CSAVR
Employment First
The unemployment rate for individuals with disabilities is one clear demonstration of the staggering consequences of the nation’s current disability public policy. The number of individuals on the Social Security disability rolls is growing at an alarming rate, while the employment rate for individuals with disabilities continues to remain unacceptably low. There is widespread agreement among rehabilitation professionals and policy experts that early intervention, provided as close to the disability onset as possible, will improve employment outcomes for individuals with disabilities. This concept has not been fully tested, however, and current attempts to provide empirical evidence are caught in the ever-present debate about cost effectiveness.
The Council of State Administrators for Vocational Rehabilitation (CSAVR) seeks to advance a proposal for Early Intervention that would build on the mutual goal of the Social Security Administration and the Public Vocational Rehabilitation (VR) Program: to increase employment outcomes and self-sufficiency for individuals with disabilities through the provision of appropriate services and supports. This proposal, the Rehabilitation Early Diversion (RED) Program, would leverage the strengths of both programs in advancing this goal. The Early Intervention Demonstration (EID) concepts proposed under Section 234 of the Social Security Act were designed to test whether the provision of employment services and other types of services and supports to specially selected applicants for SSDI can improve return to work outcomes. To expand upon the concepts under consideration by the Social Security Administration, CSAVR proposes a model that would identify those individuals most likely to pass SSA’s criteria for eligibility for SSI or SSDI and redirect many of them to the world of work through Vocational Rehabilitation. This immediate connection with an employment support program can help individuals move towards independence and self sufficiency rather than taking the path to unemployment and long-term dependency on public assistance that is characteristic of the Social Security disability programs today.
The Public VR program is a natural stop for individuals with disabilities who are eligible to apply for the Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) programs. As evidenced by the Ticket to Work data, the Public VR program is the most widely used employment support program for beneficiaries, and as such, the program is a natural place to experiment with a concept such as Rehabilitation Early Intervention.
Background
Public expenditures for the support of individuals with disabilities have outpaced economic growth. At the current rate of growth, federal expenditures supporting working-age individuals with disabilities will be difficult, if not impossible, to maintain, particularly given the approaching retirement of so many baby boomers.
The Americans with Disabilities Act (ADA) and medical and technological advances are removing barriers to work and changing the assumptions about what people with disabilities can do and want to do. This and other related concerns led the Government Accountability Office (GAO) to add “modernizing all Federal disability programs” to its high-risk list. SSA is one of the federal agencies that must respond to this development. These factors create an opportune time for some creative thinking about the role that the Public Vocational Rehabilitation (VR) program can play in assisting SSA in reducing the number of individuals with disabilities who end up in a life-time of dependency on Social Security benefits and other types of public assistance.
CSAVR maintains that the inability to work is not solely medically determinable. The majority of factors keeping individuals from working are more at a societal level, and these include attitudinal, access, and architectural barriers. At an individual level, any number of factors can come into play that can determine the ability of a person with a disability to enter the workforce and maintain employment over an extended period of time. These factors include, but are not limited to:
- a person’s education, cultural and employment experience;
- the length of time the person has been out of the workforce;
- the person’s adjustment to having a disability;
- the availability of family and friends to support a person’s work effort;
- access to assistive technology devices and services, personal assistance services, and accessible transportation;
- the availability of reasonable accommodations and other types of on-the-job supports; and
- access to services and supports that an individual needs to overcome barriers to employment resulting from the person’s disability.
When one looks more closely at just one of these factors, i.e., the length of time a person is out of the workforce, the disincentives to work built into the current SSA disability determination process become quite evident. When a person applies for disability benefits, s/he must demonstrate to SSA that s/he cannot work. SSDI eligibility requires a person with a disability to demonstrate that s/he has been unable to work for at least five months. Consequently, instead of assisting a person to re-enter the workforce at a time when their desire to work is still strong (i.e., immediately after becoming disabled), current SSA rules force that person to “prove” that s/he is not able to work over an extended period of time. If an applicant demonstrates any capacity to work prior to being determined eligible for disability benefits, that demonstration will most likely be used to determine the person ineligible for benefits. As a result, the issue of “inability to work” becomes closely associated with the disability in that person’s mind. It is enough for a person to have to adjust to having a disability without having a federal agency define the “inability to work” as a characteristic of being disabled.
Once a person is determined eligible for disability benefits, SSA starts talking about seeking services and supports to go to work (e.g., through the Public Vocational Rehabilitation Program or an Employment Network functioning under the Ticket to Work and Self-Sufficiency Program). This prospect is often confusing and frightening to a person that has spent many months proving s/he cannot work to establish eligibility for disability benefits.
Although eligibility for medical assistance (Medicaid and Medicare) is closely tied to eligibility for SSI and SSDI, respectively, work incentives programs are in place to extend access to these programs beyond the termination of cash assistance. In most states, automatic eligibility for Medicaid is available on the first day of eligibility for SSI benefits, and Medicaid coverage continues even when the person’s earnings reach the point that cash benefits are discontinued, provided that the person’s total income does not exceed a set amount. With the exception of two disabling conditions (i.e., if you have Lou Gehrig’s disease or you are a kidney dialysis or kidney transplant patient), individuals with disabilities who are determined eligible for SSDI must wait 24 months to be eligible for Medicare coverage. Prior to the passage of the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), Medicare coverage would extend three and one half years after SSDI cash benefits were terminated due to a person working above SGA. Under TWWIIA, eligibility for Medicare continues for up to eight years after a beneficiary is no longer eligible for SSDI benefits. Many people believe that ongoing access to medical assistance is more important than access to cash assistance for many, if not most, individuals with disabilities.
CSAVR believes that the ability to assist potential recipients of SSI and SSDI in entering and maintaining employment at SGA and above can be significantly increased by combining the resources of the Public VR program with resources available through SSA with the common goal of increasing the individuals overall health, wellness and economic functioning.
While SSA’s traditional Cost Reimbursement program does combine the resources of VR with the resources of SSA, the present structure of service delivery does not effectively link access to VR services with access to medical assistance unless the person has either been determined eligible for SSI or SSDI or has an income so low that they qualify for Medicaid based on poverty. Although the TWWIIA legislation authorized states to implement a Medicaid Buy-In program that would permit individuals to earn above the poverty level and still be eligible for Medicaid, the program is a state option and many states have yet to adopt a Buy-In program. In those states that do have Medicaid Buy-In programs, the challenge will be the eligibility criteria. Without a full eligibility determination for SSA, some state programs may restrict access to individuals in an Early Intervention program. Information regarding persons with disabilities who utilize Medicaid shows that these individuals often have multiple health issues with co-occurring disorders. In spite of information such as this, the coordination of health care is left largely to the individual.
The Rehabilitation Early Diversion Program
Under the current system, SSA looks at medical criteria to determine that a person has a disability and then some additional screening is conducted as deemed necessary to ascertain whether that person has the ability to work. Under the Rehabilitation Early Diversion (RED) Program being proposed by CSAVR, the intent is to provide working age individuals with disabilities the opportunity to learn about “work” as an option by being immediately referred to a vocational counselor. Many individuals with disabilities do not understand their employment potential, and may not fully comprehend the vocational options available to them. The RED program provides a new avenue for addressing this issue early in the process for a person applying for Social Security benefits.
Upon entering the SSA office, the person would be referred to a Social Security Rehabilitation Counselor (SSVRC). The SSVRC would meet with the individual and do a quick assessment to determine immediate allowance decisions, such as individuals with Lou Gehrig’s or Kidney Disease. If the individual meets these allowance criteria, they would immediately be referred to the SSA Claims Representative. If the individual is not presumptively eligible for Social Security, the SSVRC would begin to discuss vocational options, and assist the individual in making an informed choice about participation in RED. Critical factors to be considered in this informed choice process would be:
- The individual’s interest in investigating employment options
- The likelihood of allowance for disability benefits.
Vocational Rehabilitation counselors are required to have a master’s level education plus additional courses. They have the expertise and clinical background to screen out applicants who would be unlikely to be eligible for SSDI benefits. In fact VR counselors are often consulted by Disability Determination Services in the application process. While this screening would not be foolproof, it would allow SSA strong assurance that only likely beneficiaries would receive RED services.
The SSVRC would then work with the applicant to assess whether the individual meets the eligibility criteria for the VR program. The three criteria for VR eligibility are: 1) the individual has a physical or mental impairment which for such individual constitutes or results in a substantial impediment to employment; 2) the individual can benefit from VR services in terms of an employment outcome; and 3) the individual requires VR services to prepare for, secure, retain, or regain employment. Those who are determined ineligible for VR services would be referred back to SSA to continue with the traditional disability determination process. Those individuals who are determined eligible for VR services will continue to work with the SSVRC to start their own vocational planning process.
Because the applicant may have immediate need for income support, the RED program would offer short-term cash assistance. This would provide the applicant some time-limited income while pursuing employment. In return for immediate cash assistance and vocational services, the applicant would agree to suspend his/her SSDI application. It is important to note that the applicant will always have the option of reactivating his application or making a new application at a later date. The applicant would be making the informed calculation that with short-term cash assistance and immediate vocational services he/she could return to self-sustaining employment. The RED option would be as follows:
RED Program
- Immediate but time limited cash assistance
- Immediate vocational services to assist the person return to work
- Assistance accessing State funded or private health insurance
- Suspension of the SSDI application
Under the RED program an SSVRC would work with the individual to develop a comprehensive review of the individual’s knowledge, skills, abilities, capabilities, resources, and interests, as well as any mental or functional limitations that might result in an impediment or a barrier to employment. Once this assessment is completed, the SSVRC will discuss the results of the assessment with the applicant, and, as appropriate, any friends or family members that might be called on to assist the individual in his/her employment efforts. This discussion will assist the applicant in identifying vocational options that are: 1) of interest to the applicant; 2) in keeping with the results of the applicant’s assessment; and 3) reasonable in terms of other relevant factors such as the local economy, the person’s ability to relocate, etc. Once appropriate vocational options have been identified, the applicant will work with the SSVRC to narrow those options and identify a specific vocational goal or employment outcome to be sought, and the services and supports needed to facilitate the applicant’s ability to achieve that vocational goal or employment outcome and have earnings that would increase the individual’s financial self-sufficiency. All of this information would then be used to develop the Individualized Plan for Employment (IPE) required under title I of the Rehabilitation Act of 1973, as amended.
The following example illustrates this approach.
Up until one year ago, Jeffrey was working as a heavy equipment operator for a construction company. He was involved in a car accident, and sustained a spinal cord injury, which has left him with quadriplegia. He is 35 years old.
When Jeffrey comes into the office, he is introduced to the SSVRC in the Social Security field office. The SSVRC does some initial screening, and talks with Jeffrey about his vocational options. The SSVRC outlines a number of potential new career options that Jeffrey had not considered. Jeffrey had reservations about going on benefits for the rest of his life but was not aware of any alternative. The possibility of returning to work is very attractive to him.
Jeffrey has an immediate need for income and the time limited cash assistance offered under RED is attractive. He is concerned that his application for SSDI will be suspended. However, when the SSVRC explains that he can always reactivate his application at a later date and that given his disability he would almost certainly be found eligible, this appears less of a risk. So he agrees to participate.
The SSVRC authorizes short-term cash assistance for Jeffrey and begins to develop a vocational plan with him. She also works with a local benefits counselor to help Jeffrey apply for a State low-income health coverage program and Food Stamps. This support assures that Jeffrey can maintain himself until he starts working.
The SSVRC helps Jeffrey enroll in a six-month computer training program at a local college. She links him up with the local Assistive Technology program to ensure he has the necessary equipment to compete. Four months into the program Jeffrey is offered part time work processing customer orders at a local mail order company. Because of this additional income, Jeffrey loses his eligibility for the State low income healthcare program and his Food Stamps. However, his benefits counselor helps him apply for the local Medicaid Buy In program, for which he is now eligible because he is working.
After completing the computer training program at the college, Jeffrey applies for a full time data management position at the mail order company for whom he is already working. He gets the job, which comes with health insurance after six months. He retains his eligibility of the Medicaid Buy-In and Medicaid pays his premiums for the employer-based insurance. The SSVRC ends Jeffrey’s cash stipend.
VR and SSA: A Natural Partnership
The Public Vocational Rehabilitation program is in a unique position to partner with SSA on this RED proposal for a number of reasons. First, VR counselors are trained in vocational issues and disability. This training can be used in an advanced referral approach to help individual applicants sort out whether they may qualify for Social Security benefits. This serves the function of allowing the beneficiary the opportunity to exercise informed choice about the cost benefit of proceeding with a disability application, and also assists SSA by reducing the number of denials for benefits.
The issue of disability benefit denials is the second reason that VR would be a strong partner. One of the primary concerns of actuaries, both internal and external to SSA, is that Social Security Trust Fund money should be used only for individuals eligible for benefits. Recent debates on early intervention models such as RED have struggled with the issue of how to accurately determine who might be eligible for benefits, and no easy solutions have been found. By having an SSVRC as part of the model, this issue can be easily resolved. If the application goes through the Disability Determination process and the individual is not eligible for benefits, the vocational services can continue under the Rehabilitation Act. This would ensure that Trust Fund dollars are reserved for those individuals whose application for benefits is allowed.
Access to Medical Insurance
Since many individuals with disabilities are likely to be eligible for other types of public assistance (e.g., Medicaid, Medicaid Buy-In, food stamps, welfare, subsidized housing, etc.), the SSVRC would be responsible for providing the individual with accurate and timely information about other local, state and federal benefits. The SSVRC would have a basic understanding of benefits information, but the individual and their SSVRC would also be able to access the services of a benefits counselor.
A thorough analysis of the individual’s situation will include a discussion of the following health care coverage options:
- Medicaid (including Medicaid Buy-In programs in those states where eligibility criteria does not require an SSA determination)
- Medicare
- Private health insurance
- Employer Based health insurance
§ VR
Access to Transitional Cash Assistance
The SSVRC would make available transitional cash payments for the individual. In addition to determining insured status, Claims Representatives will access benefit estimate information so applicants and SSVRC may be made aware of probable stipend amounts. Stipend amounts will be equal to the usual SSDI benefit amount and will include auxiliaries who live in the same household. These monies will be paid for no more than 12 months and will be offset by earnings 1 for 2 for any money earned in excess of SGA.
These payments would be available during the time the individual is actively participating in the IPE and making progress towards the vocational goal spelled out in the IPE. Any commitment to provide medical assistance and/or pay for living expenses would also be included in the individual’s IPE.
With the incorporation of these features, the RED Program would provide for an early intervention process that provides immediate access to time-limited cash assistance, time-limited coverage of necessary medical expenses, and individualized services and supports to address specific identified barriers to employment with the ultimate goal of the individual engaging in employment leading to self-sufficiency or, at least, a significant (e.g., 50%) reduction in ongoing cash assistance. Specific limitations on cash assistance and medical coverage may be necessary to prevent applicants from accessing VR services through the RED program solely to get immediate access to cash assistance and medical coverage. Using this approach, SSA would be reaching out to individuals with disabilities who are applying for disability benefits, providing them with the opportunity to increase their independence and self-sufficiency and avoid a potential life-time of dependence.
Once the IPE is agreed upon and signed, the SSVRC would be responsible for monitoring the progress of the individual to ensure that s/he is actively participating in the services that have been identified in the IPE and making progress towards the selected vocational goal or employment outcome. As deemed appropriate by VR staff or upon request of the participant, the individual’s IPE may be reviewed and amended. If the SSVRC determines that the individual is not actively participating in the services identified in the plan and making progress towards the identified vocational goal, the individual’s access to the medical assistance and maintenance expenses outlined in the IPE could be terminated and the individual could be reported to SSA as being uncooperative.
Funding Through Partnership
State VR agencies are severely under-funded to meet the needs of individuals with disabilities who are already seeking VR assistance. In FY 2005, a total of 42 State VR agencies were operating under an Order of Selection (OOS), i.e., a system for prioritization of services mandated in the Rehabilitation Act whereby individuals with the most significant disabilities (as defined by the State) are prioritized for services when a State VR agency determines that it resources (funding and VR personnel) are insufficient to serve all of those expected to seek assistance. Under the RED Program, additional individuals with disabilities, who would have sought dependence on public assistance rather than seeking VR assistance to go to work, will be coming to the VR agency for assistance. Consequently, all expenses associated with the RED Program would need to be covered by SSA; otherwise, applicants for disability benefits automatically referred to VR for assistance would merely be put on waiting lists for services in those State operating under an OOS, and many State VR agencies that are not already operating under an OOS would be forced to implement one.
Every year the Social Security Administration (SSA) produces a report, “Recap on VR Reimbursements.” That provides detailed information on the funds disbursed to State Vocational Rehabilitation (VR) agencies based on their successfully serving beneficiaries on Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Under the SSA Cost Reimbursement Program, State VR agencies are reimbursed for the reasonable direct costs of the services provided to an SSI/SSDI beneficiary, plus a monthly administrative cost, if the beneficiary is employed for a continuous period of nine months above SGA within a 12-month period. The End of Year Reports for FY 2003 and FY 2004 programs provided significant evidence of the return on the federal investment in the Public VR program.
Year Total Reimbursements Average Reimbursement Projected Savings
Allowed Per Beneficiary to the Trust Fund
2002 $131,014,733.14 $12,453 $693.0 million
Ration of Projected Savings to Expenditures = $5 savings for every $1 spent.
2003 $ 84,568,302.76 $12,514 $458.7 million
Ration of Projected Savings to Expenditures = $5 savings for every $1 spent.
2004 $ 85,172,425.42 $12,505 $470.3 million
Ration of Projected Savings to Expenditures = $6 savings for every $1 spent.
The Public VR Program has already demonstrated significant success in serving individuals with disabilities under the Cost Reimbursement Program. The potential to impact the employment rate for individuals with disabilities who enter the RED Program is even more significant.
Individual Level Impact
The design of the Red Program would allow beneficiaries a choice of the long-term disability program or a short-term concept which would include access to cash and medical benefits as well as employment supports, while the individual pursued returning to work.
System Level Impact
We understand that the Social Security Administration is at a critical juncture. Growth in the disability programs is rapidly expanding, and only a small percentage of beneficiaries are leaving the rolls because of an employment outcome. The Public VR program has a long history of providing employment supports to individuals with disabilities, including those individuals on the Social Security disability programs. With all of the fiscal and social pressures of a disability program stretched to capacity, a partnership between the largest insurer of beneficiaries and the largest provider of employment services and supports is the most logical next step.
RED would provide SSA with a vehicle for testing the concept of Early Intervention on a national level, using a program with a strong national presence, a proven track record of success and a solid local infrastructure for service delivery. By providing employment services and supports choice at the point of application for SSA benefits, RED would also serve the purpose of developing more solid relationships between the SSA field offices, the VR program and the Benefits Counseling program.
Finally, as the VR agencies test out this model of Rehabilitation Early Diversion, the programs can work together to generate recommendations on restructuring the vocational criteria within the Disability Determination process. Given the limitations of using medical criteria as the most widely-used means of determining work-related disabilities, this project could inform the national debate by giving empirical data on work potential across disability in the working-age population.
The SSA has acknowledged that currently less than one-half of one percent of beneficiaries ever leaves the disability roles to return to work. SSA has the opportunity to positively impact this current statistic by funding and partnering with State VR Agencies to implement the RED Program.
