Recommending a Reimbursement Option Ticket Cases
When you receive the ticket, the original goes in the case file.When you complete your IPE, fax a copy of the ticket and send the filled out SSA-1365 to VR #95. Do not fill out item 7 on the SSA-1365. Attach the Reimbursement Recommendation.
Guidelines for Recommending a Reimbursement Option
At the time that you submit the SSA-1365, you need to let VR #95 know which reimbursement process you want to go with that will recoup the greatest amount. Your recommendation will be used by VR #95 in filling out item 7. Let’s look at our options:
Option One - Option one is the traditional way we have been reimbursed for years. It is called the Cost Reimbursement Program. We can be reimbursed for the cost of the case plus a monthly administrative cost. The cost of the case is determined by a total of all liquidated authorizations. The average administrative cost for the last three years is $110 per month, which is multiplied by the number of months the case is active.
Here is an example in terms of actual costs. John Consumer goes to work. He was a social security recipient, but with his new job, is off the roles. That would mean that he is making over $810 (VR client), $1,350 (blind client) if he was an SSDI consumer and $1,213 (**) if he was a SSI consumer. When John was a VR client he needed training. The cost of the case was $15,000. He was a consumer for 5 years/60 months. Multiply the $110 x 60 months which = $6,600. Add the $6,600 to the $15,000 and you get the total cost of the case, which is $21,600. If the total cost exceeded $10,193 for a former SSI recipient or $17,170 for a former SSDI recipient, pursue option one. As you can see by this example, option one was the right choice.
Unfortunately, with the ticket we have to decide on an option that we will take when we put the consumer in status 12 and fill out the SSA-1365, and not at the time of closure, which means that you have to speculate on what this consumer is going to accomplish and in the analysis choose your option. To do this, look at your total IPE cost. Then multiply your $110 times the number of months that it takes to complete the longest service line. You might want to factor in at least another six months for job placement and 90 days of employment prior to case closure. Add the total administrative cost to the Plan cost. If that amount exceeds $10,193 for SSI or $17,170 for SSDI then stay with Option 1.
Let’s look at this same example in terms of plan costs: You have just completed an IPE on John Consumer. His plan cost is $14,500 and his Administrative cost is estimated at $5,856 for a total of $20,356. Although this is a calculated guess, option 1 again is the right selection.
Option Two - This option is called the Outcome Milestone Payment Method. This option is based on four milestone payments and a monthly payment thereafter for 60 months. If your consumer is an SSI recipient, the maximum amount that the agency can receive in outcome payment is $10,193. The maximum amount for a SSDI consumer is $17,170. The Department of Rehabilitation Services, through VR #95, will choose this option under two conditions:
The first condition is when a SSDI consumer has the potential to earn more than SGA for twelve calendar months within a 15-month period, or a SSI consumer has the potential to make over $1,213 and in both SSDI and SSI cases not receive an SSA cash benefit for 60 months thereafter. As you know, we would select option 1 if the plan cost plus the monthly administrative costs exceeds $10,193 for SSI and $17,170 for SSDI recipients. In this case we want to receive milestones and monthly payments up to these amounts. This option would be a good choice for a consumer in a dependable work environment whose total case cost is projected to be much less than the total potential outcome payment.
Example: You write an IPE for a SSDI consumer who has the potential to be successfully employed within 10 months. His plan total is $1,000 because he only needs job placement and a few other sundry services such as tools and transportation. The anticipated administrative cost is $976. (10 mo x $110 = $976) so that our total cost is $2,076. If the consumer works through the milestones and 60 months thereafter, the agency will get back $17,170 although the cost was only $2,076.
Point to ponder: If would appear that former SSDI consumers with a strong previous work ethic that require limited case expenses would be a good choice for the Outcome Milestone Payment Method. The key here is to receive payments that substantially exceed the actual total case cost.
Now let’s look at the second condition for this option. Choose this option if you do not think that this consumer can continuously earn above SGA. If they do complete a milestone we will receive monetary compensation. Many supported employment consumers will fall into this option, along with consumers who do not receive supported employment services, but are only capable of obtaining high-risk, low-pay types of employment.
Example: A SSI consumer makes $900 per month but is still receiving a SSI check of $157. After 15 months of exceeding SGA, the agency will receive $2,033 but will stop there because a zero cash benefit has not been met.
Note: This is a population that this agency has not had an opportunity in the past for any type of outcome payment or reimbursement.
Attached is the Reimbursement Option Form – place a large “X” over the recommended option.
(**) The reason why the earnings are so high for SSI cases is as follows:
SSI Spend Downs
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Example 1 |
Example 2 |
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$810.00 Earned Income -$ 20.00 General Income Exclusion $790.00 -$ 65.00 Earned Income Exclusion $725.00 /2 = $362.50 $564.00 SSI federal benefit rate for 2004 -$362.00 $202.00 (cash benefit) |
$1213.00 Earned Income -$ 20.00 General Income Exclusion $1193.00 -$ 65.00 Earned Income Exclusion $1028.00 /2 = $564.00 $564.00 SSI federal benefit rate for 2004 -$564.00 $ -0- (no cash benefit) |
REIMBURSEMENT RECOMMENDATION
VR CASE # _______________________________________
CONSUMER ______________________________________
TRADITIONAL COST REIMBURSEMENT PROGRAM
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OPTION #1 – SSI Projected Earnings are Greater Than $1,213/month and Projected Total Plan and Administrative Costs Exceed $10,193.00 *Refer to VR #95 in Status 12 |
OPTION #1 – SSDI Projected Earnings are Greater Than $810/month and Projected Total Plan and Administrative Costs Exceed $17,170.00 *Refer to VR #95 in Status 12 |
OUTCOME MILESTONE PAYMENT METHOD
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OPTON #2 – SSI *Condition #1 Projected Earnings are Greater Than $1,213/month and Projected Total Plan and Administrative Costs Substantially Under $10,193.00 Speculation is Consumer Can Find a Dependable Job *Refer to VR #95 in Status 12 |
OPTION #2 – SSDI *Condition #1 Consumer Earnings are Greater Than $ 810.00/month $1,350/month (Blind) Costs Substantially Under $17,170.00 Speculation is Consumer Can Find a Dependable Job *Refer to VR #95 in Status 12 |
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OPTION #2 – SSI *Condition #2 Supported Employment Cases and all other cases where the projected earnings are less than: $1,213/month
*Refer to VR #95 in Status 12 |
OPTION #2 – SSDI *Condition #2 Supported Employment Cases and all other cases where the projected earnings are above: Less than $810/month $1,350/month (blind) *Refer to VR #95 in Status 12 |
Place a large “X” over the chosen option block
FAX this recommendation with a copy of the TICKET and completed SSA-1365 to VR #95 FAX # (405) 522-7980
