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Beyond Olmstead: Community-Based Services for All People with Disabilities

Independence Through Work


Donna Folkemer, M.A., Program Manager, National Conference of State Legislators, Washington, DC.

Peter Baird, M.A., Director, Vermont Work Incentive Program, Division of Vocational Rehabilitation, Department of Aging and Disabilities, Waterbury, VT.

The National Conference of State Legislatures (NCSL), in partnership with the Center for Health Services Research and Policy (CHSRP) at George Washington University and the Center for the Study of Disability Policy, studied Medicaid buy-in programs for the disabled in nine States (Alaska, Connecticut, Iowa, Maine, Minnesota, Nebraska, Oregon, Vermont, and Wisconsin). The study focused on eight areas:

  • The impetus for the buy-in.
  • Medicaid eligibility categories before the buy-in.
  • Buy-in eligibility rules and standards.
  • The relationship between the buy-in and other eligibility categories.
  • Administrative structure of the buy-in program.
  • Stakeholder involvement.
  • Cost estimates.
  • Program experience.

Lessons Learned

Treatment of cost-sharing: States typically structure cost-sharing either as an income-based fee schedule or as a specific percentage of income. Some States treat earned and unearned income differently, requiring participants to pay an additional share of their unearned income as a premium.

Structure of cost-sharing: There are three basic ways to structure cost-sharing in Medicaid buy-in programs:

  • Percentage of gross income.
  • Establishment of fee schedule.
  • Reimbursement of unearned income to the State.

Pre-existing eligibility: It is important to understand pre-existing eligibility categories to determine if the individuals the program seeks to reach are eligible for Medicaid under existing rules. Understanding these eligibility categories can also help States determine whether using more liberal methods for counting income and assets (as opposed to establishing a buy-in program) can accomplish a State's objectives.

Program shaping: States have the ability to shape program size, scope, and costs through careful program design.

Continuance of Medicaid: States do not yet have enough information to determine the role of continued Medicaid eligibility as an incentive to work.

The philosophy behind Vermont's program, in which the State wanted to:

  • Encourage and support workforce participation for persons with disabilities.
  • Ensure that persons with disabilities avoid institutionalization and maximize their integration into the community (by having a job).
  • Provide access to health insurance coverage as an incentive for persons with disabilities to go to work.

Key issues that policymakers confronted when developing the program were cost, design, and program administration.

Vermont's experience identified several issues that other policymakers should consider when creating buy-in programs:

  • Understand how Social Security work incentive programs work.
  • Know the status of health care coverage in your State.
  • Identify and educate stakeholders.
  • Involve persons who are going to use the program in designing the program.

Participants in the planning process learned that building partnerships is a key factor in determining the success of a buy-in program. Medicaid agencies are advised to form strong partnerships with entities that understand employment issues faced by persons with disabilities. Therefore, natural partners include:

  • Vocational rehabilitation.
  • Mental health.
  • Developmental disability services.
  • Social Security.
  • Advocates.
  • Consumers.

Establishing successful partnerships helps States:

  • Design programs that will meet the needs of end-users.
  • Gain access to data that will be useful in developing cost estimates.
  • Develop a coordinated strategy for providing services and supports for persons with disabilities who also work.
  • Overcome political barriers.
  • Ensure that other persons and entities are invested in the success of the program.

Results of an evaluation of Vermont's buy-in program found:

  • Enrollment projections were met.
  • More outreach is needed.
  • Benefits counseling is an important component of a successful program.

Vermont established a Work Incentive Initiative (Initiative) to complement its buy-in program. The goal of the Initiative is to remove barriers to employment for persons with disabilities by providing intensive benefits counseling and other supportive services. The Initiative is funded by the Robert Wood Johnson Foundation and the Social Security Administration.

Additional Resources

Access to Healthcare for Working People with Disabilities: Medicaid Buy-In Primer: What Advocates and States Need to Know. Chicago (IL): SSI Coalition;2001.

BBA and TWWIIA comparison chart. Washington (DC): Heath Care Financing Administration, U.S. Department of Health and Human Services;2001.

Cheek M. Presentation: Center for worker with disabilities. Washington (DC): American Public Human Services Association;2001.

Fact Sheet: Disability Q's and A's. Washington (DC): National Academy of Social Insurance;2001.

Mission: Center for workers with disabilities. Washington (DC): American Public Health Services Association;2001.

Scales J, Folkemer D, Jensen A. Ticket to work: Medicaid buy-in options for working people with disabilities. Washington (DC): National Conference of State Legislators;2000 Jul.

Ticket to work incentives improvement act of 1999: Questions and answer. Washington (DC): Heath Care Financing Administration, U.S. Department of Health and Human Services;2001.

Vermont Works, Division of Vocational Rehabilitation. Incentives Initiative Project. Waterbury (VT): 2000 Jan.

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