Ticket to Work: All EN Payments Call Part II April 29, 2014

EN Payment Rules and Application Phase 1/Phase 2 Milestones Benefits Attainment Month Payment Request Form Phase 1/Phase 2 Milestones Earnings 18-Month Lookback Rule State VR agency involvement EN Certification of Services Outcome Part IPart II

Phase 1/Phase 2 Milestones -Earnings 3

Phase 1/Phase 2 Milestones - Earnings (cont.) EN submits a Payment Request for an Social Security Disability Insurance (SSDI) (T2) beneficiary for a PH2/M1 for the claim month 01/2011. The pay stubs (2) submitted show: Pay stub # 1 Pay Period Beginning:01/10/2011 Pay Period Ending:01/23/2011 Pay Date:01/28/2011 Gross amount:$ Pay stub # 2 Pay Period Beginning:01/24/2011 Pay Period Ending:02/06/2011 Pay Date:02/11/2011 Gross amount:$ Determination: The P2M1 claim is denied. Denial Reason: Earnings Amounts Do Not Meet Criteria for Payment Comments: Evidence of earnings submitted are below SGA for 2011= $1,000 4

Phase 1/Phase 2 Milestones- Earnings (cont.) Explanation: SSDI (T2) If an EN submits a Payment Request for a beneficiary receiving SSDI (T2), we will determine the amount of earnings earned in the month (from the 1st day of the month to the last day of the month) for Ph1/Ph2 Milestones and for Outcome payments. If the evidence of earnings for the claim month requested is overlapping the following month, we will prorate the earnings for each month. $ / 14 (days in the pay period) = $47.20 X 8 (days 01/24-01/31) = $ Then: $ (pay stub #1) + $ (8 days in 01/2011, pay stub # 2) = The PR submitted by the EN for Ph2/M1 for the claim month of 01/2011 will be denied due to total earnings amount is below Substantial Gainful Activity (SGA) (SGA for 2011=$ ). 5

Phase 1/Phase 2 Milestones- Earnings (cont.) 6

Supplemental Security Income (SSI) (If beneficiary was SSI or T16) If an EN submits a Payment Request for a beneficiary receiving T16, we will determine the amount of earnings paid in the month (pay dates may fall on any day of the month) for Ph1/Ph2 Milestones and for Outcome payments. Even if a pay stub shows that the days are overlapping the following month, we will consider only the pay date. 7

Phase 1/Phase 2 Milestones - 18-MLB Rule 8

Phase 1/Phase 2 Milestones - 18-MLB Rule (cont.) EN submits a Payment Request for a P1M1 with an attainment date of 01/2013. The beneficiary’s Ticket was assigned 12/10/2012. The EN supplied copies of pay stubs with earnings that met were above Trial Work Level (TWL) to meet the criteria for a Phase 1 Milestone. The EN also submitted a Look Back form and indicated the beneficiary had earnings at or above TWL for 10/2012 and 11/2012. Determination: The P1M1 claim is denied. Denial Reason: Not Eligible for Payment Due to Look Back Earnings Comments: Earnings above TWL exist prior to the Ticket assignment date. EN is not entitled to receive P1M1 payment. The timeframe use to calculate Phase 1 Milestones that may be unavailable is listed below: Phase 1 Milestone # Timeframe of TWL Earnings 1 1 Month before Ticket assignment 2 3 out of 6 Months 3 6 out of 12 Months 4 9 out of 18 Months 9

Phase 1/Phase 2 Milestones - 18-MLB Rule (cont.) 10 In the example above, 18 months prior to 12/2012 is 06/2011. If the beneficiary has earnings ≥ TWL: 3 months between 06/12 and 12/12; Phase 1 Milestone 2 would be excluded 6 months between 12/11 and 12/12; Phase 1 Milestone 3 would be excluded 9 months between 06/11 and 12/12; Phase 1 Milestone 4 would be excluded

Phase 1/Phase 2 Milestones – State Vocational Rehabilitation (VR) Involvement 11

Phase 1/Phase 2 Milestones – State VR agency Involvement (cont.) EN submitted a Payment Request for Phase 1 Milestones 1-3. The Ticket assignment date was 01/10/2011. The attainment dates were 03/11, 05/11 and 08/11. The EN supplied pay stubs with earnings above Substantial Gainful Activity (SGA) for the 6 months and filled out Section V of the PR with a summary of services and dates of services between each Phase 1 milestone. Determination: Phase 1 Milestones 1- 4 were denied. Phase 2 Milestones 1- 6 paid. Denial Reason: Due to VR services Phase 1 Milestone cannot be paid. Comments: Ticket assignment to a State VR agency under Cost Reimbursement was closed successfully. No Phase 1 Milestone payments can be made. 12

Phase 1/Phase 2 Milestones – State VR Involvement (cont.) According to §411 Code of Federal Regulations: (iii) If a beneficiary had a ticket that otherwise was available for assignment and chose to receive services under an IPE from a State VR agency that elected the VR cost reimbursement option, payment of Phase 1 Milestones to an EN or a different VR agency acting as an EN with respect to the same ticket is precluded if the State VR Agency that elected the VR cost reimbursement option achieved an employment outcome (as described in 34 CFR ) before case closure. 13

Phase 1/Phase 2 Milestones – EN Certification of Services 14

Phase 1/Phase 2 Milestones – EN COS (cont.) EN submitted a PR for a Phase 2 Milestone 11 claim with an attainment month of 03/13. The beneficiary was in a current pay payment status and earnings posted in Social Security’s system were above SGA for 03/13. Phase 2 Milestone 10 had been paid for attainment month 02/13. Determination: The P2M11 is paid. EN Payments staff request PHD to submit a request to the EN for an EN COS for P2M11. Explanation: The beneficiary met the criteria for payment of the P2 M11; however, ENs should submit an EN COS when submitting PRs for: Phase 1 Milestone 4 Phase 2 Milestone 11 Outcome 11 Outcome 22 15

Outcomes - Benefits 16

Outcomes – Benefits (cont.) EN submits a Payment Request for Outcomes for attainment months 03/13 – 04/13. EN submitted pay stubs with earnings above Substantial Gainful Activity (SGA) for 03/13 – 04/13. The beneficiary is a concurrent beneficiary (SSDI and SSI). Determination: Outcomes for attainment months 03/ /14 are denied. Denial Reason: Benefits not suspended or terminated due to work Comment: Benefits are in current pay status for 3/13 - 4/13. Outcome payments cannot be processed when beneficiary is receiving Federal cash benefits. 17

Outcomes – Benefits (cont.) Explanation: The beneficiary has earnings above SGA and his SSI (T16) record indicates the beneficiary has been placed in a non-pay payment status due to work and earnings. However, the beneficiary’s SSDI (T2) record indicates the beneficiary is in current pay payment status (receiving a Federal cash benefit). To be eligible for outcome payments, a concurrent beneficiary must be in a non-pay or suspense payment status under both programs (SSDI and SSI) and the reason for non-pay or suspense under at least one of the two programs must be due to work and earnings. This beneficiary had been in an outcome period (i.e. non-pay due to work and earnings) under both SSDI and SSI previously. Therefore, the only payments available for this beneficiary are outcomes. Since the beneficiary is not in a non-pay or suspense payment status under both programs (and one of the two non-pay reasons are due to work and earnings), outcome payments are not available. 18

Outcomes - Availability 19

Outcomes – Availability (cont.) The EN has chosen the Outcome Only payment method and submitted a PR for an outcome 1 payment with an attainment month of 02/13. The Ticket assignment date was 02/13/2013. The EN submitted pay stubs with earnings for 02/13 well above SGA. The beneficiary is an SSI beneficiary and is in suspense due to work and earnings. Determination: Outcome #1 for attainment months 02/13 is denied. Denial Reason: Can not pay until month after first assignment Comment: Claim not payable until first month after Ticket assignment date. Explanation: The EN submitted a claim for the same month the Ticket was assigned; 02/13. The first month available for payment is the first month after Ticket assignment. In this case, the first month available for payment is 03/13. 20

Outcomes – SGA Levels 21

Outcomes – SGA Levels (cont.) An EN submitted a PR for an outcome payment and pay stubs with earnings well over SGA ($1240) for the attainment month 12/10. The Ticket was assigned 06/10 and the SSDI beneficiary was in a suspense payment status due to work and earnings. Determination: Outcome was denied. Denial Reason: Earnings amounts do not meet criteria for payment Comment: Evidence of earnings submitted are below Blind Substantial Gainful Activity for 2010 = $1,640. Explanation: The earnings requirement for outcome payments for this particular beneficiary was Blind SGA instead of normal SGA. The requirement for Blind SGA earnings is higher than non-blind SGA. 22

Outcomes – Payment/Denial Decision EN Payments Specialists make payment/denial decisions based on the information posted on Social Security databases at the time claims are processed. This information can change; therefore Payments Specialists save all information used (i.e., a snapshot of status, earnings and other information at the time claims processed) to make a determination. An EN submitted a PR for a claim (no specific type of claim) and submitted pay stubs for the attainment month 11/12. The beneficiary had a Ticket assignment date of 06/10. The EN Payments staff created and denied an outcome claim with a Denial Reason: Insufficient earnings. The EN resubmitted the claim with the same pay stubs and EN Payments staff created a P2M10 and denied the P2M10 claim with a Denial Reason: Insufficient earnings. The EN submitted an inquiry and wanted to know: 1.Why was the claim created as an outcome the first time and a Phase 2 Milestone claim the second time. 2.Why was the claim denied for insufficient earnings because pay stubs exceeded SGA based on her calculation of $1,001.93? 23

Outcomes – Payment/Denial Decision (cont.) Explanation: The first time the claim was correctly created and processed as an outcome claim. The beneficiary’s pay status at the time the claim was processed was: Suspended Due to Work and Earnings. The Social Security field office had placed the beneficiary in and out of suspense beginning 09/11 – 12/12. For the month of 11/12, the field office posted the beneficiary in a suspense pay status due to work and earnings. This is the correct pay status of an outcome claim. 24

Outcomes – Payment/Denial Decision (cont.) The second time the claim was correctly created and processed as a Phase 2 Milestone 10 claim. At the time this claim was processed the Social Security field office retroactively placed the beneficiary in a current pay payment status (i.e., receiving a monthly Federal Benefit) with NO outcome periods since the beneficiary’s disability award was approved. The beneficiary remained in a current pay status, so a Phase 2 Milestone payment was appropriate. The last payment processed under the beneficiary’s Social Security Number was a Phase 2 Milestone 9; therefore, the current claim created for a Phase 2 Milestone 10 was appropriate. ISSUE OF INSUFFICIENT EARNINGS - EN Payments staff review of pay stubs submitted resulted in agreement with the EN’s calculation of $1, However, SGA for 2012 was $1,010. When informed the EN realized that she had not updated tables of earnings for 2012 and made the necessary changes. 25

Outcomes – Notification Policy Changes EN Payments Staff resumed processing payment denials for Universal Auto Pay and all claims submitted by ENs. In February 2013 the EN Payments Staff stopped processing payment denials for auto pay claims since ENs did not request these payments. EN Payment staff only created and processed claims for payment from the Universal Auto Pay file. During this time, EN Payments staff also grouped denials under one work case number when a large number of denials were processed for the same reason and provided an explanation in the comments section of the EN Payment Status Report. This process made it more difficult for ENs to reconcile their account receivable balances. Therefore, EN Payments Staff resumed the process of creating payment denials for these claims in August

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Questions 28