Medicaid and Ticket to Work: States' Early Efforts to Cover	 
Working Individuals with Disabilities (13-JUN-03, GAO-03-587).	 
                                                                 
Over 7 million individuals with disabilities rely on medical and 
supportive services covered by Medicaid. However, if working-age 
individuals with disabilities desire to increase their		 
self-sufficiency through employment, they could jeopardize their 
eligibility for Medicaid coverage, possibly leaving them without 
an alternative for health insurance. In an effort to help extend 
Medicaid coverage to certain individuals with disabilities who	 
desire to work, Congress passed the Ticket to Work and Work	 
Incentives Improvement Act of 1999. This legislation authorizes  
states to raise their Medicaid income and asset eligibility	 
limits for individuals with disabilities who work. States may	 
require that working individuals with disabilities "buy in" to	 
the program by sharing in the costs of their coverage--thus,	 
these states' programs are referred to as a Medicaid Buy-In. The 
act also required that GAO report on states' progress in	 
designing and implementing the Medicaid Buy-In. GAO identified	 
states that operated Buy-In programs as of December 2002 and	 
analyzed the income eligibility limits and cost-sharing 	 
provisions established by those states. GAO also assessed the	 
characteristics of the Buy-In participants in four states that	 
were among the most experienced in implementing the program.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-587 					        
    ACCNO:   A07162						        
  TITLE:     Medicaid and Ticket to Work: States' Early Efforts to    
Cover Working Individuals with Disabilities			 
     DATE:   06/13/2003 
  SUBJECT:   Disability insurance				 
	     Employees with disabilities			 
	     Health care programs				 
	     Managed health care				 
	     Persons with disabilities				 
	     Program evaluation 				 
	     State-administered programs			 
	     Strategic planning 				 
	     Connecticut					 
	     Illinois						 
	     Medicaid Program					 
	     Medicare/Medicaid Buy-In Program			 
	     Minnesota						 
	     New Jersey 					 
	     Social Security Disability Insurance		 
	     Program						 
                                                                 
	     Supplemental Security Income  Program		 

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GAO-03-587

Report to Congressional Committees

United States General Accounting Office

GAO

June 2003 MEDICAID AND TICKET TO WORK

States* Early Efforts to Cover Working Individuals with Disabilities

GAO- 03- 587

As of December 2002, 12 states had implemented Medicaid Buy- In programs
under the authority of the Ticket to Work legislation, which was effective
October 1, 2000, enrolling over 24,000 working individuals with
disabilities. These states used the flexibility allowed by the legislation
to raise income eligibility and asset limits as well as cost- sharing
fees. Across the 12 states, income eligibility levels ranged from 100
percent of the

federal poverty level (FPL) in Wyoming to no income limit in Minnesota,
with 11 states setting income eligibility limits at twice the FPL or
higher. In addition to increasing income and asset levels, these states
required participants to buy in to the program by charging premiums,
ranging from $26 to $82 a month, and copayments, generally ranging from
$0. 50 to $3 for office visits and prescription drugs.

In detailed analysis of four states* Connecticut, Illinois, Minnesota, and
New Jersey* GAO found that most Buy- In participants had prior insurance
coverage by Medicaid and Medicare, few had prior coverage by private
health insurance, and many earned low wages* most making less than $800
per month.

In commenting on a draft of this report, the Centers for Medicare &
Medicaid Services noted that it expects to report in 2004 on its current
study of states* experiences in 2001 and 2002 with the Medicaid Buy- In
programs.

Enrollment and Income Eligibility Characteristics of 12 States with Ticket
to Work Medicaid Buy- In Programs State Enrollment Buy- In start date
Income limit as a percentage of FPL a Missouri 8,461 July 2002 250%

Minnesota 6,178 July 2001 No limit Indiana 3,318 July 2002 350%
Connecticut 2,433 Oct. 2000 $75,000 per year b Pennsylvania 1,325 Jan.
2002 250%

New Hampshire 968 Feb. 2002 450% New Jersey 551 Feb. 2001 250% (earned)
and 100% (unearned) Kansas 489 July 2002 300% Illinois 323 Jan. 2002 200%
Washington 144 Jan. 2002 220% Arkansas 65Feb. 2001 250% Wyoming 3 July
2002 100% Source: State- reported data as of December 2002. a The FPL for
an individual in 2002 was $8, 860 annually. b Connecticut*s income
eligibility limit is not determined by the FPL.

Over 7 million individuals with disabilities rely on medical and
supportive services covered by Medicaid. However, if working- age
individuals with disabilities desire to increase their self- sufficiency
through employment, they could jeopardize their eligibility for

Medicaid coverage, possibly leaving them without an alternative for health
insurance. In an effort to help extend Medicaid coverage to certain
individuals with disabilities who desire to work, the Congress passed the
Ticket to Work and Work Incentives Improvement Act

of 1999. This legislation authorizes states to raise their Medicaid income
and asset eligibility limits for individuals with disabilities who work.
States may require that working individuals with

disabilities *buy in* to the program by sharing in the costs of their
coverage* thus, these states* programs are referred to as a Medicaid Buy-
In. The act also required that GAO

report on states* progress in designing and implementing the Medicaid Buy-
In. GAO identified states that operated Buy- In programs as of December
2002 and analyzed the income eligibility limits and cost- sharing
provisions established by those states. GAO also assessed the
characteristics of the Buy- In participants in four states that were among
the most experienced in implementing the

program.

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 587. To view the full product,
including the scope and methodology, click on the link above. For more
information, contact Kathryn G. Allen at (202) 512- 7118. Highlights of
GAO- 03- 587, a report to the

Senate Committee on Finance and the House Committee on Energy and Commerce

June 2003

MEDICAID AND TICKET TO WORK

States* Early Efforts to Cover Working Individuals with Disabilities

Page i GAO- 03- 587 Medicaid and Ticket to Work Letter 1 Results in Brief
4 Background 6 Individuals with Disabilities Had Lower Employment,
Education,

and Income* and More Insurance Coverage* than the General Population 14
States* Buy- In Programs Expanded Eligibility and Increased Cost

Sharing for More Workers with Disabilities 16 Buy- In Participants in Four
States Generally Had Prior Medicaid Coverage and Worked in Low- Wage Jobs
27 Agency and State Comments 32 Appendix I Methodology for Developing
Estimates and

Characteristics of Working- Age Individuals with Disabilities 34

Appendix II Comments from the Centers for Medicare & Medicaid Services 36

Tables

Table 1: Highlights of SSI and DI and Their Links to Medicare and Medicaid
9 Table 2: Comparison of Criteria for the Ticket to Work Buy- In and

the BBA Option 12 Table 3: Enrollment and Eligibility Characteristics of
12 States With Ticket to Work Medicaid Buy- In Programs 17 Table 4: Twelve
States* Premium Requirements for Ticket to Work Medicaid Buy- In Programs
25 Table 5: Number of Buy- In Participants Reporting Other Sources of
Health Care Coverage in Four States 29 Table 6: Average Monthly Income for
Ticket to Work Buy- In Participants in Four States 31 Table 7: MEPS Sample
and Estimated Population Sizes, 1997 and 1998 35 Contents

Page ii GAO- 03- 587 Medicaid and Ticket to Work Figures

Figure 1: Selected Characteristics of Working- Age Individuals with
Disabilities Compared with the Rest of the General Working- Age Population
15 Figure 2: Twelve States* Medicaid Buy- In, SSI Work Incentive, and

Spend- Down Income Eligibility Levels, as a Percentage of the FPL 20
Abbreviations

ADL activities of daily living AHRQ Agency for Healthcare Research and
Quality AWI average wage index BBA Balanced Budget Act of 1997 CMS Centers
for Medicare & Medicaid Services DI Social Security Disability Insurance
EPE extended period of eligibility FPL federal poverty level IADL
instrumental activities of daily living MEPS Medical Expenditure Panel
Survey NHIS National Health Interview Survey SGA substantial gainful
activity SSA Social Security Administration SSI Supplemental Security
Income

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Page 1 GAO- 03- 587 Medicaid and Ticket to Work June 13, 2003 The
Honorable Charles E. Grassley

Chairman The Honorable Max Baucus Ranking Minority Member Committee on
Finance United States Senate

The Honorable W. J. *Billy* Tauzin Chairman The Honorable John D. Dingell
Ranking Minority Member Committee on Energy and Commerce House of
Representatives

During fiscal year 2000, over 7 million individuals with disabilities were
enrolled in Medicaid, a federal- state program that finances health care
for certain low- income Americans. For these individuals, Medicaid gives
states the option to cover a wide array of medical and supportive
services, including assistance with basic daily activities such as
bathing, dressing, and eating. Depending on state Medicaid rules,
individuals with disabilities who qualify for cash assistance from the
Supplemental Security Income (SSI) or Social Security Disability Insurance
(DI) programs may qualify for Medicaid. Nearly all individuals who qualify
for SSI, which primarily covers low- income individuals who are disabled
and have little or no work experience, 1 are assured eligibility for
Medicaid coverage. Under DI, which assists people who worked but became
disabled before their retirement age, 2 individuals are eligible for
Medicare, a federal health insurance program for elderly individuals and
some individuals with disabilities. Depending on their income and assets,
individuals eligible for DI also may

1 SSI beneficiaries also include individuals who are blind or aged.
References to the SSI program throughout this report address individuals
who are disabled, not blind or aged, except where noted.

2 DI beneficiaries also include certain other persons, including
dependents and survivors of workers with disabilities. References to the
DI program throughout this report address only workers with disabilities,
not dependents or survivors. United States General Accounting Office
Washington, DC 20548

Page 2 GAO- 03- 587 Medicaid and Ticket to Work qualify for Medicaid and
thus receive coverage for some services not covered by Medicare, such as
most outpatient prescription drugs.

Because eligibility for Medicaid is generally linked to individuals*
income and assets, working- age individuals* aged 16 to 64* with
disabilities who live in the community and work may jeopardize their
Medicaid coverage due to earnings from work, possibly leaving them without
an adequate health insurance alternative. The loss of Medicaid may be of
particular concern for working- age individuals with disabilities because
some benefits* including personal assistance with daily activities and
adaptive equipment (such as household items modified for use by those with
disabilities)* may not be available through other sources of health
insurance. For example, private health insurance, such as that offered by
employers, often does not cover personal assistance with basic daily
activities or adaptive equipment. As a result, working- age individuals
with disabilities may forgo employment and associated earnings in order to
ensure their continued financial eligibility for Medicaid coverage of
their health care needs.

In an effort to help extend Medicaid coverage to certain individuals with
disabilities who desire to work, the Congress passed the Ticket to Work
and Work Incentives Improvement Act of 1999 (Pub. L. No. 106- 170, 113
Stat. 1860). This legislation, effective October 1, 2000, authorizes
states to raise their Medicaid income and asset limits for individuals
with disabilities who work. States may require that working individuals
with disabilities *buy in* to the Medicaid program by sharing in the costs
of their coverage* therefore, such states* programs are referred to as a
Medicaid Buy- In. A Medicaid Buy- In program is intended to assist
individuals by allowing them to work and thereby increase their
independence and self- sufficiency, while at the same time enabling them
to obtain or maintain health care coverage. The act directed that we
report

to the Congress on characteristics of individuals with disabilities,
including their health care costs and health insurance coverage, as well
as states* progress in designing and implementing the Medicaid Buy- In

program. Accordingly, as agreed with the committees of jurisdiction, we
examined

Page 3 GAO- 03- 587 Medicaid and Ticket to Work 1. characteristics of
working- age individuals with disabilities compared with the rest of the
working- age U. S. population with regard to

employment, education, income, health insurance status, and health care
expenditures,

2. how states that have chosen to establish a Ticket to Work Medicaid Buy-
In program have designed their programs, including income eligibility
limits and any cost- sharing provisions, and

3. characteristics of selected states* Ticket to Work Medicaid Buy- In
participants, including previous health insurance coverage and income from
employment.

To compare characteristics of working- age individuals with disabilities
to individuals in the rest of the working- age population, we analyzed
data available from the Agency for Healthcare Research and Quality*s
(AHRQ) Medical Expenditure Panel Survey (MEPS)* the survey of individuals*
demographics, employment, health characteristics, and medical spending
(household component) for 1997 and 1998, the most recent years for which
relevant data were available. We analyzed data from MEPS because such data
provided both a way to identify working- age individuals with

disabilities and details on their health care expenditures. Our estimates
based on MEPS resulted in a relatively broad definition of disability for
individuals aged 16 to 64 because it included individuals who reported one
or both of the following conditions: (1) needing help or supervision in
performing activities of daily living (ADL) (such as bathing or dressing)
or instrumental activities of daily living (IADL) (such as taking
medications or preparing meals) because of an impairment or a physical or
mental health problem, 3 or (2) being completely unable to work at a job,
do housework, or go to school. For individuals meeting this definition of
disability, we compared characteristics such as income level, insurance
status, and health care expenditures to those of the rest of the U. S.
population aged 16 to 64. AHRQ collected these data prior to

3 MEPS identifies ADLs as basic physical activities such as bathing,
dressing, or getting around the house and identifies IADLS as cognitive or
social functions such as using the telephone, paying bills, taking
medications, preparing light meals, doing laundry, or going shopping. MEPS
offers a relatively expansive definition of disability in that it does not
distinguish the number of ADLs or IADLs with which an individual may
require assistance. Other national surveys that provided details on the
number of ADLs and IADLs with which an individual required assistance*
such as the National Health Interview Survey (NHIS) Disability Supplement*
were based on older data* 1994 and 1995. As of March 2003, the NHIS
Disability Supplement had not been updated.

Page 4 GAO- 03- 587 Medicaid and Ticket to Work implementation of Ticket
to Work Medicaid Buy- In programs and thus the data do not reflect any
effects of states* Buy- In programs. (App. I provides detailed information
on our methodology for developing estimates and

characteristics of working- age individuals with disabilities.) To examine
the designs of the Buy- In programs for states that had chosen to
establish a Buy- In program and whose programs were in effect as of
December 2002, we reviewed state Medicaid plan amendments describing the
BuyIns, analyzed published state documents, and conducted telephone
interviews with state Medicaid officials. Additionally, we analyzed the
BuyIn implementation experience of four states* Connecticut, Illinois,
Minnesota, and New Jersey* that were among the most experienced in
implementing the program. At the federal level, we interviewed officials
at the Centers for Medicare & Medicaid Services (CMS), which oversees
states* Medicaid programs, to gather information about states* programs.
We reviewed documents, including federal laws and reports, related to the
state Buy- In programs. We conducted our work from May 2002 through June
2003 in accordance with generally accepted government auditing standards.

Compared with the rest of the working- age U. S. population, the estimated
6.7 million working- age individuals with disabilities were more likely to
be not working, have less education, and have incomes below the federal
poverty level (FPL). However, they were less likely to be uninsured than
the rest of the working- age U. S. population* just 9 percent of those
with disabilities reported being uninsured, compared with 15 percent of
the rest of the working- age population. Nearly half of individuals with
disabilities who reported having health insurance obtained coverage
through public sources, such as Medicare and Medicaid. Annual average
health care expenditures for working- age individuals with disabilities
were about five times the expenditures for other working- age individuals.

Of the 12 states that had opted to implement Medicaid Buy- In programs
under the Ticket to Work authority, all expanded eligibility to include
working individuals with higher incomes or more assets than generally
allowed under the states* traditional Medicaid programs. As of December

2002, the 12 states had enrolled over 24,000 working individuals with
disabilities. Enrollment ranged from a low of 3 individuals in Wyoming to
8,461 in Missouri. Eleven of the 12 states set Buy- In eligibility limits
for

income at twice the FPL or higher*$ 17,720 per year for an individual in
2002. Additionally, the states* Buy- In programs generally allowed
participants to keep more assets, such as retirement accounts and medical
savings accounts, than allowed in states* traditional Medicaid programs.
Results in Brief

Page 5 GAO- 03- 587 Medicaid and Ticket to Work The higher income
eligibility and asset levels set by states for the Buy- In programs
provided additional opportunities* particularly for DI- eligible

individuals, who had prior working experience before becoming disabled* to
secure and maintain Medicaid coverage. In addition to increasing income
and asset levels, all states took advantage of the statute*s flexibility
by requiring participants to buy in to the program by paying premiums or
copayments. Generally, states assessed premiums for individuals with
incomes above the FPL and adjusted premiums upward as income increased.
Across the 10 states that charged premiums in 2002, the average monthly
premiums paid ranged from $26 in New Hampshire to $82 in Indiana.
Additionally, the percentage of participants who were charged premiums
varied significantly across the states, from 12 percent of participants in
Connecticut to all or nearly all participants in Illinois, Pennsylvania,
Washington, and Wyoming.

Our more detailed analysis of four states that were among the most
experienced in implementing this program found that most Buy- In
participants had prior insurance coverage by Medicaid and Medicare, few
had prior coverage by private health insurance, and many earned low wages
while participating in the Buy- In. More than half of the Buy- In
participants in these four states had previous Medicaid coverage. Those
Buy- In participants who had switched from another Medicaid eligibility
category generally did so because they were able to increase their income
and assets and maintain their Medicaid eligibility. Many Buy- In

participants in these states were eligible for health care coverage
through the Medicare program. However, Medicaid eligibility gave these
individuals additional benefits that were not offered under Medicare, such
as outpatient prescription drugs and personal care services. Few
participants* less than 10 percent of participants in any of the four
states* reported having employer- sponsored coverage at the time of their
enrollment into the Medicaid Buy- In programs. Available employment data
showed that participants generally were working in low- wage jobs* most

making less than $800 per month* although they could earn more and still
retain Buy- In Medicaid benefits. These four states, however, had little
information regarding the extent to which the Buy- In programs fostered
employment among individuals with disabilities.

In its comments on a draft of this report, CMS noted it is conducting an
extensive study of states* experiences with the Medicaid Buy- In programs
and expects to issue a report in 2004. CMS and 11 of the 12 states in our
sample also provided technical comments, which we incorporated as
appropriate.

Page 6 GAO- 03- 587 Medicaid and Ticket to Work Eligibility for benefits
under SSI, DI, Medicare, and Medicaid programs for individuals with
disabilities is determined in part on whether an individual

has a disability as defined in the Social Security Act. 4 For purposes of
these programs, a person is disabled if he or she has a medically
determined physical or mental impairment that (1) has lasted or is
expected to last at least 1 year or result in death and (2) prevents the
person from engaging in substantial gainful activity (SGA). As of January
2003, SGA is defined as countable earnings* generally gross earnings less
the cost of items that, because of the impairment, a person needs to work*
of more than $800 per month. 5 The Social Security Administration*s (SSA)
interpretation of disability specifies that for a person to be determined
to be disabled, the impairment must be of such severity that the person
not only is unable to do his or her previous work but, considering the
person*s age, education, and work experience, is unable to do any other
kind of substantial work that exists in the national economy. 6 The Ticket
to Work and Work Incentives Improvement Act of 1999 allowed

states to expand the availability of Medicaid coverage for individuals
with 4 The DI program and SSI program are authorized under titles II and
XVI, respectively, of the Social Security Act. The definition of
disability for the DI program is in section 223( d) of the Social Security
Act. The definition of disability for the SSI program is in section 1614(
A)( 3). In all material respects, the two definitions are similar and have
been interpreted by the Social Security Administration (SSA) similarly.

5 Under the Social Security Act, the Commissioner of Social Security has
the authority to set the SGA level for individuals who have disabilities
other than blindness. SSA has increased the SGA level several times over
the past decade, to $500 per month in 1990 and to $700 per

month in July 1999. In December 2000, SSA finalized a rule calling for the
annual indexing of the nonblind SGA income limit to the average wage index
(AWI) and on this basis increased the SGA income limit to $780 in January
2002. The SGA income limit for individuals who are blind is set by statute
and indexed to the AWI. For 2002, the SGA income limit for blind
individuals was $1,300 of countable earnings. In January 2003, the SGA
limit increased to $800 per month for nonblind individuals and to $1,330
per month for

blind individuals. To calculate countable earnings for SGA, SSA deducts
from gross earnings the cost of items that, because of the impairment, a
person needs to work (for example, attendant care services performed in a
work setting, wheelchairs, or Braille devices).

6 SSA uses a series of steps to evaluate the applicant*s level of
disability. As part of the steps, SSA compares the applicant*s condition
to a Listing of Impairments that describes medical conditions that are
severe enough to prevent a person from engaging in SGA. If an applicant*s
impairment is cited in the Listing of Impairments or the applicant*s
impairment

is as severe as or more severe than those impairments in the Listing of
Impairments, then the applicant would be considered disabled and awarded
benefits without any further evaluation to determine whether he or she has
vocational limitations that, when combined with the medical impairment,
prevents work. Background

Page 7 GAO- 03- 587 Medicaid and Ticket to Work disabilities who work,
even though they earn more than the SGA level. States that implement
Ticket to Work Buy- In programs may consider as

disabled those individuals who, except for the fact that they are earning
more than the SGA $800 monthly amount, otherwise would meet the Social
Security Act definition of disabled.

Individuals with disabilities become eligible for Medicaid in a variety of
ways but primarily through SSI or DI eligibility (see table 1).
Individuals with disabilities, however, must also meet Medicaid income and
asset requirements in order to obtain Medicaid coverage. Both the SSI and
DI programs contain work incentive provisions designed to assist
individuals with disabilities to achieve gainful employment while
retaining some

eligibility for health care coverage. 7 Individuals receiving SSI also are
assured eligibility for Medicaid in 39 states and the District of
Columbia. The remaining 11 states (known as 209( b) states) may use
different standards for disability, income, or assets; thus, SSI
beneficiaries in these 11 states may not have assured eligibility for
Medicaid. 8 Work incentives under SSI allow individuals to (1) have their
SSI cash benefits gradually reduced as earnings increase, rather than
having cash benefits removed entirely once earnings exceed the SGA limit,

and (2) maintain their Medicaid coverage up to an income limit that varies
7 These work incentive provisions can help individuals pay for services or
items that they need in order to work or enable individuals to maintain or
increase their cash benefits until they are stable in employment. Other
work incentives allow individuals with disabilities to recover impairment-
related work expenses, such as attendant care services and transportation
costs.

8 Under Section 1902( f) of the Social Security Act, 42 U. S. C. 1396a(
f), states may use their 1972 state assistance eligibility rules in
determining Medicaid eligibility for individuals with disabilities, rather
than SSI eligibility rules, and 11 states do so. The 11 states are
Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New
Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. These states are
often referred to as 209( b) states because the origin of this authority
is S:209( b) of the Social Security Amendments of 1972. The 209( b)
states* definitions of disability or their income/ resource standards for
Medicaid

eligibility tend to be more restrictive than those for SSI but can be the
same as or more liberal. If a state*s 209( b) rules are more restrictive,
it must also allow individuals to spend down into Medicaid eligibility by
deducting incurred medical care expenses from income. Individuals with
Disabilities Qualify for

Medicaid Primarily through SSI or DI Eligibility

SSI

Page 8 GAO- 03- 587 Medicaid and Ticket to Work across the states (from
$15,049 (170 percent of the FPL) in Arizona to $39,228 (443 percent of the
FPL) in New Hampshire as of 2002). 9 Individuals receiving DI also may
become eligible for Medicaid under

certain circumstances. By virtue of their DI disability determination,
they meet one of the categorical eligibility requirements for Medicaid. 10
However, they must also meet Medicaid*s income and asset requirements

as defined by each state. DI beneficiaries can *spend down* their income
on medical expenses in order to meet state- determined income limits for
the medically needy eligibility category, if a state provides this
optional coverage. 11 While DI beneficiaries receive health care coverage
through Medicare, 12 eligibility for the medically needy category provides
Medicaidcovered services that are not covered by Medicare, such as most
outpatient prescription drugs. Work incentives under DI are structured
such that if an individual*s work activity increases to a level where he
or she is no longer deemed disabled, the individual loses DI eligibility,
and in turn, Medicaid eligibility.

9 In contrast to other Medicaid income eligibility thresholds, which are
usually set by the state within federal guidelines, SSA sets the income
threshold for SSI- related Medicaid eligibility annually. The income
threshold for a particular state is based on the current SSI cash benefit
in each state and a state*s per capita Medicaid expenditures. If an SSI
beneficiary has gross earnings higher than the threshold amount for his or
her state, SSA can calculate an individual threshold amount if he or she
has medical or impairmentrelated

work expenses above the state amount. 10 States receive federal Medicaid
matching funds for health care provided to certain individuals meeting
broad federal requirements for eligibility, including categorical, income,
resource, immigration status, and residency requirements. The categorical

requirement includes individuals who fall into specified categories, which
can be classified into five broad coverage groups: individuals with
disabilities, children, pregnant women, individuals in families with
dependent children, and the elderly. 11 The medically needy category
refers to individuals who meet certain categorical

requirements for Medicaid eligibility* for example, children, individuals
with dependent children, and individuals who are aged, disabled, or
pregnant* and have incurred medical expenses to the point where their
income, less the medical expenses incurred, makes them eligible for
Medicaid. As of November 2002, 35 states and the District of Columbia
opted to cover Medicaid beneficiaries under the medically needy
eligibility category. 12 After they have received DI cash benefits for 24
months, DI beneficiaries are entitled to

Medicare part A coverage and are eligible to enroll in part B. Medicare
part A helps cover inpatient care in hospitals, critical access hospitals,
and skilled nursing facilities. It also covers hospice care and some home
health care. Medicare part B helps cover physician services and outpatient
hospital care. DI

Page 9 GAO- 03- 587 Medicaid and Ticket to Work Table 1: Highlights of SSI
and DI and Their Links to Medicare and Medicaid Program SSI DI

General description

 Means- tested income assistance program for disabled, blind, or aged
individuals with or without prior participation in the labor force.

 Federal income limit of $545 in countable income per month for an
individual ($ 817 for a couple) and $2,000 in assets for a single adult ($
3,000 for a couple) as of 2002. a  SSI cash benefits are based on a
beneficiary*s countable income, living arrangements, and state

of residence. Most states pay some beneficiaries an additional amount
referred to as a *state supplement.* The amounts and qualifications for
these state supplements vary by state.

 Income assistance program for individuals who have lost their ability to
work as a result of a severe, longterm disability and have worked long
enough in Social Security- covered employment and during a specified time
period to meet program requirements. b  No federal income or asset limit
for participation in the

DI program, other than meeting the SGA earnings limit to be determined
disabled ($ 800 per month in 2003).

 The DI cash benefits are based on a beneficiary*s lifetime average
earnings that were covered by Social Security. The payment amount is
adjusted each year

to account for changes in the cost of living. Number of working- age
individuals covered

 In 2001, 3.8 million individuals aged 18- 64 received SSI benefits.

 In 2001, 5.3 million individuals through age 64 received DI benefits
because of a disability they incurred. Link to Medicaid and Medicare  In
39 states and the District of Columbia, SSI

eligibility assures an individual*s eligibility for Medicaid benefits.

 Eleven states use more restrictive disability, income, or asset
requirements than SSI for Medicaid eligibility. c  No direct link to
Medicare.

 Individuals eligible for DI meet the Medicaid categorical designation
for disability, but they also must meet the Medicaid income and asset
requirements as defined by the state. DI individuals may spend down their

income and assets and thus become eligible for Medicaid under the
medically needy eligibility category, if a state uses this optional
coverage category.

 Entitled to part A Medicare coverage after they have received DI cash
benefits for 24 months. d Program work

incentives and effect on health coverage

Under section 1619 (a),( b) of the Social Security Act, 42 U. S. C. 1382h(
a),( b), disabled SSI beneficiaries who work may be eligible for continued
Medicaid coverage through two work incentive programs:

 Section 1619( a): Allows disabled beneficiaries to continue to receive
SSI cash payments even when earnings exceed the SGA ($ 800 per month in
2003). However, as earnings increase, the SSI

cash payment decreases until earnings completely replace cash benefits.
There is no effect on Medicaid coverage as long as an individual receives
SSI cash benefits.

 Section 1619( b)* SSI work incentive: e Allows disabled beneficiaries to
continue to receive Medicaid coverage even when they no longer qualify for
SSI cash benefits. Medicaid coverage continues until earnings reach a
threshold amount that varies by state. In contrast to other Medicaid
income eligibility thresholds, which are usually set by the state within
broad federal parameters, SSA sets the income threshold for SSI- related
Medicaid eligibility, which varies from state to state on the basis of
each state*s current SSI cash benefit (the f d lb fi d l ) d

DI beneficiaries who work may retain eligibility for Medicaid as long as
their medical disability continues and they continue to meet a state*s
Medicaid income and asset requirements.

Medicare coverage for DI beneficiaries who work may be retained under the
following circumstances:

 Trial work period: Allows DI beneficiaries to have a trial work period
of 9 months (not necessarily consecutive) within a 60- month rolling
period during which they can earn any amount without affecting their DI
benefits. Medicare part A coverage continues for the 9- month period.

 Extended period of eligibility (EPE): Immediately after the trial work
period, DI beneficiaries enter a 36- month EPE as long as medical
disability continues. Cash benefits continue for the first 3 months of
this period regardless of the earnings level. For the remaining 33 months,
DI cash benefits are paid only in months in

which countable earnings were less than SGA ($ 800 per month in 2003). For
those who earn at or above SGA level after the 36- month EPE, part A
Medicare coverage continues for at least 7 years and 9 months

Page 10 GAO- 03- 587 Medicaid and Ticket to Work Program SSI DI

federal benefit and any state supplement) and a state*s per capita
Medicaid expenditures. f Across the 50 states and the District of
Columbia, Medicaid eligibility for SSI- related individuals in 2002 ranged
from 170 percent of the FPL in Arizona to 443 percent of the FPL in New
Hampshire.

(including the 36 months of the EPE), unless the person is determined to
be not disabled for a reason other than earning the SGA level.

With the trial work period and the EPE, DI beneficiaries who work, and
continue to have a medical disability, are entitled to at least 8- 1/ 2
years of Medicare part A coverage following the start of a trial work
period. g Source: SSA.

Note: GAO analysis of SSA documents, as of December 2002. a Not all income
or assets are counted in order to calculate *countable* income or assets.
Income

exclusions include $20 per month of most income, $65 per month of wages
and one- half of wages over $65, food stamps, and home energy and housing
assistance. Assets excluded are the home a person lives in; a car,
depending on its use or value; certain burial spaces and burial funds up
to $1,500; and life insurance with a face value of up to $1,500. b To be
eligible for DI benefits, workers (except those who are blind) also must
meet a test of

substantial recent covered work, which means that workers aged 31 and
older must have been in Social Security covered employment for at least 20
quarters of the 40 calendar quarters ending with the quarter in which the
disability began. Workers disabled before age 31 may qualify for benefits
under a special insured status requirement.

c In identifying eligible individuals with disabilities, states generally
are required to use the SSI eligibility requirements; however, they also
have the option to use their January 1972 state assistance eligibility
rules under section 1902( f) of the Social Security Act, which tend to be
more restrictive than SSI rules. If a state*s 209( b) rules are more
restrictive, it must also allow individuals to spend down into Medicaid
eligibility by deducting incurred medical care expenses from income. As of
2002, 11 states had elected this option: Connecticut, Hawaii, Illinois,
Indiana, Minnesota, Missouri, New Hampshire,

North Dakota, Ohio, Oklahoma, and Virginia. d Medicare part A helps cover
inpatient care in hospitals, critical access hospitals, and skilled
nursing

facilities. It also covers hospice care and some home health care.
Medicare part B helps cover physician services and outpatient hospital
care. DI beneficiaries are eligible to enroll in part B Medicare coverage
after they have received DI cash benefits for 24 months. e Throughout this
report, we refer to individuals who qualify for Medicaid under 1619( b) as
participants

in the SSI work incentive program. f If an SSI beneficiary has gross
earnings higher than the threshold amount for his or her state, SSA

can calculate an individual threshold amount if he or she has medical or
impairment- related work expenses above the state amount. g Under section
1818A of the Social Security Act, a disabled individual who has lost
entitlement to

premium- free Medicare part A solely because of SGA may be able to enroll
in part A as long as the disability continues. The individual is
responsible for paying the premiums.

Page 11 GAO- 03- 587 Medicaid and Ticket to Work The Ticket to Work
Medicaid Buy- In builds on an earlier effort to expand Medicaid
eligibility for individuals with disabilities who desire to work.

Through the Balanced Budget Act of 1997 (BBA) (Pub. L. No. 105- 33, 111
Stat. 251), the Congress gave states the option of implementing a coverage
category for working individuals with disabilities. For these individuals,

the BBA authorized states to extend Medicaid coverage to those who meet
the SSI definition of disability and exceed the SSI income eligibility
limit but whose income remains under 250 percent of the FPL. States
electing the BBA option may require beneficiaries to pay premiums or may
use other cost- sharing provisions as long as they are set on a sliding
scale based on income. As of December 2002, 12 states had implemented a
BBA option for working individuals with disabilities. 13 The Ticket to
Work Medicaid Buy- In legislation expands the availability of Medicaid
coverage for individuals with disabilities who desire to work by

allowing them to gain or maintain Medicaid eligibility as they enter the
workforce or to increase their earnings if they are in the workforce. The
Ticket to Work Buy- In builds on the BBA option by giving states unlimited
flexibility to set higher income and asset levels for two new eligibility
groups* Basic Coverage Group and Medical Improvement Group* for working
individuals with disabilities. (For a comparison of the two programs, see
table 2.)

13 States with the BBA option as of December 2002 included Alaska,
California, Iowa, Maine, Mississippi, Nebraska, New Mexico, Oregon, South
Carolina, Utah, Vermont, and Wisconsin. Medicaid Buy- In Program

Designed to Expand Coverage for Working Individuals with Disabilities

Page 12 GAO- 03- 587 Medicaid and Ticket to Work Table 2: Comparison of
Criteria for the Ticket to Work Buy- In and the BBA Option Criteria Ticket
to Work Buy- In BBA Option

Who can be covered Basic Coverage Group: Working disabled individuals,
aged 16* 64 (SSI disability definition). a

Medical Improvement Group: Employed Individuals losing Basic Coverage
because they no longer meet the SSI disability definition, but still have
severe impairment.

Working disabled individuals of any age (SSI disability definition). a
Income standard For both the Basic Coverage and Medical Improvement

groups, the state establishes its own standard or chooses not to have an
income standard.

Up to 250 percent of the FPL, and unearned income must meet SSI income
test. b Asset standard For both the Basic Coverage and Medical Improvement

groups, the state establishes its own standard or chooses not to have one.

SSI asset standard ($ 2,000/ person, $3,000/ couple). b Premiums and cost

sharing For both the Basic Coverage and Medical Improvement groups, the
state may require premiums and other cost- sharing

mechanisms on an income- based sliding scale. For annual incomes less than
450 percent of the FPL, state may charge premiums and use other cost-
sharing mechanisms of up to 7.5 percent of income. States must charge the
highest amount of premium under the

states* premium structure for those with adjusted gross annual incomes
exceeding $75,000.

State may require premiums and other cost- sharing mechanisms on an
incomebased sliding scale.

States using this option as of December 2002 c Basic Coverage Group:
Arkansas, Connecticut, Illinois,

Indiana, Kansas, Minnesota, Missouri, New Hampshire, New Jersey,
Pennsylvania, Washington, Wyoming

Medical Improvement Group: Connecticut, Indiana, Missouri, Pennsylvania,
Washington

Alaska, California, Iowa, Maine, Mississippi, Nebraska, New Mexico,
Oregon, South Carolina, Utah, Vermont, Wisconsin

Source: CMS. Note: GAO analysis of CMS documents, as of December 2002. a
For those individuals who have not been determined disabled by SSA, the
state must do a disability determination to ensure that the individual
would meet the definition of disability under the SSI

program. The disability test must be identical to the SSI or DI disability
test except that employment activity, earnings, and SGA cannot be
considered in determining whether the individual meets the definition of
disability. b Under usual eligibility rules, states are required to use
the processes used by SSI and the former Aid

to Families with Dependent Children program in determining eligibility for
Medicaid. However, section 1902( r)( 2) of the Social Security Act, 42 U.
S. C. 1396a( r)( 2), allows states to disregard (not include) additional
kinds and amounts of income and assets beyond what is allowed under these
programs. For example, a state could disregard a select amount of earned
or unearned income or income used for home maintenance or repair.

c Florida received approval for a Ticket to Work Medicaid Buy- In program
in June 2002; however, the state had not implemented the program as of
December 31, 2002. Arizona received approval for a Ticket to Work Medicaid
Buy- In program in December 2002. The program was implemented in January
2003, which was after the cut- off date of December 2002 for inclusion in
this study.

Page 13 GAO- 03- 587 Medicaid and Ticket to Work The Basic Coverage Group
allows states to cover people aged 16 to 64 who, except for the amount of
their earned income, would be eligible to

receive SSI benefits. States may establish their own income and asset
standards or elect to have no standards at all. 14 As with the BBA option,
states electing the Basic Coverage Group may require participants to pay
monthly premiums or may impose other cost- sharing mechanisms if they are
set on an income- based sliding scale. However, for individuals with
annual incomes less than 450 percent of the FPL, states may not impose
premiums that exceed 7.5 percent of income. Additionally, if the
individual*s adjusted gross income for federal income tax purposes exceeds
$75,000, the state must require the individual to pay the highest amount
of premiums that an individual would be required to pay under the state*s
premium structure, although a state is allowed to subsidize this cost with
its own funds. While the Basic Coverage Group Buy- In participants must
have earnings, the Ticket to Work legislation does not specify a minimum
level of employment for this group. Since states cannot adopt rules
defining employment for this group that are more restrictive than those in
federal law, states cannot establish requirements such as minimum earnings
or hours worked. The Medical Improvement Group allows states to cover
working

individuals who lose Medicaid eligibility under the Basic Coverage Group
because their conditions have improved to the point that they no longer
meet the SSI definition of disability but still have *a severe, medically
determinable impairment.* The same premium requirements apply as for

the Basic Coverage Group. If a state elects to cover the Medical
Improvement Group, it must also cover the Basic Coverage Group. While the
Ticket to Work legislation does not set an employment standard for the
Basic Coverage Group, it provides a definition and also allows a state to
define employment for the Medical Improvement Group. According to the
legislation, an individual qualifying for the Medical Improvement Group is
considered employed if the individual is earning at least the minimum wage
and working at least 40 hours per month. Alternatively, a state may

14 If states establish income and asset standards, SSI income and asset
methodologies are used to determine eligibility, including the SSI earned
income disregard of $65, plus onehalf of remaining earnings. Other income
disregards include $20 of unearned income, and certain impairment- related
work expenses, such as certain attendant care services, transportation
costs, and medical devices. The SSI asset methodology allows for exclusion
of such things as the home a person lives in, a car depending on its use
or value, and life insurance valued up to $1, 500.

Page 14 GAO- 03- 587 Medicaid and Ticket to Work use hours of work, wage
levels, or other measures to define employment if the Secretary of Health
and Human Services approves the definition.

Compared with the rest of the working- age population, the estimated 6.7
million working- age individuals with disabilities nationwide were more
likely to be not working, have less education, and have incomes below the
FPL. Specifically, 82 percent of working- age individuals with
disabilities, or about 5.5 million individuals, reported that they were
not working. (See fig. 1.) Nearly three- fourths of working- age
individuals with disabilities reported they had a high school education or
less. Furthermore, these individuals were nearly three times more likely
than individuals without disabilities to have incomes below the FPL. At
the same time, individuals with disabilities were less likely to be
uninsured compared with the rest of the working- age U. S. population,
with just 9 percent of those with disabilities reporting being uninsured,
compared with 15 percent for the rest of the working- age population.
Nearly half of individuals with disabilities who reported having health
insurance obtained coverage through public sources, such as Medicaid and
Medicare. Individuals with

Disabilities Had Lower Employment, Education, and Income* and More
Insurance Coverage* than the General Population

Page 15 GAO- 03- 587 Medicaid and Ticket to Work Figure 1: Selected
Characteristics of Working- Age Individuals with Disabilities Compared
with the Rest of the General Working- Age Population

Note: GAO analysis of AHRQ*s MEPS household component, 1997 and 1998. a
Individuals reported income levels from either 1997 or 1998. The FPL in
1997 was $7, 890 for an individual; the FPL in 1998 was $8, 050 for an
individual.

b Individuals reported being uninsured during the entire year for 1 of the
2 years. c Public health insurance coverage primarily includes Medicaid
and Medicare.

020 4060 80100

Individuals with disabilities General population Source: AHRQ.

10 29 Income below

FPL a

50 73 High school

education or less

22 82 Not working

Percentage

6 49 Covered by public

health insurance c Uninsured b

15 9

Page 16 GAO- 03- 587 Medicaid and Ticket to Work Working- age individuals
with disabilities were far more likely to have public health coverage than
working- age individuals in the general

population. Specifically, working- age individuals with disabilities were
about eight times more likely to have public health insurance coverage
than other working- age individuals. Generally, the lower the income
level, the more likely an individual with disabilities was to have public
health insurance coverage. For example, 75 percent of individuals with

disabilities who had incomes below the FPL had public health insurance,
while fewer than 20 percent of those with incomes at or exceeding 400
percent of the FPL had public coverage. The extent of their health care
costs underscores the need for individuals with disabilities to maintain
some type of health insurance coverage to help cover the costs of their
care. Health care expenditures for workingage individuals with
disabilities were about five times the expenditures for other working- age
individuals, annually averaging about $7,600 and $1,500, respectively. 15
The 12 states that opted to implement the Ticket to Work Medicaid Buy- In

program as of December 2002 set income and asset levels for eligibility
that provided new opportunities for working individuals with disabilities
to secure and maintain Medicaid coverage. DI- eligible individuals
benefited particularly because states* broader eligibility categories
under the Buy- In allowed individuals to become eligible for Medicaid
without spending down their incomes and to remain eligible when their
incomes rose to higher levels. In addition to expanding income eligibility
and asset limits, all states took advantage of the flexibility of the
statute to charge premiums or copayments to ensure that Buy- In
participants shared in the cost of their health care coverage.

Across the 12 states that opted to implement Ticket to Work Medicaid Buy-
In programs, all set eligibility requirements that expanded eligibility
for working individuals with higher incomes or more assets than usually
allowed under their Medicaid programs. As of December 2002, the number of
Buy- In participants for the 12 states totaled 24, 258, ranging from 3
participants in Wyoming to almost 8,500 participants in Missouri. (See

15 In our MEPS analysis of health care expenditures of individuals with
disabilities, we did not find a difference in average expenditures between
those in and out of the workforce. States* Buy- In Programs Expanded

Eligibility and Increased Cost Sharing for More Workers with Disabilities

Twelve States Expanded Medicaid Eligibility Levels for Working Individuals
with Disabilities

Page 17 GAO- 03- 587 Medicaid and Ticket to Work table 3.) Eleven of the
12 states set Buy- In eligibility limits for income at twice the FPL or
higher* or $17,720 per year for an individual in 2002*

thereby expanding opportunities for individuals to secure and maintain
Medicaid coverage. Buy- In programs also allowed participants to retain
more assets than usually allowed in states* Medicaid programs. Of the 12
states, 7 states set asset limits that ranged from $10,000 to $30,000 for
individuals, couples, or both. Three states* Missouri, Indiana, and
Arkansas* opted for asset requirements of $4,000 or less for an
individual, 16 while the remaining two states* Washington and Wyoming*
imposed no asset limits. Table 3: Enrollment and Eligibility
Characteristics of 12 States With Ticket to Work Medicaid Buy- In Programs
State Enrollment a Buy- In start date Income limit as a percentage of FPL
b Asset limits c

Missouri 8,461 July 2002 250% $999.99 individual d Minnesota 6,178 July
2001 e No limit $20,000 individual Indiana 3,318 July 2002 350% $2,000
individual;

$3,000 couple Connecticut 2,433 Oct. 2000 $6,250 monthly gross income,

or $3,082 monthly net income f $10,000 individual; $15,000 couple

Pennsylvania 1,325 Jan. 2002 250% $10,000 couple New Hampshire 968 Feb.
2002 450% $20,000 individual;

$30,000 couple New Jersey 551 Feb. 2001 250% (earned) and

100% (unearned) $20,000 individual;

$30,000 couple Kansas 489 July 2002 300% $15,000 couple Illinois 323 Jan.
2002 200% $10,000 individual;

$10,000 couple Washington 144 Jan. 2002 220% No limit Arkansas 65 Feb.
2001 250% $4,000 individual;

$6,000 couple g Wyoming 3 July 2002 100% No limit

Source: State- reported data. Note: GAO analysis of state- reported data,
as of December 2002. a States* enrollment data represent either the number
of participants enrolled on a specific day in

December 2002 or the total number who were ever enrolled during that
month. Also, some states included individuals who were retroactively
enrolled for that month. 16 Indiana set asset requirements for a couple at
$3,000, while Missouri allowed the spouse of a Buy- In participant to
retain assets up to $100,000 and excluded one- half of the participant*s
marital assets.

Page 18 GAO- 03- 587 Medicaid and Ticket to Work b In 2002, the FPL for an
individual was $8,860 annually; for a family of three, the FPL was
$15,020. Not all income is counted in order to calculate *countable*
income. Income exclusions include $20 per

month of most income, $65 per month of wages and one- half of wages over
$65, food stamps, and home energy and housing assistance. c Not all assets
are counted in order to calculate *countable* assets. Assets excluded are
the home a

person lives in; a car, depending on its use or value; certain burial
spaces and burial funds up to $1,500; and life insurance with a face value
of up to $1,500. d Missouri allowed the spouse of an individual with
disabilities to retain assets up to $100,000 and

excluded one- half of the participant*s marital assets. e Minnesota
originally opted to cover workers with disabilities through the BBA
option, implemented in

July 1999, and amended its program to follow Ticket to Work Buy- In
requirements. f Connecticut uses a two- step method that is not based on
the FPL to determine income eligibility.

First, an applicant*s individual gross income must be $6,250 a month or
less ($ 75,000 maximum per year). If the applicant*s income is higher than
$6,250, the state applies a second test whereby the SSI income disregards
and impairment- related work expenses are excluded; if an individual*s
adjusted

income (after applying these exclusions) is less than or equal to $3, 082
per month, the individual is income- eligible for the Medicaid Buy- In. g
Arkansas increases the asset limit by $200 for each additional family
member.

States generally allowed Ticket to Work participants to exclude certain
assets from the asset limits. In addition to excluding the value of
certain assets that applied to most individuals with disabilities in the
Medicaid program when determining eligibility, 17 10 of the 12 states
allowed Buy- In participants to save money in retirement accounts such as
Individual Retirement Accounts, Keoghs, and 401( k) s; medical savings
accounts; or special accounts that allow individuals to save for expenses
such as modifications for job or home and education costs. These accounts
are not considered when determining asset limits for participants. Two
states* Arkansas and Indiana* set $10, 000 and $20,000 limits,
respectively, on the amount of savings participants can accumulate in
these accounts. State officials in a few states said allowing participants
to exclude these retirement accounts and other assets helped support
states* goals of affording working individuals with disabilities greater
independence and self- sufficiency. For example, under these rules,
participants can save to buy cars or homes and can set aside money for
retirement.

17 For example, a home, personal property, one vehicle under certain
conditions, a burial space, and life insurance valued at up to $1, 500 are
disregarded for individuals applying for Medicaid.

Page 19 GAO- 03- 587 Medicaid and Ticket to Work In most of the 12 states,
the Buy- In programs were especially beneficial for DI- eligible
individuals who, in contrast to most SSI individuals, were not

always eligible for Medicaid coverage. Prior to the Ticket to Work
legislation, DI individuals in 11 of the 12 states could qualify for
Medicaid by spending down their incomes to specified levels (Wyoming did
not offer a spend- down option). 18 In these 11 states, the spend- down
income eligibility levels ranged from 15 percent to 100 percent of the
FPL. Under

the new Buy- In programs, the income eligibility levels significantly
exceeded those established under the spend- down categories (see fig. 2),
thus allowing individuals to qualify for the Medicaid Buy- In directly*
rather than spending down their incomes to qualify for Medicaid coverage.
For example, an individual receiving DI in Arkansas could obtain Medicaid
coverage through the Buy- In program with an income up to 250 percent of
the FPL; prior to the Buy- In, the individual would have had to incur
medical expenses that reduced his or her income to approximately 15
percent of the FPL in order to qualify for the spend- down category of
Medicaid. This allows an individual with disabilities in Arkansas to
maintain an income of up to $22, 150 per year under the Buy- In, whereas
that person would have had to spend down to an income of $1,300 a year to
qualify for Medicaid.

18 States may offer spend- down coverage through an optional medically
needy eligibility category. However, 209( b) states that do not offer a
medically needy eligibility category must allow individuals who are aged,
blind, or disabled (including SSI and DI individuals) to spend down their
incomes, using their incurred medical expenses, to meet the 209( b)
category income eligibility requirements. Buy- In Programs May Offer
Greatest Benefit to

DI Participants

Page 20 GAO- 03- 587 Medicaid and Ticket to Work Figure 2: Twelve States*
Medicaid Buy- In, SSI Work Incentive, and Spend- Down Income Eligibility
Levels, as a Percentage of the FPL

71 100

71 438

286 76

277 200

350 300

231 250

Spend down c SSI work incentive b

Buy- In Source: State- reported data, SSA data on SSI work incentive, and
Kaiser Family Foundation data on spend down.

Arkansas Kansas

Indiana Illinois

Connecticut

311 70 350

Minnesota

15

Percentage of FPL 0 50

100 150

200 250

300 350

400 450

500 (Note a ) (No limit)

Page 21 GAO- 03- 587 Medicaid and Ticket to Work Note: GAO analysis of
states*, SSA*s, and the Kaiser Family Foundation*s data, as of December
2002. a Connecticut uses a two- step method that is not based on the FPL
to determine Medicaid Buy- In income eligibility. First, an applicant*s
individual gross income must be $6,250 a month or less ($ 75,000 maximum
per year). If the applicant*s income is higher than $6,250, the state
applies a second test whereby SSI income disregards and impairment-
related work expenses are excluded; if

an individual*s adjusted income (after applying these exclusions) is less
than or equal to $3,082 per month, the individual is income- eligible for
the Medicaid Buy- In. b SSI*s work incentive program, known as Section
1619( b), 42 U. S. C. 1382h( b), provides for continued Medicaid
eligibility for individuals whose incomes are too high to qualify for an
SSI cash payment but

are not high enough to offset the loss of Medicaid or publicly funded
attendant care. 76 55 63 78 74

443 300

242 227 215 250

450 250 250

100

Washington Wyomingd

Pennsylvania New Jersey New Hampshire

Missouri

220 278

Page 22 GAO- 03- 587 Medicaid and Ticket to Work c Spend- down refers to
two approaches to Medicaid eligibility. First, most states offer spend-
down coverage through their medically needy category of eligibility, where
individuals deduct incurred

medical expenses from their income to spend down into Medicaid coverage.
Second, 209( b) states that use their 1972 state assistance eligibility
rules in determining Medicaid eligibility for individuals with
disabilities must allow individuals who are aged, blind, or disabled
(including SSI and DI

individuals) to spend down their incomes by incurred medical expenses,
regardless of whether they offer a medically needy eligibility category in
Medicaid. Of the six 209( b) states with Ticket to Work Medicaid Buy- In
programs, two states* Indiana and Missouri* do not offer medically needy
coverage, but these states must allow individuals with disabilities to
spend down into Medicaid. d Wyoming does not provide a spend- down option.

Buy- In programs afforded DI beneficiaries more immediate* and sometimes
expanded* Medicaid coverage. In addition to relieving individuals of the
requirement to spend down their income to qualify for Medicaid, DI
individuals, who are not entitled to receive Medicare coverage until they
have been receiving DI cash benefits for 24 months, also received more
immediate health insurance coverage through the Medicaid Buy- In. Buy- In
participants may also have access to a more expanded benefit package than
individuals who receive Medicaid through a state*s medically needy
program. 19 However, when considering participation in the Buy- In
program, DI

beneficiaries must weigh the benefits of the higher earnings allowed under
the program against the possible loss of DI cash benefits and Medicare
coverage if their earnings increase beyond a certain threshold.
Specifically, after a 9- month trial work period and a 36- month extended
period of eligibility, if a DI beneficiary*s earnings increase over the
SGA limit in any month, the individual loses DI eligibility entirely.
Additionally, DI beneficiaries who earn more than the SGA level after the
initial 9- month trial period could lose Medicare coverage after 8- 1/ 2
years. The loss of entitlement for Medicare may be of concern for those
individuals with disabilities who would not reach age 65 by the end of the
8- 1/ 2- year time

19 States may offer different sets of benefits depending on whether an
individual*s eligibility for Medicaid is considered mandatory or optional
by federal statute; optional benefits may vary by state. Most adults with
disabilities who receive SSI payments have mandatory coverage under
Medicaid, while individuals who are medically needy (and spend down to
receive Medicaid benefits) are considered to be in the optional category.
Thus, adults with

disabilities who move from medically needy coverage to the Medicaid Buy-
In may receive additional benefits, depending on states* coverage
policies.

Page 23 GAO- 03- 587 Medicaid and Ticket to Work period. 20 To the extent
that a state reduced its Medicaid Buy- In eligibility level, or
discontinued its Buy- In program, these former DI- eligible Buy- In

participants could potentially be without health care coverage until they
reached age 65.

In contrast, SSI beneficiaries have different considerations than those
weighed by DI beneficiaries in deciding whether to enroll in the Medicaid
Buy- In program. Most SSI beneficiaries were assured eligibility for
Medicaid and thus did not need the Buy- In program or to spend down their
incomes in order to qualify for Medicaid. SSI beneficiaries in Medicaid
would receive the same benefit package as those in a Buy- In program. Even
SSI beneficiaries who worked could remain eligible for Medicaid as
participants in a work incentive program, which allowed individuals to

increase their incomes while maintaining their Medicaid coverage. In 5 of
the 12 states, Buy- In income eligibility levels were lower than the
Medicaid eligibility levels for individuals in the SSI work incentive
program, and Buy- In eligibility levels only slightly exceeded those for
the SSI work incentive beneficiaries in another 5 states. Additionally,
beneficiaries in SSI*s work incentive program are not subject to premium
payments in Medicaid, while Buy- In programs generally have imposed
premium requirements for participants.

States may require Buy- In participants to share in the cost of their
health care coverage. All 12 states adopted cost- sharing mechanisms,
primarily premiums or copayments, for Buy- In participants. States
calculated premiums for Buy- In participants using various methods. For
example, Pennsylvania and Washington set premiums as a percentage of
allowable income, while Indiana and Kansas established varying premium
levels for different incomes. (See table 4.) Generally, states assessed
premiums when income was at 100 percent of the FPL or higher. Among states
that charged premiums in 2002, the percentage of participants whose
incomes were high enough to be charged premiums varied significantly
across the

20 Under section 1818A of the Social Security Act, a disabled individual
who has lost entitlement to premium- free Medicare part A solely because
of SGA may be able to enroll in part A as long as the disability
continues. The individual is responsible for paying the premiums.
Furthermore, an individual who has lost his or her benefits under DI due
to earning more than SGA and who then fails to earn at least SGA due to
being disabled, could

be eligible for reinstatement of his or her DI benefits and Medicare
coverage. Section 112 of the Ticket to Work legislation allows certain
previously entitled individuals to request expedited reinstatement of
disability benefits under title II and title XVI when their disabling
impairment no longer permits them to perform SGA. All States* Buy- In

Programs Required Cost Sharing

Page 24 GAO- 03- 587 Medicaid and Ticket to Work states, from 12 percent
of participants in Connecticut to all or nearly all participants in
Illinois, Pennsylvania, Washington, and Wyoming. Average monthly premiums
ranged from $26 to $82, with nearly half of the states

setting premiums from $40 to $60. Two states* Arkansas and New Jersey* did
not charge premiums as of December 2002. Stating that premiums were
difficult to administer and collect, Arkansas chose not to impose a
premium requirement. New Jersey has a premium requirement for participants
with incomes greater than 150 percent of FPL; however, the state did not
assess premiums because only about 5 percent of beneficiaries owed a
payment.

Page 25 GAO- 03- 587 Medicaid and Ticket to Work Table 4: Twelve States*
Premium Requirements for Ticket to Work Medicaid Buy- In Programs State

Percentage of FPL at which state assesses premiums

Monthly premium Participant*s

average monthly premium

Percentage of participants

charged premiums

Arkansas a N/ A N/ A N/ A N/ A Connecticut 200% 10% of family*s income
that exceeds 200% of the FPL

for the appropriate family size; not to exceed 7.5% of net family income
for families with incomes less than 450% of the FPL. Family includes the
participant and his or her spouse. b $50 c 12% Illinois 100% 24 premium
levels based on the participant*s earned

and unearned income, ranging from $6 to $100. Premiums increase as income
increases.

$48 99.7% Indiana 150% Six premium levels based on the participant*s
income,

ranging from $48 to $187, and six premium levels based on participant*s
and spouse*s income, ranging from $65 to $254. Premiums increase as income
increases.

$82 c 22% Kansas 100% Eight premium, levels based on the participant*s

income, ranging from $55 to $152, and eight premium levels, based on
participant*s and spouse*s income, ranging from $74 to $205. Premiums
increase as income increases.

$68 57% Minnesota 100% Premium begins at 1% of income and the percentage
of

the premium increases as income increases, up to a premium of 7.5% of
participant*s income.

$57 77% Missouri 150% Four premium levels, ranging from approximately $48

to $123. Premiums increase as income increases. d 16%

New Hampshire 150% Six premium levels, ranging from $80 to $220. Premiums
increase as income increases. $26 e 15% New Jersey f f f f Pennsylvania N/
A 5% of countable income (premiums under $10 are not

collected). $43 95% Washington N/ A The lesser of

50% of unearned income above $571, plus 5% of total unearned income, plus
2.5% of earned income minus $65, or (2) 7.5% of total income.

$70 100% Wyoming N/ A 7. 5% of earned income plus 7.5% of unearned income
over $600 per year. $44 100% Source: State- reported data.

Legend: N/ A = not applicable Note: GAO analysis of state data, as of
December 2002. a Arkansas* Medicaid Buy- In program did not impose
premiums.

b The FPL calculation is dependent upon family size. For example, 100
percent of the FPL for an individual in 2002 was $8, 860 annually, while
100 percent of the FPL for a family of three was $15,020.

Page 26 GAO- 03- 587 Medicaid and Ticket to Work c State reduces a
participant*s premium liability by any amount the participant pays for
employersponsored coverage.

d Missouri does not collect data on average monthly premiums. e Although
premiums in New Hampshire begin at $80 per month, nearly half of the
participants have premiums reduced because the state allows deductions for
the costs of premiums that participants pay for Medicare and employee-
sponsored health insurance for family members. f New Jersey has a premium
requirement for participants with incomes greater than 150 percent of

FPL; however, as of December 31, 2002, the state was not assessing
premiums because only about 5 percent of beneficiaries owed a payment.

Three states* Connecticut, Indiana, and New Hampshire* reported
discounting the Buy- In premium if participants also paid premiums for
Medicare part B, for employer- sponsored insurance coverage, or for
individual insurance coverage. For example, New Hampshire deducted the
Medicare part B premium from a participant*s total Buy- In premium. If a
Buy- In participant were paying a Medicare part B premium of $54 a month,
his or her Medicaid Buy- In premium would be discounted by that amount.
Thus, if a participant*s Buy- In premium were $80 a month, the monthly
premium for the Buy- In program would be discounted to $26 a month. In
Connecticut, any amount that participants pay for Medicare part B
premiums, employer- sponsored coverage, or other out- of- pocket medical
insurance is deducted from their premium liability. For example, if a
participant owes a Buy- In premium of $100 a month and also is paying an
employer $80 a month for private coverage, the individual*s Buy- In

premium liability would be reduced to $20. Participants in 8 of the 12
states also were required to pay copayments for health care services, such
as $0.50 to $3 for an office visit or prescription drugs. Copayments for
inpatient hospital care generally varied from $3 per day in Illinois to
$48 per hospital stay in Kansas. In 7 of these states, copayments were the
standard cost- sharing requirements for Medicaid. The remaining state*
Arkansas* imposed a two- level copayment system for participants. Arkansas
Buy- In participants with incomes below 100 percent of the FPL had the
same copayment requirements and were charged the same amounts for pharmacy
and inpatient hospital services as usually prescribed under the state*s
Medicaid program. Participants with incomes of 100 percent of the FPL or
greater were charged additional copayments for services and equipment such
as physician services ($ 10 per visit), outpatient mental and behavioral
health services ($ 10 per visit), and prosthetic devices (10 percent of
the maximum Medicaid payment).

Page 27 GAO- 03- 587 Medicaid and Ticket to Work In the four states in
which we conducted more detailed work* Connecticut, Illinois, Minnesota,
and New Jersey* Buy- In programs

enrolled many individuals who previously were enrolled in Medicaid, often
in eligibility categories with more restrictive income limits, such as the
medically needy category. Buy- In participants in the four states
generally also had Medicare coverage. Across the four states, few Buy- In

participants had coverage from private insurance at the time of their
enrollment in the Medicaid Buy- In programs. Based on the limited
participation in private insurance, officials in several states did not
believe that *crowd- out** the substitution of newly available public
coverage for private health insurance* was a concern for the Medicaid Buy-
In programs. The limited employment information available for participants
from two of the four states* Connecticut and Minnesota* showed that

Buy- In participants generally were employed in low- wage jobs* many
making less than the SGA threshold, which at the time was $780 per month.
These four states, however, had little information regarding the extent to
which the Buy- In programs fostered employment among individuals with
disabilities.

Across these four states, the share of Buy- In participants with previous
Medicaid coverage was 53 percent in Connecticut, 81 percent in Illinois,
61 percent in Minnesota, and 58 percent in New Jersey. Whereas previous
Medicaid coverage was largely due to eligibility through spend- down
provisions, Buy- In participation allowed them to retain more of their
income or assets and still qualify for Medicaid. Of those who switched
from existing Medicaid coverage to the Buy- In program, Illinois and
Minnesota estimated that 79 percent and 51 percent of participants,
respectively, were beneficiaries who originally had spent down their
income to qualify for Medicaid. While not offering a specific estimate, a
New Jersey official indicated that most of the Buy- In participants who
were enrolled in Medicaid before switching to the Buy- In category also
had spent down their income to qualify for Medicaid. Buy- In eligibility
was particularly beneficial for individuals in New Jersey because the
state*s Medicaid coverage for medically needy beneficiaries did not
include prescription drugs or community- based long- term care services,
both of which were covered under the Buy- In. Buy- In Participants in

Four States Generally Had Prior Medicaid Coverage and Worked in Low- Wage
Jobs

Buy- In Participants Often Had Previous Coverage under Medicaid and
Medicare

Page 28 GAO- 03- 587 Medicaid and Ticket to Work In three of the four
states* Connecticut, Minnesota, and New Jersey* more than 80 percent of
Buy- In participants also received health care

coverage through Medicare. 21 (See table 5.) State officials reported that
those with Medicare relied on the Medicaid Buy- In for purposes of
obtaining outpatient prescription drug coverage since Medicare generally
does not cover this benefit. Few participants* less than 10 percent of

participants in any of the four states* reported having employersponsored
coverage at the time of their enrollment into the Medicaid BuyIn programs.
For example, Connecticut, which requires Buy- In applicants who have
access to employer- sponsored insurance coverage to apply for this
coverage, found that less than 6 percent of Buy- In applicants had health
care coverage through their workplace. For Buy- In participants with
private health insurance coverage, which often has more limited benefits
than those covered by Medicaid, the Buy- In can serve as a *wrap around*
to private coverage by providing such services as home health and personal
care, and items such as durable medical equipment. 22 21 Illinois was
unable to identify Buy- In participants who had Medicare.

22 Medicaid- eligible individuals enrolled in employer- sponsored health
plans are entitled to receive full Medicaid benefits. The health plans
become the primary payers for the services they cover. States must provide
coverage for those Medicaid services not included in the employer plans.

Page 29 GAO- 03- 587 Medicaid and Ticket to Work Table 5: Number of Buy-
In Participants Reporting Other Sources of Health Care Coverage in Four
States

Participants with other sources of coverage a (percentage of total
enrollment) State Medicare

Employersponsored coverage Other b Connecticut 1,870 (82%) 128 (5.6%) 34
(1.5%) Illinois c 4 (1.6%) 3 (1.2%) Minnesota 5,394 (90%) d 459 (7%) e 367
(6%) e New Jersey 408 (82%) 38 (7.3%) 8 (1.5%)

Source: State- reported data. Note: GAO analysis of state data, as of
December 2002. a These categories are not mutually exclusive, as
individuals may have more than one source of

coverage. b *Other* may include coverage held through a spouse or other
family member, or Medicare

supplemental coverage. Most Medicare beneficiaries purchase Medicare
supplemental coverage (known as Medigap) to protect themselves against
large out- of- pocket costs and help fill Medicare*s coverage gaps.

c Illinois was unable to identify Buy- In participants who had Medicare. d
Minnesota*s Medicare data are as of September 2002. e Minnesota*s
employer- sponsored and other coverage data are as of December 2001.

According to officials in several states, crowd- out was not a concern for
Buy- In programs because most participants did not report having private
health insurance coverage at the time of their enrollment into the
Medicaid

Buy- In programs. For example, Minnesota and New Jersey state officials
said they did not view crowd- out as a significant issue for this
population because many of the participants worked part- time and were
rarely offered private insurance coverage. Additionally, both Minnesota
and Connecticut required individuals to either enroll or remain enrolled
in employer- sponsored coverage if it was offered. As of December 2002,
these states had not formally analyzed whether Buy- In participants
withdrew from private health insurance coverage prior to obtaining
Medicaid coverage. New Jersey officials plan to monitor whether employees
are deciding to or are being urged to pursue the Buy- In program rather
than their employer- sponsored coverage.

Page 30 GAO- 03- 587 Medicaid and Ticket to Work In the three states with
data available, working individuals with disabilities who qualified for
the Medicaid Buy- In program generally worked in lowwage

jobs. (See table 6.) While one purpose of the Ticket to Work legislation
was to enable individuals with disabilities to reduce their dependency on
federal cash benefit programs through earnings from work, available data
from Connecticut, Illinois, Minnesota showed that few participants earned
more than the SGA limit, which was $780 in December 2002. Sixty- four
percent of participants in Connecticut, 61 percent of participants in
Illinois, and 77 percent of participants in Minnesota had earned income
well below the SGA limit. None of these states had asked participants to
identify their occupation or the industry in which they were employed on
their Medicaid Buy- In applications; however, some states may conduct
broader analyses of participants* employment as part of required
evaluations under a related Ticket to Work grant program. 23 23 Section
203 of the Ticket to Work and Work Incentives Improvement Act of 1999

authorized the Medicaid Infrastructure Grant Program, which is an 11- year
grant program beginning in fiscal year 2001 ($ 150 million for the first 5
years) that allows states to design, establish, and operate state
*infrastructures* to facilitate the competitive employment of individuals
with disabilities. Grant activities include (1) implementing Medicaid Buy-
In programs, (2) developing demonstration programs that offer the ability
to purchase Medicaid coverage for people with a severe impairment who do
not yet meet the SSI disability test, (3) making significant improvements
to Medicaid services that support

people with disabilities in their competitive employment efforts, and (4)
creating regional technical assistance centers for health care
improvements supporting employment* known as State- to- State Medicaid
Infrastructure Partnerships. As of December 2002, thirtyeight states
received Infrastructure Grants, including 10 of the 12 states with
Medicaid BuyIn programs (all except Arkansas and Indiana). Indiana was
awarded an Infrastructure Grant in 2003. Available Employment

Information Shows Participants Worked in Low- Wage Jobs and Experienced
Minimal Increases in Earnings

Page 31 GAO- 03- 587 Medicaid and Ticket to Work Table 6: Average Monthly
Income for Ticket to Work Buy- In Participants in Four States

State State- reported categories

of average monthly income from earnings Percentage of

participants a Connecticut b $200 or less $201-$ 600 $601-$ 800 $801 and
greater

23 41 17 19 Illinois $200 or less

$201-$ 599 $600-$ 799 $800 and greater

12 49 23 17 Minnesota Less than $200 $200-$ 599

$600-$ 799 $800 and greater

36 41 12 10 New Jersey c c

Source: State- reported data. Note: GAO analysis of state data, as of
December 2002. a Percentages may not add to 100 due to rounding. b
Connecticut*s data on earned income are from 2001.

c State did not provide these data.

Two of the four states we reviewed could identify whether participants had
increased their earnings once enrolled in the Buy- In. Forty percent of
Minnesota participants and 28 percent of Connecticut participants
increased their earnings between the time of initial enrollment and
December 2001, the most recent date for which these data were available.
24 Average monthly increases over previous earnings were $306 in Minnesota

and $332 in Connecticut. New Jersey and Illinois were not able to provide
this information. Minnesota found that 64 percent of those in the state*s
Buy- In program as of December 2001 earned wages for at least one 3- month
period in the 2- year period prior to enrollment. 25 Minnesota officials
24 Connecticut officials said that as a part of their state*s
Infrastructure Grant, their primary

research question will be to determine whether the Medicaid Buy- In, along
with other factors such as participation in vocational rehabilitation and
a new benefits counseling program, leads to increases in earnings among
participants. 25 Minnesota officials used data collected by the state*s
Department of Economic Security

from employers who report information on employees who pay federal taxes.

Page 32 GAO- 03- 587 Medicaid and Ticket to Work cautioned that the
analysis was limited by the lack of detail in the state database; for
example, they did not know whether participants were

disabled during this entire period, or whether individuals were
consistently employed.

We provided a draft of this report for comment to CMS and the 12 states in
our sample. In its comments, CMS said that, in addition to the states with
existing BBA and Ticket to Work Buy- In programs, at least three more
states are planning to implement a Medicaid Buy- In program within the
coming year, which would result in over half of the states offering health
insurance to workers with disabilities. CMS noted that the expansion of

Medicaid coverage to these individuals is encouraging particularly because
states are experiencing fiscal budget constraints. CMS also said that it
is collecting information on Medicaid Buy- In participants* earnings and
Medicaid costs for the first 2 years of operation. In addition, CMS
expects to complete an extensive study of states* experiences for 2001 and
2002 with the Buy- In programs authorized under both the BBA and the
Ticket to Work and Work Incentives Improvement Act of 1999 in the fall of
2003 and

to report its findings in 2004. CMS also suggested that, in view of
general concerns over racial disparities and access to care in rural
areas, it might be helpful for us to comment on these demographic factors
as part of our findings. We did not include these factors in our scope of
work, even for the four states where we did more detailed work, and
therefore cannot comment on them. CMS provided technical comments, which
we have incorporated as appropriate. The full text of CMS*s written
comments appears in appendix II.

Eleven of the 12 states responded with technical comments, which we
incorporated where appropriate.

We will send copies of this report to the Administrator of the Centers for
Medicare & Medicaid Services and other interested parties. We also will
make copies available to others upon request. In addition, the report will
be available at no charge on the GAO Web site at http// www. gao. gov.
Agency and State

Comments

Page 33 GAO- 03- 587 Medicaid and Ticket to Work If you or members of your
staffs have any questions regarding this report, please contact me on
(202) 512- 7118 or Carolyn Yocom at (202) 512- 4931.

Other major contributors to this report were Catina Bradley, Karen Doran,
Kevin Milne, and Elizabeth T. Morrison.

Kathryn G. Allen Director, Health Care* Medicaid

and Private Health Insurance Issues

Appendix I: Methodology for Developing Estimates and Characteristics of
Working- Age Individuals with Disabilities

Page 34 GAO- 03- 587 Medicaid and Ticket to Work To develop a national
estimate and compare the characteristics of working- age individuals with
disabilities with those for working- age

individuals in the rest of the population, we analyzed data available from
the Medical Expenditure Panel Survey (MEPS) household component, which
provides data on individuals* demographics, employment, health
characteristics, and medical spending.

MEPS, conducted by the Agency for Healthcare Research and Quality (AHRQ),
consists of four surveys and is designed to provide nationally
representative data on health care use and expenditures for U. S. civilian
noninstitutionalized individuals. For our analysis, we used one of the
four surveys* the Household Component. The Household Component is a

survey of individuals regarding their demographic characteristics, health
insurance coverage, and health care use and expenditures. The 1997 and
1998 versions of the MEPS Household Component were the most recently
available at the time of our analysis that had both (1) a pooled
estimation file published by AHRQ that allows pooling 2 or 3 years of
data, and (2) complete demographic, health insurance, and health care
expenditure data. We pooled data from 1997 and 1998 in order to increase
our sample sizes for individuals with disabilities. Using the Medical Care
Consumer Price Index from the Bureau of Labor Statistics, we inflated 1997
medical care expenditures to 1998 values.

Our estimate of working- age individuals with disabilities includes
individuals aged 16 to 64 with one or both of these conditions: (1)
needing help or supervision in performing activities of daily living (ADL)
or instrumental activities of daily living (IADL) because of an impairment
or a physical or mental health problem 1 or (2) being completely unable to
work at a job, do housework, or go to school.

Our analyses of working- age individuals with disabilities are based on a
sample size of 1,680, representing a population of 6.68 million
individuals with disabilities. Table 7 shows the unweighted and weighted
sample sizes

on which our analyses are based. 1 MEPS identifies ADLs as basic physical
activities such as bathing, dressing, or getting around the house and
identifies IADLS as cognitive or social functions such as using the
telephone, paying bills, taking medications, preparing light meals, doing
laundry, or going shopping. MEPS offers a relatively expansive definition
of disability in that it does not distinguish the number of ADLs or IADLs
with which an individual may require assistance. Appendix I: Methodology
for Developing

Estimates and Characteristics of WorkingAge Individuals with Disabilities

Appendix I: Methodology for Developing Estimates and Characteristics of
Working- Age Individuals with Disabilities

Page 35 GAO- 03- 587 Medicaid and Ticket to Work Table 7: MEPS Sample and
Estimated Population Sizes, 1997 and 1998 Individuals with

disabilities aged 16- 64 Rest of the general population aged 16- 64

Sample size (unweighted) 1,680 32,068 Estimated population size (weighted)
6,682,106 166,509,028

Source: Agency for Healthcare Research and Quality. Note: GAO*s analysis
of AHRQ*s MEPS household component, 1997 and 1998.

Appendix II: Comments from the Centers for Medicare & Medicaid Services
Page 36 GAO- 03- 587 Medicaid and Ticket to Work

Appendix II: Comments from the Centers for Medicare & Medicaid Services

Appendix II: Comments from the Centers for Medicare & Medicaid Services
Page 37 GAO- 03- 587 Medicaid and Ticket to Work (290189)

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