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Ticket to Work and Healthcare: Incentivizing Employment with Medicaid and Medicare

October 28, 2016
Annette Shea, Administration for Community Living Program Specialist

In 1999 Congress passed groundbreaking legislation which broke down barriers to employment for people with disabilities. In addition to providing Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) beneficiaries with a range of new and improved options related to employment, the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999 offered states an unprecedented opportunity to eliminate barriers to employment for individuals with disabilities who received Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) and those who met the Social Security Administration definition of disability, were working, and needed access to services only offered by Medicaid. It also added a provision extending Medicare coverage for disability benefit recipients.

Section 201 of the TWWIIA provided states with the authority to implement Medicaid coverage to working beneficiaries with disabilities age 16 through 64. In addition, Section 202 extended Medicare coverage for disability benefit recipients.

Advocates were the driving force in ensure the legislation would give states the authority to create opportunities in which individuals with disabilities wouldn’t need to choose between healthcare and work.

“The National Council on Independent Living’s Social Security Subcommittee, Centers for Independent Living (CILs) and State Independent Living Councils were some of the predominate forces working on drafting the law. They played an important role in advocating, lobbying and collecting data to substantiate its passage with members of Congress. Advocates and policy makers knew we needed to include different provisions. We also knew people were concerned about healthcare and that people were not going to work if that meant jeopardizing their health and well-being,” according to Dr. Thomas Golden, a member of the Ticket to Work and Work Incentives Advisory panel, and Executive Director of the K. Lisa Yang and Hock E. Tan Institute on Employment and Disability at Cornell University. Golden added that CILs and other advocates sought to answer a key question, “what were the challenges that SSI and SSDI beneficiaries experience in realizing their full work potential?”

The healthcare provisions became a prominent feature of the law. Golden added, “it is a critical piece—affording SSI and SSDI beneficiaries a pathway to work with healthcare. Prior to the Medicaid Buy-In there wasn’t enough of a safety net to allow them to work to their full potential and many lived in fear of working in excess of certain thresholds. In addition, Congress extended Medicare under the TWWIIA because prior to its passage extended Medicare coverage didn’t provide an adequate enough safety net.”

According to Golden there were three initial target populations for the healthcare provisions of the law:

  • SSDI beneficiaries without access to 1619b Medicaid coverage or private insurance due to pre-existing conditions.
  • SSI beneficiaries who exceeded 1619b limits.
  • Individuals with disabilities not enrolled in SSI or SSDI and possibly not receiving Medicare or Medicaid.

“The latter provided an incentive to those not thinking about a cash benefit but who needed healthcare. Advocates wanted them to have a healthcare safety net,” said Golden. This was before the Affordable Care Act when individuals with pre-existing conditions could not access private or employer sponsored insurance.

The Affordable Care Act established the Health Insurance Exchanges and expanded coverage for the poorest Americans by creating an opportunity for states to provide Medicaid eligibility to individuals younger than 65 with incomes up to 133 percent of the federal poverty level (FPL) and eliminated coverage denials due to pre-existing conditions. Much like employer-based plans, the private plans offered through the exchanges generally do not cover services such as personal care attendant services, long-term community based services, durable medical equipment, and extended therapies. Therefore, Medicaid Buy-in programs continue to be an important path to employment and community living for people with disabilities. The Affordable Care Act did not make any changes to the Medicaid Buy-In program or change its critical role.

The TWWIIA Medicaid Buy-In group is similar to the group created by the Balanced Budget Act (BBA) of 1997 except that eligibility is not limited to people with family income below 250% of the Federal Poverty Level. With the TWWIIA group, states are free to establish their own income and resource standards—including having the option of no income or asset limits at all.

Today, there are 46 Medicaid Buy-In programs throughout the country. Enrollment has grown from 28,700 beneficiaries in 2001 to approximately 200,000 beneficiaries in 2011 with more than $1.15 billion in earnings. States have the option of amending their programs to align with employment goals and incentive earnings, creating more equitable opportunities. Some states implemented their programs with income and earning thresholds at the onset and later changed their policies to promote financial well-being and independence. Currently, four states have no income limit for their Medicaid Buy-In and five have no asset limit.

Golden said that at the time of the legislation there wasn’t a lot of thought given to individuals with disabilities who use the Medicaid Buy-In to supplement private or employer-sponsored insurance.

“We never thought of the secondary group in the 1999 TWWIIA environment. Healthcare changes in the last decade have seen this population emerge as a potential target,” Golden said. The Medicaid Buy-In offers beneficiaries access to services and supports generally not offered by Medicare or private insurance.

The impact of the Medicaid Buy-In has been good for beneficiaries and Medicaid programs. “People on the Medicaid Buy-In had greatly reduced Medicaid expenditures and costs,” Golden said referencing a Cornell study on the New York Medicaid Buy-In. “This study informed in part New York State’s Employment First Commission recommendations. Work has a positive influence on the big picture and the person themselves.”

More information about the Medicaid Buy-In:



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Last modified on 04/20/2017


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