Statement of Dan O’Brien, MPA,
Program Manager, Ticket to Work and Community Rehabilitation
Oklahoma Department of Rehabilitation Services, Oklahoma City, Oklahoma

Testimony Before the Subcommittee on Social Security
of the House Committee on Ways and Means

Hearing on Fourth in a Series on Social Security Disability Programs' Challenges and Opportunities

September 26, 2002

Chairman Shaw, Ranking Member Matsui and members of the subcommittee, thank you for asking the Oklahoma Department of Rehabilitation Services to share it’s experience as one of the 13 initial rollout states for the Ticket to Work. My name is Dan O’Brien; I am the Program Manager for the Ticket to Work for the Oklahoma DRS, the State Vocational Rehabilitation and Visual Services Agency.

Oklahoma’s Experience with the Ticket – Just the Facts

• Tickets mailed – 99,915

• 4,000 existing SSA cases (18% of DRS caseload)

• Ticket Hotline Calls – 1456 calls (1.5% of Tickets mailed)

• Outreach/Ticket Orientation Meetings at One Stops –100+

• OK Tickets Officially Assigned as of 9/10/02 – 462

• About 92% of all OK tickets assigned have gone to VR

• New applications for services from Ticket –150+

• In over 50% of OK DRS Ticket cases Milestone/Outcome payment system was chosen, the remainder are traditional reimbursement.

• OK DRS is the VR leader in Ticket Milestone System, OK DRS had 90% of all VR Agency Milestone Cases nationally on 8/12/02.

• Counselors are recommending the Milestone system be used instead of traditional reimbursement if they determine the beneficiary is not likely to go off benefits or the case cost is projected to be low.

• 90 of 254 Milestone cases had some work activity since Ticket issued, only 13 worked above SGA (14%).

• Milestone claims billable on the 13 beneficiaries working over SGA worth about $5000 as of 9/23/02.

The Oklahoma Ticket Model (see attachment A)

Oklahoma DRS designed the Milestone Payment system in 1992 as a method for sharing risk and improving service outcomes. It has been widely imitated and  was a finalist in the 1997 Kennedy School of Government Innovations in American Government awards. As a result of the success of the Milestone system it was included in the Ticket legislation. In 1998 we were the recipients of a 5 year SSA State Partnership Initiative Grant to pilot an assertive engagement/outreach system for a vocational voucher system.

In 2001 we developed a Ticket implementation model based on our SSA SPI grant assertive engagement/outreach model. The Oklahoma Model involves specially trained outreach staff working through the One Stop system, who conduct work incentive training, make referrals to the BPAO and expedite the application and eligibility.

General Comments and Recommendations:

Comment #1: The low Ticket assignment rate, as of September 2002, 1/3 of 1%, is a red flag that there may be substantial barriers to service access. In order for the stated goal of 1/2 of 1% of the Ticket holders to leave the rolls a substantial multiple of that figure will be needed in entries to the program. I have been told that the current ratio of employment effort to exits is 14 to 1, thus at least 7% assignments would be needed. One of the barriers to access is the high level of risk that EN's must accept, the milestones were meant to obviate some of this risk. The 15% reduction in total ticket payments available for the milestone/outcome over the straight outcome payments seems excessive. Another barrier is fear, misunderstanding and mistrust. Assertive engagement and outreach techniques are needed to increase participation.

• Recommendation #1.1: Reduce the penalty for choosing the milestone/outcome system from 15% to 5%. Therefore, the total payment for the milestone/outcome system would be 95% rather than 85% of the total funds available under the outcome only system. In addition invest all of that addition money in increasing the milestone payments. See attachment B for details.
• Recommendation #1.2: Fully fund an Outreach effort that has three prongs, the Benefits Planning Grantees (BPAO), the ESR and an Outreach effort that has a local presence in the Comprehensive One Stops. Engage DOL and the One Stop system in funding and implementing an Assertive Outreach effort. See attachment C, for details.

Comment #2: The focus on going off benefits as opposed to a goal of increasing self-sufficiency misses the big savings to SSA. The sole focus on leaving the rolls does not recognize the reality that many SSA beneficiaries take a series of steps, each time increasing their work activity, leading to leaving the rolls over a period of years. An all or nothing strategy makes these customers undesirable to EN’s and generally discourages participation from EN’s by raising their level of risk unreasonably high. See attachment B for detail.

• Recommendation #2: Implement a partial self-sufficiency return to work strategy. Milestone and outcome payments should be paid as a percentage of benefits not payable. When partial cash benefits are paid to the beneficiary, the milestone and outcome payments would be based on a percentage of benefits not payable. For administrative simplicity a two tier payment structure could be implemented, a lower milestone and outcome payment at the Trial Work level and the full milestone and outcome payment at SGA. (See Attachment B).

Administrative Issues:

Comment #3: Rollout schedule was too aggressive – SSA sent Tickets out over 5 months – 10% the first month, 20% the third month, 30% the fourth month and 40% the fifth month. The fourth and fifth months were difficult to keep up with phone calls and created a lag in determining eligibility that took several months to clear up.

• Recommendation #3: Consider either a ten month 10% per month rollout or a six month rollout, 10% first two months and 20% the last four months. This will allow the larger states particularly Texas and California to manage the increase in applications.

Comment #4: The procedure for confirming whether a Ticket is assignable is cumbersome. OK DRS had about 4,000 SSA beneficiaries on caseloads when the Ticket program began. To confirm whether a Ticket was assignable DRS staff had to call or fax in a list of names to Maximus. Maximus staff initially refused to take lists longer than 20 names. Ultimately DRS staff were told they could no longer fax in lists and had to read hundreds of names to the Maximus staff over the phone. This verbal only system is not a particular burden for an EN building a caseload one client at a time, but for a state agency with thousands of SSA customers it is a huge burden.

• Recommendation #4: Allow states to electronically submit lists of existing customers with SSN's before the mail out so that they can be alerted to those who are expected to have a Ticket mailed.

Comment #5: DRS Ticket Unit staff report that some Maximus phone staff are lacking in English proficiency, making the aforementioned hours of phone confirmation take two or three times longer than necessary.

• Recommendation #5: Verbal English proficiency should be a requirement for Maximus phone staff.

Concern from Peter Baird, Connecticut Bureau of Rehabilitation Services shared by many of the Rehabilitation State Agencies

We have significant concerns regarding ticket assignment procedures for a "new case."  New cases are defined by Social Security as those individuals who sign an IPE after becoming eligible for the ticket.  SSA has determined that for a "new case," a State VR Agency will need to have the ticket assigned to receive either cost-reimbursement or one of the new EN outcome payments.  (Section 12.2B))  SSA considers the signature on the IPE to be an indication that an individual has decided to use the ticket to obtain services from the State VR Agency.  As a result, a State VR agency is allowed to have the ticket assigned to them for a "new case" even when the person does not sign the Ticket Assignment Form.  Section 12.10(C) states:

If the beneficiary (or the beneficiary’s representative) does not sign the form, submit the unsigned form, with the front (or cover) page and last (or signature) page of the IPE, to MAXIMUS.

We have two concerns regarding the issues above, and are seeking guidance from RSA on these matters.

1) SSA has subsumed the traditional cost-reimbursement system under the Ticket to Work Program for all "new cases." SSA has verbally cited that the basis for this opinion can be found in section 101(b) of The Ticket to Work legislation. We do not believe that this is the intent of the legislation, and we are unaware of any authority SSA has to subsume the cost-reimbursement system under the Ticket to Work Program, thereby making reimbursement contingent upon ticket assignments.  We also believe that the provisions allowing for reimbursement for non-ticket holders and for pipeline cases demonstrate that the reimbursement program is in fact separate from the ticket program. 

2) We have significant concerns regarding confidentiality. SSA has stated that the Ticket Assignment form and IPE can and should be submitted to Maximus without the consumer's explicit signed consent.  We believe that the principles of confidentiality, informed choice and the Ticket legislation's principles of "voluntary assignment" (see Chapter 12.1 (B)) are violated by the assignment of Tickets without a consumer's explicit consent. We do not believe that we have the authority to share the IPE with Maximus without the consumer's explicit consent.

Attachment A.

Oklahoma DRS and Workforce Oklahoma Collaboration on Ticket to Work (aka “THE OKLAHOMA TICKET MODEL”)

In Oklahoma, 100,000 SSI/SSDI recipients received a Ticket to Work from the Social Security Administration between February and July 2002.  Recipients were instructed to call the program manager, Maximus for Employment Networks in their local area. The DRS asked that Maximus only give out the Ticket Unit toll free number for the OK DRS Ticket Unit (866) 882-4515. The toll free number is staffed by Rehab Technicians who are trained on SSA work incentives by the Benefits Planning Assistance and Outreach contractor (BPAO), the Ticket and VR/VS services. The callers are invited to a Ticket Orientation meeting at the One Stop where detailed work incentive information is presented at the meeting or individually using WorkWorld software at the One Stop. The presentation uses a simple scenario based PowerPoint slide show, developed by OK DRS specifically to answer the two main customer questions “what will happen to my benefits if I go to work” and “how can VR help me accomplish my career goals.”

Purpose of the Ticket Unit

1) Inform Ticket Holders about VR services and available Work Incentives so that they can make an informed choice to pursue employment.

2) Expedite application and eligibility determination for Ticket customers.

3) Increase SSA reimbursement by creating follow-along caseloads of closed (26) cases that are eligible for reimbursement or milestone payments from SSA.

Procedure:

1) When the Ticket Holder calls the DRS Ticket Hotline their call will be routed to the Ticket Unit in OKC. They will be offered an opportunity to attend a three-hour orientation session on the Ticket and VR services.  One-Stop staff will also invite Ticket holders to the Ticket Orientation sessions who call or come to the center. Sessions are scheduled at all the Comprehensive One-Stops on a regular basis.

2) The Ticket Orientation will cover the Ticket, VR services available and a brief overview of Social Security Work Incentives.  The orientation is not required; it is intended as a step in the Ticket holder making an informed choice of employment service provider.  Ticket holders who wish to immediately apply for VR services will be directed to the local DRS office.

3) The One-Stop will have Work World available in their resource room. The Work World program allows consumers to enter several work scenarios into the computer and advises them on the use of work incentives.

4) At the end of the presentation consumers will have an opportunity to apply.

5) The Ticket Unit Tech III or the assigned local staff will take an application. The Ticket Unit VR Counselor IV, will review the documentation and determine the customer eligible within 3-5 working days following the application.

6) The case will be referred back to the local counselor after eligibility determination. The home counselor will obtain the Ticket from the beneficiary when the IPE is signed, keep the original and fax a copy to Ticket unit.

7) When the case is moved to an employed status (status 18 for SE and 22 for all others) the Ticket unit will be alerted by ORMIS. After 26 closure a Ticket Unit Tech III will begin tracking the case until all SSA reimbursement is submitted.

Questions: email Dan O’Brien at deobrien@drs.state.ok.us or deobrien@aol.com

Attachment B.

Example of a Ticket Scenario that Addresses a Number of the Equity of Access Issues

Prepared by Dan O’Brien, Ticket Program Manager OK Dept of Rehabilitation Services

Potential Breakeven scenario for SSI recipients

If the intent of the Ticket is to create a breakeven scenario for the SSA then SSI must be considered separately from SSDI, as the baseline assumptions are different. At least until a 2 for 1 work incentive system is in place for SSDI.

Specifically, savings accrue, i.e., some benefits are not payable, from any SSI work activity that exceeds $85 per month.  This allows a breakeven scenario for SSI based on payment of Milestone and Outcome payments as a percentage of the benefits not payable due to work activity.

The chart below reflects a recommendation that the total payments available under the Milestone/Outcome system be increased from 85% to 95% of the Outcome only system. This increases the total payment (2002 figures) available under the Milestone system form $9,720 currently to $10,887. The additional $1167 is distributed evenly among the milestone payments in this example. The payment threshold is set at the Trial Work level, $560 for 2002,for the first three milestone payments, to allow Ticket holders to work up to SGA. The dual level of Outcome payments recognizes the reality that some beneficiaries will not achieve SGA but SSA will accrue savings. This involves a slightly higher level of risk sharing on the part of SSA but still results in savings to SSA from a partial reduction of benefits scenario rather than the "0" benefits level and overall could lead to substantially higher cumulative savings.

Two payment tiers are envisioned for the two levels of significant work activity recognized and tracked by the Social Security Administration, the Trial Work (TW) level, currently $560/mo.and the SGA level, currently $780/mo. For the lower TW level the last Milestone payment would not be paid until achievement of SGA. This withholding of funds would serve as an incentive for EN’s to boost work hours to the SGA level at the appropriate time. When a higher level of work activity was achieved an additional Milestone payment would be paid and a higher level of Outcome payments would begin.

With this shift in risk sharing and marketing of “partial self-sufficiency”, a reasonable goal would be for 5% of SSI beneficiaries (200,000 of 4 Million) to work part-time at the Trial Work level or above. This level of work activity is generally achieved now in RSA Supported Employment programs that predominantly serve SSA beneficiaries. This work activity level is achievable and would result in a savings to SSA of $159 per month per worker ($237-$78) for a net of $32 Million per month. This scenario could also apply to SSDI if the 2 for 1 was applied to Title II, as is being considered.

¹ Trial Work Level for 2002 $560/mo.                ² 34% of benefits not payable

Attachment C.

Assertive Engagement/Outreach of SSA Ticket Holders as a method to increase workforce participation rates

There are troubling signs of service access barriers in the assignment rate of Tickets from the initial rollout states. Less than one-third of 1% of the Tickets mailed out in the first 13 states have been assigned as of September 10, 2002. Part of the rationale for the Ticket program was to give the SSA beneficiary greater access to services through choice of vocational provider beyond the VR system. Assertive Engagement/Outreach may help with this problem.

Key elements of Assertive Engagement/Outreach approach include the staff work in the community in the clients own settings, outreach includes the possibility of home visits, clients are not dropped because they don’t take the initiative or miss appointments, contact is frequent even if there is no initial response, staff make use of families and client support systems. Assertive Engagement is a concept borrowed from the Mental Health field. Participation rates in MH treatment were recognized as inadequate, the etiology of the problem could be traced to fear, lack of trust and disengagement in social support systems. Reports indicate that SSA beneficiaries suffer from similar low levels of trust and fear; front line workers report that a common reason given for not using the Ticket is that it is a trick. One of the OK-DRS Ticket Outreach staff, Judi Fretwell, writes of her experience.

“Both in the meetings and on the telephone, I've noticed a high degree of suspicion among most of the attendees but those who have been diagnosed with mental disorders seem almost paralyzed with fear about the program, sometimes to the extent that they can't seem to grasp the idea that it is a voluntary program and that non-participation will not come back to hurt them.  Most consumers have been so traumatized by the process they have had to follow to reach the status of SSI or SSDI recipient and have been so man-handled by the system (however they might define it), that any "official"-looking envelope will be immediately put aside as a threat they can't deal with right away. This initial reaction complicated by the very nature of their illness will extend the response time far beyond that of those with physical limitations only. Eventually, peer pressure or family pressure or a combination of things will embolden them to call (hurdle number one) but the process is so cumbersome (call Maximus for a list, call the list etc.) that even people with no thought disturbances and those with no depression would find it highly confusing and very discouraging to follow such a "trail of breadcrumbs".

Assertive engagement is a term used for a group of strategies meant to address barriers to service access. Traditional helping systems have developed self-protection strategies that increase barriers to entry as the work load increases. Long periods of unemployment such as many Ticket holders have experienced lower self-esteem and reduce resilience and consequently the Ticket holder’s ability to tolerate long waits for services and assertively advocating for their needs.

At least one new barrier to access has been created under the Ticket program. The EN risk assessment, a business requirement for a successful EN, presents a barrier to access and may represent an even higher bar than the access barriers in the public program.  The danger is that the Ticket program has only increased the choice of the chosen, those who have good prospects of obtaining and retaining high-income employment. Worse yet it may simply result in payment for those who would have gone to work without help, paying for something that SSA got free last year. Creaming, selection or profiling of the best candidates is implicit in the outcome payment system. The Milestone payment system was included in the Ticket legislation to obviate some of the risk to the EN and lower the threshold for entry into the program. Milestone rates will need to increase in order to reduce EN risk, for an assertive engagement strategy to lead to higher levels of employment, rather than rising rates of rejection.

Assertive engagement involves investing in interactive information delivery through a trusted, objective and stable helper.  The beneficiary must have the sense that the information is being provided from their point of view with their interests as a central focus.

The assertive engagement requires multiple outreach efforts through all available means, mail, phone, home visits and third party contact through trusted helpers, advocacy organizations and family members. Consistency and physical availability to meet and answer questions are essential. The goal of assertive engagement is to get the individual in the front door. The front door could be a Ticket holder Orientation session held an easily accessible location such as a Workforce/One Stop Center. The Orientation session should cover basic work incentives available, the effect of work on benefits and information on available EN's. Ideally the available EN's would be represented at the sessions and be available to take applications after the session. Many of the existing EN's are Workforce Partners and would support this function for the One Stop Centers.

The Benefits Planning Assistance and Outreach (BPAO) grants are a good example of this focus. The benefits planners are independent of the service provider system and SSA and can provide objective information.  The BPAO effort is woefully under funded, at $23 million for the entire country the funding is a fraction of what it should be just for the Benefits Planning portion of their mission. The outreach function has little possibility of being operationalized unless adequate funding is available for the core service of Benefits Planning. A team effort would be ideal that included three components, a Ticket Outreach/Disability Specialist at the Comprehensive One Stops, the BPAO Benefits planner available for difficult cases and the SSA Employment Support Representative to attend the outreach meetings, lend credibility, handle earnings reports and work generated CDR’s.