The Social Security Cost Reimbursement Program: Processing a Cost Reimbursement Claim

Introductions, Federal Ken McGill, Moderator, Ticket to Work Operations Support Manager Nate Arnold, Vocational Rehabilitation/Partnership Plus Lead, SSA Office of Employment Support Programs Kathy Schriver, Senior Analyst, SSA office of Employment Support Programs 11/30/20112Cost Reimbursement Webinar – Part 2: Processing a Claim

Introductions, State Partners Abygail Medina, Chief, Social Security Programs Section, California Department of Rehabilitation Eugenia Cox, Ticket to Work Program Coordinator, Oregon Office of Vocational Rehabilitation Services Ann Lynn Banton, SSA/Ticket to Work Coordinator, Virginia Department for the Blind and Vision Impaired 11/30/20113Cost Reimbursement Webinar – Part 2: Processing a Claim

Earnings 11/30/20114Cost Reimbursement Webinar – Part 2: Processing a Claim

Earnings When a beneficiary has had earnings above Substantial Gainful Activity (SGA) for a period of 9 months within a 12 month period, the SVRA can submit a cost reimbursement claim SSA strongly suggests that you include documentation of earnings when submitting a claim. However, if you don’t have wage data, SSA will look for documentation in their databases Wage documentation can be obtained with a variety of tools 11/30/20115Cost Reimbursement Webinar – Part 2: Processing a Claim

State Wage UI Database The most useful tool is the State Unemployment Insurance (UI) database Wages on the state UI database are shown as quarterly earnings If SSI/SSDI benefits are in current pay, at the time of CR claim, the SGA level plus the tolerance amount is applied $1010/mo. + $200 = $1210 a month (2012 – non-blind) $1690/mo. + $100 = $1790 a month (2012 – blind) If SSI/SSDI benefits are terminated, at the time of CR claim, then regular level for SGA is used 11/30/20116Cost Reimbursement Webinar – Part 2: Processing a Claim

Types of Documentation Available to SSA for Earnings SSA has access to a number of databases that they can use to assist you in finding/documenting earnings. These are included in the next several slides: Disability Control File (DCF) - Includes information on Monthly earnings Tolerance does not apply If the earnings documented lead to a denied claim (i.e., are below SGA), you can always resubmit the claim later with new documentation 11/30/20117Cost Reimbursement Webinar – Part 2: Processing a Claim

Type of Earnings Documentation (cont’d) Supplemental Security Income Display (SSID): Monthly earnings Tolerance does not apply Use verified earnings in the ENIH field Impairment Related Work Expenses posted Subsidies posted 11/30/20118Cost Reimbursement Webinar – Part 2: Processing a Claim

eWork: Monthly earnings Tolerance does not apply Use verified earnings to establish SGA Subsidies can be posted Impairment Related Work Expenses (IRWE) can be posted 11/30/20119 Type of Earnings Documentation (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

Master Beneficiary Record (MBR) : Use the first month the beneficiary went into suspense due to work and earnings (LAF S7) Tolerance does apply, unless benefits are terminated 11/30/ Type of Earnings Documentation (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

Detailed Earnings Query: Yearly earnings – Tax returns from IRS Employer name and address is listed Tolerance applies unless benefits terminated Add tolerance for each month, tolerance X3 11/30/ Type of Earnings Documentation (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

National Directory of New Hires Quarterly earnings Employer name and address listed Tolerance applies unless benefits terminated Add tolerance for each month, tolerance X3 11/30/ Type of Earnings Documentation (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

The Work Number – Accessible to State VR Agencies by fee-based subscription only These are weekly or bi-weekly earnings Employer name and address is listed These earnings are received from a clearing house Tolerance does apply, unless benefits are terminated Learn more at: 11/30/ Type of Earnings Documentation (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

Self-Employment and Federal Employment Documentation of self-employment and federal employment earnings can be difficult to find. If you have contacted your client and cannot obtain earnings documentation, you may either: Call or the VRA Operations Team to request help in documenting earnings, or When the claim is submitted, ask that we investigate the earnings 11/30/201114Cost Reimbursement Webinar – Part 2: Processing a Claim

SSA Wage Investigations If all else fails and you are unable to document wages, you can still submit a claim for SSA to help document If benefits are in current pay and the earnings are at the regular SGA level, but not at the tolerance level, SSA will send out a request for a work investigation 11/30/201115Cost Reimbursement Webinar – Part 2: Processing a Claim

Work Investigations (cont’d) The form for an investigation is sent to other components within SSA for completion. They will contact the beneficiary about potential work, develop the work record and report the results back to us This process can be time-consuming. It can take from a month to a year or more to receive documentation 11/30/201116Cost Reimbursement Webinar – Part 2: Processing a Claim

Processing a Cost Reimbursement Claim 11/30/201117Cost Reimbursement Webinar – Part 2: Processing a Claim

Categories of Claims There are 2 categories of claims SGA claims – Initial – Supplemental – Resubmittal – Second Period – Reconsideration VR Medical Cessation Claims (301) 1811/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Types of Claims Initial Claim - An initial claim is the first claim filed for reimbursement by a provider for a specific disability beneficiary and social security number (SSN) Supplemental Claim - A supplemental claim is a claim for reimbursement for additional direct costs after SSA has paid a previous claim. It is a claim for costs incurred for the same person as the initial claim and is based upon the same period of VR as the initial claim 1911/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Type of Claims (cont’d) Resubmittal Claim - A resubmittal is a claim that was previously denied with no payment made to the VR provider because the person did not complete a 9-month continuous period of SGA. The VR provider is resubmitting the claim because the beneficiary has now completed the 9-month continuous period. It is for the same period of VR services as the original claim 2011/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Second Period Claim - A second period claim is a claim for reimbursement for the costs of VR services submitted by a provider for the same beneficiary and on the same SSN as a previous claim. A second period claim is processed as a new claim because it is based on a new period of VR services. However, the amount that can be reimbursed to the VR provider may be offset by the amount previously paid for this same beneficiary to assure that savings to the trust funds are achieved 2111/30/2011 Type of Claims (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

Reconsideration Claim - A reconsideration claim is the first level of administrative appeal filed by a State VR Agency on a denied or partially denied claim 2211/30/2011 Type of Claims (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

VR Medical Cessation Claim (301) A medical cessation claim can be submitted by a SVRA when: SSA has ceased a beneficiary’s disability benefits following a continuing disability review; and The beneficiary, at the time of cessation, is in an approved VR program which is likely to lead to permanent removal from the benefit rolls Note—performance of SGA is not required 2311/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

In-Use SVR Each VR agency can decide, on a case by case basis, whether to seek compensation under the Cost Reimbursement program or function as an EN and seek compensation under the Ticket Program – Exception: a prior CR case, for which a claim has been paid, cannot be assigned under the EN payment option When the SVRA chooses to serve a beneficiary under cost reimbursement, this choice must be reported to MAXIMUS via an electronic process MAXIMUS will check the Ticket status If the Ticket is available for assignment, the Ticket will be placed “In-Use SVR” 2411/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

In-Use SVR (cont’d) Placing a beneficiary’s Ticket “In-Use SVR” is very important for a number of reasons: The “In-Use SVR” status extends the protection from medical Continuing Disability Reviews (CDRs) to beneficiaries being served under the cost reimbursement program, so long as they meet SSA’s requirements for Timely Progress If the beneficiary’s Ticket is not placed “In-Use SVR”, an EN can secure the Ticket assignment which would result in the denial of all or part of a subsequent cost reimbursement claim submitted by the SVRA 2511/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Effective April 1, 2012, Cost Reimbursement claims submitted on beneficiaries whose Tickets are not/were never listed as “In-Use SVR” while the VR case was open will be denied regardless of whether or not the Ticket was subsequently assigned to an EN A letter from Bob Williams will go out in the next week or two clarifying that State VR Agencies must report their cost reimbursement cases to MAXIMUS for a CR claim to be approved after April 1, 2012 SSA and MAXIMUS will be working with State VR Agencies to get their CR files in order prior to this deadline 2611/30/2011 In-Use SVR (cont’d) Cost Reimbursement Webinar – Part 2: Processing a Claim

Period of Services For SSA purposes, the period of VR is the period during which the beneficiary received VR services, including eligibility, assessment services, etc. provided prior to plan development It begins the first day of the month the beneficiary entered into or started VR services It ends the last day of the month in which the state VR agency finished providing services to the individual, that is, closed the case 2711/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Period of Services Scenario 4/18/08: Beneficiary applies to VR and is determined presumptively eligible for services 4/28/08: VR provides assessment services to identify a vocational goal and services need to achieve goal 5/5/08: Beneficiary and VR counselor develop and sign IPE 5/8/08: IPE services initiated 4/19/09: Services outlined in IPE are completed, beneficiary has been working a minimum of 90 days, and VR closes beneficiary’s case 2811/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Period of Services (cont’d) The period of VR for this consumer begins April 1, 2008 (the first day of the month the client received VR services) The period of VR ends April 30, 2009 (the last day of the month the provider finished providing services to the individual) 2911/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Reimbursable Services Direct cost services that are reimbursable are purchased services, including, but not limited to: Intake and Assessment Counseling and Guidance Physical and Mental Restoration Vocational and other training services Transportation to/from training/work 3011/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Reimbursable Services (cont’d) Interpreter/reader/note-taking services Technological aids/devices and rehabilitation technology services Personal assistance services Job development/Job coaching services Placement services 3111/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

The VR Agency may request payment for post- employment services if the services were furnished after the month the VR agency closed the case (end of period of VR) and before the end of the payment period (last day of 9 th month of SGA) These costs may be claimed by showing the amounts and the months the services were provided on line 14 ("Other Costs") of the SSA-199 (VR Provider Claim) form The next two slides provide examples of how to determine payment periods and whether costs for post- employment services may be claimed: 11/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim32 Post-Employment Services Are Also Reimbursable

Post-Employment Case Example #1 Date Entered VR 10/2000 IPE date 3/2001 Dates of SSI eligibility9/ /2003 Reimbursable Period Begins 9/2001 (The reimbursable period begins the first month of SSI eligibility which is 9/2001) Month of VR Closure6/2002 Month Completed 9-month3/2003 Continuous Period of SGA Reimbursable Period Ends 3/ /30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim33

Nov 25, 2010: VR successfully closes beneficiary’s case after 90 days of employment. Beneficiary is earning above SGA Jan 23, 2011: Beneficiary’s wheelchair breaks and the beneficiary seeks VR assistance to buy a new wheelchair so he can continue working Jan 27, 2011: VR approves beneficiary’s request as a post- employment service Jan 29, 2011: VR purchases wheelchair for beneficiary May 2011: Beneficiary completes 9 months of SGA level earnings July 2011: VR submits CR claim which includes purchase cost of wheelchair as a reimbursable post-employment expense 11/30/2011 Cost Reimbursement Webinar - Part 2: Processing a Claim 34 Post-Employment Case Example #2

Indirect Expenses Are Also Covered Indirect cost - Administrative, counseling, and placement (ACP) costs are indirect services such as overhead expenses and services provided by the State VR employees. These costs are covered through a monthly amount that is approved by Social Security Tracking cost – These cost are payable up to 9 months after VR closes the case, as long as the cost is within the payment period. These costs are a monthly amount that is approved by Social Security 3511/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Cost Reimbursement and Partnership Plus Partnership Plus allows SSA to pay a State VR Agency a Cost Reimbursement claim and an EN Phase 2 milestone and outcome payments on behalf of the same Ticket Holder This provides beneficiaries with access to ongoing supports that are sometimes needed to maintain and advance in employment after VR case closure 3611/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

CR and Partnership Plus (cont’d) A variety of Partnership Plus models are emerging across the country Several states (FL, IN, MA, OK, TX, VA) are using a model that provides a benchmark job retention payment to a provider/EN that assist a beneficiary to achieve 8 or 9 months of SGA If the benchmark payment is made prior to the end of the 9th month of SGA, it can be included in the cost reimbursement claim as a post-employment service 3711/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

Two Key Actions Support Partnership Plus Beneficiaries being “handed off” to ENs for assistance after VR case closure VR reporting cost reimbursement case openings and closures to MAXIMUS through one of the established electronic processes – Reporting Cost Reimbursement cases to MAXIMUS in a timely manner is the cornerstone of Partnership Plus – How does this relate to Cost Reimbursement claims? – VR and an EN cannot both be reimbursed for services provided in the same month 3811/30/2011Cost Reimbursement Webinar – Part 2: Processing a Claim

QUESTIONS? 11/30/201139Cost Reimbursement Webinar – Part 2: Processing a Claim

QUESTIONS? 11/30/201140Cost Reimbursement Webinar – Part 2: Processing a Claim

QUESTIONS? 11/30/201141Cost Reimbursement Webinar – Part 2: Processing a Claim

QUESTIONS? 11/30/201142Cost Reimbursement Webinar – Part 2: Processing a Claim