) SSDI: $363/mo.(up to 11 mos.) SSI: $207/mo.(up to 18 mos.) Type: Total Phase 2 Payments SSDI: $3,993 SSI: $3,726 Type: Total Potential Ticket Payments Phases 1 and 2 SSDI: $8,837 SSI: $8,570 The following chart summarizes the Outcome Phase payment rates for calendar year 2009, based on the type of benefit received. Type: Outcome Phase Earnings: Net > SGA ($980) AND 0 cash benefit SSDI: $363/mo. for 36 months SSI: $207/mo. for 60 months Type: Total Outcome Phase Payments SSDI: $13,068 SSI: $12,420 Type: Total Potential Ticket Payments SSDI: $21,905 SSI: $20,990 F. Reporting and Processing Payments SSA recently revised their process for reporting and processing payments under the Ticket to Work Program. ENs are required to submit evidence of a beneficiary’s earnings for any month in which they are requesting payment. Once an EN has established a history of Outcome Payments, they may continue to request payment by sending the evidence of earnings each month to the program manager or can choose to certify earnings by either: continuing with submitting evidence of beneficiary earnings at the end of each month; wait three months and send a letter to the program manager stating that to the best of your knowledge the Ticket-holder is continuing to work at the requested SGA levels (under this option the EN would be paid for the past three months); send a letter on a monthly basis to the program manager stating that you have firsthand knowledge that the Ticket-holder is continuing to work at the required SGA level (under this option the EN would be paid for the prior month); or, send a letter that states the EN has firsthand knowledge that the Ticket-holder is continuing to work at the required SGA level and they would like to receive monthly advanced payments (under this option the EN would begin receiving monthly payments and continue to receive monthly payments as long as the EN sends a letter to the program manager by the 15th day of the month following the payment quarter again stating similar content as before). G. What Is the Benefit of Participating in This Program for Our Support Group And Our Constituents? As a peer support group you should seriously consider how exactly to participate in the Ticket to Work Program and gain an understanding of not only the impact on the support group as an EN but also the constituents you may serve. For the beneficiaries that a support group may serve, the Ticket to Work Program offers choice, empowerment and self-determination. The Ticket to Work Program validates a concern we have heard for too long now -- that we need our federal programs to shift from funding generic, one-size fits all programs to paying for quality employment outcomes based on customized services and supports, because people want to work. For an EN to succeed under the Ticket to Work Program, it must facilitate quality jobs with livable wages. Otherwise beneficiaries will not make choices resulting in work. For SSI and SSDI beneficiaries the Ticket to Work Program could provide the vehicle for increased financial wellness and greater economic independence. For you as a support group, becoming an EN provides an added revenue base to support services that are critical to assisting individuals with disabilities in going back to work – something that traditional funding streams have never appropriately compensated for. It also assists the support group in providing specialized services and supports for a target segment of their constituents who continue to be underserved by our existing service delivery systems. V. Enhancing Service Options for Peer Support Groups The success of any individual considering employment hinges on three primary factors: the extent to which they understand and have access to needed services and supports to achieve their work goal; the comprehensive nature of the plan they develop toward their goals; and, the extent to which they actively pursue their ultimate objective—work. Given the breadth and depth of services offered by peer support groups, they are uniquely positioned to support the employment efforts of the constituents they serve—in fact, many already do so, on some level. The difference is that they may not be utilizing all the resources available to support their constituent outcomes. The Ticket to Work Program is an example of an untapped resource for peer support groups. With a streamlined application process, technical support from the program manager, and a built-in referral base of Ticket-holders, peer support groups are well-positioned to benefit from this service expansion opportunity. VI. The Operations Support Manager and the Program Manager for Recruitment and Outreach Since September 29, 2001, MAXIMUS, Inc. of McLean, Virginia has served in a competitive bid contractual role as the Program Manager (PM), now known as the Operations Support Manager (OSM), assisting SSA in managing the Ticket program. The responsibilities of the OSM include: *recruiting, recommending, and monitoring of ENs; *facilitating access by beneficiaries to ENs; *facilitating payments to ENs; *performing administrative duties such as reviewing IWPs; *reviewing amendments to IWPs; *ensuring that ENs only refer beneficiaries to a State VR agency for services pursuant to an agreement regarding the conditions under which such services will be provided; *resolving disputes between ENs and State VR agencies with respect to agreements; *resolving disputes between a beneficiary and an EN which cannot be resolved by the EN’s internal grievance procedures; and *referring disputes between beneficiaries and ENs to SSA for a final decision if this is requested by either of the parties. SSA periodically evaluates the performance of the OSM. This evaluation includes, but is not limited to, an assessment examining the following areas: 1. Quality of services; 2. Cost control; 3. Timeliness of performance; 4. Business relations; and 5. Customer satisfaction MAXIMUS, Inc. has created a website and a toll-free number to provide information about the Ticket program and the availability of ENs to provide services to beneficiaries. The Maximus toll-free line is 1-866-968-7842. Their toll-free TTY line for Hearing and Speech Impaired: 1-866-833-2967 and their web site is www.yourtickettowork.com. In 2008, SSA decided to add an additional Program Manager for Recruitment and Outreach. Cherry Engineering Support Services, Inc. (CESSI) serves as SSA’s Ticket to Work Program Manager for Recruitment and Outreach (PMRO). As the PMRO, CESSI has implemented a nationwide strategy to recruit ENs to serve beneficiaries under the Ticket program. The PMRO is involved with numerous activities, including recruitment events and participation at conferences, to recruit new ENs and encourage idle ENs to actively participate in the Ticket program. The PMRO is also involved in developing outreach to beneficiaries through a series of events called Work Incentives Seminars (WISE). The purpose of WISE events is twofold: to provide beneficiaries with general information about the work incentives and the Ticket program; and to provide them with access to local providers that are available to support their work preparation efforts The WISE events are delivered through the Work Incentives Planning and Assistance (WIPA) projects, with the assistance of the PRMO, and are designed to target beneficiaries in all or part of their service-delivery area. CESSI can be contacted by phone (703-448-6155) via TTY for people with hearing impairments(703-448-1108), or via email (info@cessi.net). VII. Summary For more information on the Ticket to Work and Work Incentives Improvement Act of 1999, visit SSA’s Office of Employment Support Program’s web site at www.ssa.gov/work. Link to “General Information” for up-to-date information on legislation and regulations pertaining to the employment supports of individuals with disabilities. Additional information is available on the MAXIMUS website at www.yourtickettowork.com. For a more in-depth review of the new Ticket to Work regulations, please read “The “New” Ticket to Work and Self-Sufficiency Program: Enhancing Economic Self-Sufficiency of Beneficiaries through Work Opportunities and Public / Private Partnership” located online at http://www.nymakesworkpay.org/m-research.cfm. www.NYMakesWorkPay.org Contact Information Employment and Disability Institute ILR School / Cornell University 201 Dolgen Hall Ithaca, New York 14853-3901 607.255.7727 (voice) 607.255.2891 (tty) 607.255.2763 (fax) ilr_edi@cornell.edu www.edi.cornell.edu Partnering Organizations New York State Office Of Mental Health Employment and Disability Institute (Cornell University) Burton Blatt Institute (Syracuse University) Alternate Formats This publication is available in alternate formats. To request an alternate format, please contact us using the information provided above. This series of briefs are also available online in both text and pdf formats. They are located at www.NYMakesWorkPay.org.