The Ticket and Medicaid Buy-In Programs: 
Considerations for States 
BY: Courtney Snyder
SSI Coalition for A Responsible Safety Net


Ticket to Work legislation
Promotes consumer choice for training and employment services 
Promotes competitive employment
Promotes accumulation of assets or resources
Eliminates reliance on public benefits


Medicaid Buy-In
Access to health care 
Promotes competitive employment
Promotes earnings
Allows for accumulation of assets/resources
Eliminates reliance on public benefits


How are the Ticket and Medicaid Buy-In linked?
Without health care coverage an individual will not return to work
Resources and Assets
Income
Self-sufficiency and independence 


What are the concepts behind the Medicaid Buy-in?
Allows working people with disabilities to “buy-in” to the state’s Medicaid program
Creates an affordable option for individuals and employers
Lots of flexibility for the states on how to design, finance and administer the program


Types of Buy-Ins
Balanced Budget Act 1997
     Up to 250%

Ticket to Work & Work Incentives Improvement Act
     Above 250%
     Medically Improved
     Demonstrations

Medicaid Buy-in: Basics
Plan amendment, not a waiver
Medicaid Buy-in plans must be statewide
Medicaid Buy-in plans must have the same comprehensive health care package as the state’s regular Medicaid plan


Key Questions for States
How to design it?
How to finance it?
How to administer it?


Designing the Program
SSA work incentives utilization, e.g. 1619(b)?
Personal attendant care?
Income thresholds for medically needy?


Designing the Program: CHECKLIST
Parity of programs
1902(r)(2) exclusions
1915(c) waivers
Review of Disability Programs/ Other Benefits
Payment of Medicare premiums
Private, group or employer sponsored health insurance 
Role of Employers paying premiums
Income eligibility level


Design: INCOME
What income level do you want to cover?
Do you want to get at the basic level at 250% of the federal poverty limit? (BBA of 1997)
Do you want to go above 250% of the federal poverty limit? (TWIIA)
Do you want to continue eligibility for those participating in the program but lose eligibility for federal disability programs? (medical improvement)


Design: ASSETS
Assets: How much do you want people to keep to promote self-sufficiency?
Amount: How much do you want to disregard?
Type: Are there particular assets you want to treat differently?
Source: Do you want to differentiate between assets accumulated while in program versus before entering program?
Designing the Program: Premiums & Cost Sharing


Design: PREMIUMS
Premiums: Must be structured according to income
     How will you treat earned income (wages) and unearned income (benefits)?
     How will you calculate the premium -- based on income or percentage of the federal poverty level?
     Other considerations


Financing the Program
Designing a cost model or cost projection
     How many will enroll?
     How many will transfer into the Buy-in from other programs 
     What kind of cost savings will accrue to the state as a result of the Buy-in?


Administering the Program
Planning and Design
     Who will Administer? 
     Training?
Operationalize the Plan
     Who will do the disability determinations?
     Who will do the eligibility determinations?
     Will there be a systems cost?


What do you need to know to create an effective Medicaid Buy-in?
Know SSA Work Incentives
Know the status of health care in your state 
     What does your state Medicaid plan cover?
     What about HIPAA?
Does your state have a CHIP?
Identify stakeholders
Educate stakeholders


Resources and Tools 
SSA Red Book on Work Incentives and web site-- www.ssa.gov
SSI Coalition web site -- www.ssic.org
Health Care Financing Administration
Karen Tritz - ktritz@hcfa.gov
410/786-0789


Issues to Think About?
Evaluation component to examine who is utilizing the Ticket and the Medicaid Buy-In
CDRs -- Ticket users are protected; Medicaid Buy-in users are not
Final Ticket rules and implementation
Promote both programs and the opportunities it brings to consumers


How to Build a Successful Buy-In
Take advantage of the infrastructure grants-- can help with design, administration and research & evaluation
Involve the individuals who will use the program -- create a program people will use


Can’t Have One Without the Other
In order to have a successful Ticket to Work program, have to have a good Buy-In program
Ticket provides the training and support; Buy-In provides the health care to keep customers in the workplace