TANF and SSI: Opportunities Exist to Help People with Impairments
Become More Self-Sufficient (15-SEP-04, GAO-04-878).		 
                                                                 
The nation's social welfare system has been transformed into a	 
system emphasizing work and personal responsibility, primarily	 
through the creation of the Temporary Assistance for Needy	 
Families (TANF) block grant. The Supplemental Security Income	 
(SSI) program has expanded policies to help recipients improve	 
self-sufficiency. Given that SSA data indicate an overlap in the 
populations served by TANF and SSI, and the changes in both	 
programs, this report examines (1) the extent that TANF 	 
recipients with impairments are encouraged to apply for SSI and  
what is known about how SSI caseload growth has been affected by 
such TANF cases, (2) the extent that work requirements are	 
imposed on TANF recipients applying for SSI, and the range of	 
services provided to such recipients, and (3) the extent that	 
interactions exist between the SSI and TANF programs to assist	 
individuals capable of working to obtain employment.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-878 					        
    ACCNO:   A12411						        
  TITLE:     TANF and SSI: Opportunities Exist to Help People with    
Impairments Become More Self-Sufficient 			 
     DATE:   09/15/2004 
  SUBJECT:   Aid for the disabled				 
	     Aid for the elderly				 
	     Block grants					 
	     Interagency relations				 
	     Social security benefits				 
	     Surveys						 
	     Welfare benefits					 
	     Welfare recipients 				 
	     Workfare						 
	     HHS Temporary Assistance for Needy 		 
	     Families Block Grant				 
                                                                 
	     SSA Supplemental Security Income			 
	     Program						 
                                                                 

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GAO-04-878

United States Government Accountability Office

 GAO	Report to the Chairman, Subcommittee on Human Resources, Committee on Ways
                      and Means, House of Representatives

September 2004

TANF AND SSI

Opportunities Exist to Help People with Impairments Become More Self-Sufficient

GAO-04-878

[IMG]

September 2004

TANF AND SSI

Opportunities Exist to Help People with Impairments Become More Self-Sufficient

  What GAO Found

In our nationwide survey of county TANF offices, we found that nearly all
offices reported that they refer recipients with impairments to SSI, but
the level of encouragement to apply for SSI varies. While almost all of
the county TANF offices stated that they advise such recipients with
impairments to apply for SSI, 74 percent also follow up to ensure the
application process is complete, and 61 percent assist recipients in
completing the application. Because TANF offices are referring individuals
with impairments to SSI, these referrals will have some effect on the SSI
caseload. However, due to data limitations, the magnitude of the effect
these referrals have on SSI caseload growth is uncertain. While SSA can
identify whether SSI recipients have income from other sources, it cannot
easily determine whether this income comes from TANF or some other
assistance based on need. In addition, past research has not found
conclusive evidence regarding the impact that TANF referrals have on SSI
caseload growth.

Estimates from our survey found that although some TANF offices impose
work requirements on individuals with impairments, about 86 percent of all
offices reported that they either sometimes or always exempt adult TANF
recipients awaiting SSI determinations from the work requirements. One key
reason for not imposing work requirements on these recipients is the
existence of state and county TANF policies and practices that allow such
exemptions. Nevertheless, county TANF offices, for the most part, are
willing to offer noncash services, such as transportation and job
training, to adult recipients with impairments who have applied for SSI.
However, many recipients do not use these services. This low utilization
may be related to exempting individuals from the work requirement, but it
may also be due to the recipients' fear of jeopardizing their SSI
applications. Another reason for the low utilization of services is that
many services are not necessarily available; budgetary constraints have
limited the services that some TANF offices are able to offer recipients
with impairments.

Many county TANF offices' interactions with SSA include either having a
contact at SSA to discuss cases or following up with SSA regarding
applications for SSI. Interactions that help individuals with impairments
increase their self-sufficiency are even more limited. In all the states
we visited, we found that such interactions generally existed between TANF
agencies and other agencies (such as the Departments of Labor or
Education). In addition, 95 percent of county TANF offices reported that
their interactions with SSA could be improved. State and county TANF
officials feel they have to take the lead in developing and maintaining
the interaction with SSA. One SSA headquarters official stated that SSA
has no formal policy regarding outreach to TANF offices but would consider
a partnership provided there is some benefit for SSA. Still, about 27
percent of county TANF offices reported that they were discouraged in
their attempts to establish a relationship with SSA because staff at the
local SSA field office told them that they did not have the time or the
interest.

United States Government Accountability Office

Contents

  Letter

Results in Brief
Background
TANF Recipients with Impairments Are Encouraged to Apply to

SSI; Impact on SSI Caseload Growth Is Inconclusive

TANF Offices Differ in Their Exemptions from Work Requirements, but
Utilization of Noncash Services Is Generally Low

Some Interaction Between County TANF Offices and SSA Exists,

but Opportunities Exist for Improvement Conclusions Recommendations Agency
Comments and Our Response

                                       1

                                      3 5

10

13

16 19 20 21

Appendix I Scope and Methods

Appendix II	Comments from the Department of Health and Human Services

Appendix III Comments from the Social Security Administration

  Appendix IV GAO Contacts and Staff Acknowledgments 31

GAO Contacts 31 Staff Acknowledgments 31

  Tables

Table 1: County TANF Office Policies for Referring Adult Cash Recipients
to SSI 10 Table 2: Information Used by County TANF Offices to Determine
whether to Refer Adult Recipients to SSI 11 Table 3: Agencies or Programs
That Support TANF Offices by

Providing Services to At Least Some Adult TANF Cash

Recipients Awaiting SSI Eligibility Determinations 19

Abbreviations

AFDC Aid to Families with Dependent Children
ALJ Administrative Law Judge
DDS Disability Determination Service
DI Disability Insurance
HHS Department of Health and Human Services
PRWORA Personal Responsibility and Work Opportunity

Reconciliation Act of 1996 SSA Social Security Administration SSI
Supplemental Security Income TANF Temporary Assistance for Needy Families

This is a work of the U.S. government and is not subject to copyright
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separately.

United States Government Accountability Office Washington, DC 20548

September 15, 2004

The Honorable Wally Herger
Chairman, Subcommittee on Human Resources
Committee on Ways and Means
House of Representatives

Dear Mr. Chairman:

Over the past several years, the nation's social welfare system has been
transformed from a system emphasizing income support to one
emphasizing work and personal responsibility. Central to this
transformation was the creation of the Temporary Assistance for Needy
Families (TANF) block grant in 1996. Administered by the Department of
Health and Human Services (HHS), TANF provides states with
$16.5 billion each year. The Social Security Administration's (SSA)
disability programs, including the Supplemental Security Income (SSI)
program, have also recently expanded policies and initiated demonstration
projects aimed at helping recipients enter the workforce and achieve self
sufficiency. SSI, which serves adults with low income and assets, paid
about $18.6 billion in benefits in 2002 to about 3.8 million working age
(18-64) recipients with blindness or other disabilities.1

SSA's disability determination process can be lengthy, extending over
2 years when all administrative appeals are included. Concerns exist
whether TANF recipients with impairments who are applying for SSI
receive employment-related services while waiting for an eligibility
determination. The disability management literature has emphasized that
the longer an individual with an impairment remains out of the workforce
the less likely the individual is to ever return to work. Providing such
services in a timely manner also has implications for TANF recipients
running up against the TANF program's 5-year time limit because in
2000, nearly 59 percent of all working age applicants for SSI were denied

2

benefits.

1SSI also provides income assistance to children with disabilities and the
aged who have low income and assets.

2This includes individuals who may have been denied benefits and abandoned
their claims before exhausting all appeals.

While TANF caseloads have decreased since the program's inception, in
1996, not all recipients leave TANF to go to work. Some recipients with
impairments severe enough to qualify them for SSI leave TANF once they are
determined eligible for SSI. SSA administrative data have shown an overlap
in the populations served by TANF and SSI: Up to 25 percent of the SSI
caseload age 18 to 64 received income assistance based on need (including
TANF) prior to becoming eligible for SSI, and this figure has remained
fairly stable over the past few years.3

Given the new environment in which both programs have placed increased
emphasis on encouraging recipients to find employment, and the overlap in
both populations, this report examines (1) the extent to which TANF
recipients with impairments are encouraged to apply for SSI and what is
known about how SSI caseload growth has been affected by such TANF cases;
(2) the extent to which work requirements are imposed by TANF agencies on
their recipients who are applying for SSI, and the range of services TANF
agencies provide to such recipients with impairments; and (3) the extent
to which interactions exist between the SSI and TANF programs to assist
individuals capable of working obtain employment.

To do this work, we conducted a mail survey of a stratified random sample
of 600 county TANF offices,4 representative of county TANF offices
nationwide. The survey gathered data on the extent that TANF recipients
with impairments are encouraged to apply for SSI, whether work
requirements are imposed and the type of services provided during the
period of SSI eligibility determination, and the extent that interactions
exist between the SSI and TANF programs. Our survey achieved an 88 percent
response rate, and we weighted the results to generalize our findings to
all county TANF offices nationwide.5 To determine what is known about how
SSI caseload growth has been affected by TANF referrals for SSI, we
identified and reviewed reports studying this issue and assessed each
study's findings. We also visited five states (Arizona,

3A field in SSA's database does indicate whether an applicant receives
assistance based on need, but this includes TANF as well as other forms of
income assistance based on need. While this does not give an accurate
estimate of the portion of SSI recipients who were TANF recipients, it
does provide an upper bound.

4The surveys were mailed to either the director of the county TANF office
or the regional director, depending on the structure of the TANF program
in each state. The surveys were completed by the director or his/her
designee.

5Sampling errors for estimates presented in this report did not exceed 5
percentage points. See appendix I for a more detailed discussion of
sampling errors.

  Results in Brief

Colorado, Iowa, Oregon, and Vermont) known for providing employmentrelated
services to TANF recipients with impairments, to gain an understanding of
the types of interactions that exist between the SSI and TANF programs and
to assess whether there are opportunities for improving these agencies'
efforts at assisting their recipients with impairments into employment. In
each of these states, we interviewed state and county TANF officials, and
SSA field office staff, as well as SSA headquarters officials. We
conducted our work between June 2003 and May 2004 in accordance with
generally accepted government auditing standards. See appendix I for a
more detailed discussion of our methods.

Estimates from our nationwide survey of county TANF offices indicated that
almost all offices reported that they encourage at least some TANF
recipients with impairments to apply for SSI, but the effect these TANF
referrals have had on SSI caseload growth is inconclusive. In order to
better serve individuals with impairments, nearly all TANF offices rely on
one or more methods to identify impairments. Although nearly all county
TANF offices reported that they refer recipients with impairments to SSI,
the level of encouragement that these individuals receive to apply for SSI
appears to vary. While almost all county TANF offices stated that they
advise such recipients with impairments to apply for SSI, about 74 percent
also follow up to ensure the application process is complete, and about 61
percent assist recipients in completing the application. Because TANF
offices are referring individuals with impairments to SSI, these referrals
will have some effect on the SSI caseload. However, due to data
limitations, the magnitude of the effect these referrals have on SSI
caseload growth is uncertain. While SSA can identify whether SSI
applicants have income from other sources, it cannot easily determine
whether this income comes from TANF or some other assistance based on
need. Furthermore, SSA does not collect any data indicating whether an
applicant is referred from another program. In addition, past research has
not found conclusive evidence regarding the impact that TANF referrals
have on SSI caseload growth.

Although some TANF offices impose work requirements on individuals with
impairments, about 86 percent of all offices reported that they either
sometimes or always exempt adult TANF recipients with impairments awaiting
SSI eligibility determinations from the work requirement. One key reason,
cited by some county TANF officials we interviewed, for not imposing work
requirements on adult TANF recipients with impairments awaiting SSI is the
existence of state or county TANF policies and practices that exempt
recipients from the work requirements.

Nevertheless, county TANF offices, for the most part, are willing to offer
noncash services, such as transportation and job training, to adult
recipients with impairments who have applied for SSI. However, our survey
and interviews with state and county TANF officials indicate that many
recipients do not use these services. This low utilization may be related
to exempting individuals from the work requirement, but there are other
reasons. Some TANF officials we interviewed in the states we visited said
that one of the reasons recipients with impairments do not use these
services is because of the recipient's fear of jeopardizing their SSI
applications. Another reason for the low utilization of services is that
many services are not necessarily available. Forty percent of county TANF
offices noted that one of the reasons adult TANF recipients with
impairments were not participating in work activities was an insufficient
number of job training or related services. Some state and county TANF
officials we interviewed indicated that budgetary constraints have also
limited the services that they are able to offer recipients with
impairments.

Interactions between TANF offices and SSA are limited. Our survey showed
that some TANF offices have stated an interest in developing a
relationship with SSA. However, estimates from our survey showed that 53
percent of counties reported that their interactions included having a
contact with SSA, and 64 percent reported that their interactions included
following up with SSA regarding a recipient's application for SSI.
According to our survey results and interviews with TANF officials in the
states we visited, interactions that help individuals with impairments
increase their self-sufficiency are limited. In the states we visited, we
found that such interactions generally existed between TANF agencies and
other agencies (such as the Department of Labor or Department of
Education). Nevertheless, county TANF offices would like to improve their
interactions with SSA, with 95 percent of county TANF offices reporting
that their interactions could be improved. For example, about 57 percent
of counties reported that receipt of training on the SSI application
process and eligibility requirements is a useful interaction. However,
only 6 percent of counties reported that they would like to improve
interactions with SSA specifically related to providing SSA with
information on employment-related services, such as vocational
rehabilitation, that recipients received prior to applying for SSI. Some
state and county TANF officials that we interviewed also said that they
felt they had to take the lead in developing and maintaining interactions
with SSA. One SSA headquarters official indicated that SSA has no formal
policy regarding outreach to TANF offices but would consider such a
partnership provided there is some benefit for SSA. The official also
added that they will always respond to TANF training or information
requests.

However, about 27 percent of county TANF offices reported that they were
discouraged in their attempts to establish a relationship with SSA because
the local SSA field office told them that they did not have the time or
the interest.

In order to help individuals with impairments increase self-sufficiency
and to address the gap in continuous work services between TANF and SSI,
we are recommending that SSA, as part of a new demonstration project, work
with TANF agencies to identify those low-income individuals with
impairments who while potentially eligible for SSI may also have the
capacity to work, and coordinate services to increase the likelihood that
such individuals can obtain employment and become more self-sufficient. In
order to facilitate and encourage a sharing of information among TANF
offices to increase self-sufficiency of recipients with impairments, we
are recommending that HHS provide space on its Web site to serve as a
clearinghouse for information regarding best practices and opportunities
for TANF agencies to interact with SSA. HHS should be able to minimize its
work and expense by using its Web site to share this information. Both SSA
and HHS generally agreed with our recommendations and indicated that they
look forward to working together to help low-income individuals with
impairments become more self-sufficient.

The Personal Responsibility and Work Opportunity Reconciliation Act of
1996 (PRWORA) replaced the individual entitlement to benefits under the
61-year-old Aid to Families with Dependent Children (AFDC) program with
TANF block grants to states and emphasized the transitional nature of
assistance and the importance of reducing welfare dependence through
employment. Administered by HHS, TANF provides states with $16.5 billion
each year,6 and in fiscal 2002, the total TANF caseload consisted of 5
million recipients. PRWORA provides states with the flexibility to set a
wide range of TANF program rules, including the types of programs and
services available and the eligibility criteria for them. States may
choose to administer TANF directly, devolve responsibility to the county
or local TANF offices, or contract with nonprofit or for-profit providers
to administer TANF. Some states have also adopted "work first" programs,
in which recipients typically are provided orientation and

6In addition to federal funds, states must also provide funding for TANF.
However, states are not required to spend all of their block grant in the
year the money is received; instead they can accumulate unused funds to be
used at a later time. Therefore, total TANF expenditures in 2002,
including federal, state, and accumulated funds, totaled $28.4 billion.

  Background

assistance in searching for a job; they may also receive some readiness
training. Only those unable to find a job after several weeks of job
search are then assessed for placement in other activities, such as
remedial education or vocational training.

While states have great flexibility to design programs that meet their own
goals and needs, they must also meet several federal requirements designed
to emphasize the importance of work and the temporary nature of TANF aid.
For example, TANF established stronger work requirements for those
receiving cash benefits than existed under AFDC. Furthermore, to avoid
financial penalties, states must ensure that a steadily rising specified
minimum percentage of adult recipients are participating in work or
work-related activities each year. To count toward the state's minimum
participation rate, adult TANF recipients in families must participate in
a minimum number of hours of work or a work-related activity a week,
including subsidized or unsubsidized employment, work experience,
community service, job search, providing child care for other TANF
recipients, and (under certain circumstances) education and training. If
recipients refuse to participate in work activities as required, states
must impose a financial sanction on the family by reducing the benefits,
or they may opt to terminate the benefits entirely. States must also
enforce a 60-month limit (or less at state option) on the length of time a
family may receive federal TANF assistance,7 although the law allows
states to provide assistance beyond 60 months using state funds.8

The TANF caseload includes, as did AFDC, low-income individuals with
physical or mental impairments considered severe enough to make them
eligible for the federal SSI program. Administered by SSA, SSI is a
meanstested income assistance program that provides essentially permanent
cash benefits9 for individuals with a medically determinable physical or
mental impairment that has lasted or is expected to last at least 1 year
or to result in death and prevents the individual from engaging in
substantial

7A state may exempt up to 20 percent of its average monthly caseload for
hardship or having been subjected to domestic violence.

8Estimates from our survey show that only 2 percent of counties always,
and 16 percent sometimes, move TANF recipients with impairments awaiting
SSI determinations to state only funded cash assistance.

9While the SSI regulations do not guarantee permanent benefit status, only
0.4 percent of SSI disability recipients leave SSI because of work, and
only 6.8 percent are no longer eligible because of medical improvement.
Excess income or resources can also end a person's SSI benefits.

gainful activity. To qualify for SSI, an applicant's impairment must be of
such severity that the person is not only unable to do previous work but
is also unable to do any other kind of substantial gainful work that
exists in the national economy. Work is generally considered substantial
and gainful if the individual's earnings exceed a particular level
established by statute and regulations.10 SSA also administers the
Disability Insurance program (DI), which uses the same definition of
disability, but is not means-tested and requires an individual to have a
sufficient work history.

For both DI and SSI, SSA uses the Disability Determination Service (DDS)
offices to make the initial eligibility determinations.11 If the
individual is not satisfied with this determination, he or she may request
a reconsideration of the decision with the same DDS.12 Another DDS team
will review the documentation in the case file, as well as any new
evidence, and determine whether the individual meets SSA's definition of
disability. If the individual is not satisfied with the reconsideration,
he or she may request a hearing before an Administrative Law Judge (ALJ).
The ALJ conducts a new review and may hear testimony from the individual,
medical experts, and vocational experts. If the individual is not
satisfied with the ALJ decision, he or she may request a review by SSA's
Appeals Council, which is the final administrative appeal within SSA.13
Despite recent improvements to the process, going through the entire
process, including all administrative appeals, can average over 2 years.

In most states, SSI eligibility also entitles individuals to Medicaid
benefits. TANF recipients may apply for Medicaid benefits and are likely
to qualify, but receipt of TANF benefits does not automatically qualify a
recipient for Medicaid.

10In 2004 the substantial and gainful activities level for nonblind
individuals is $810 per month, and for blind individuals is $1,350 per
month, of countable earnings. Both levels are indexed to the average wage
index.

11There are 54 primarily state-operated DDS offices; their staff consists
generally of a variety of positions such as disability examiners, medical
consultants, vocational specialists, and quality assurance personnel.

12In September 2003, the Commissioner testified before the House Committee
on Ways and Means, saying that she intended to revise the disability
determination process. For example, she proposed eliminating the
reconsideration and the Appeals Council stages of the current process.

13If the individual is not satisfied with the Appeals Council action, the
individual may appeal to a federal district court. The individual can
continue legal appeals to the U.S. Circuit Court of Appeals and ultimately
to the Supreme Court of the United States.

While SSA has recently expanded policies and initiated demonstration
projects aimed at helping DI and SSI beneficiaries enter or return to the
workforce and achieve or at least increase self-sufficiency, its
disability programs remain grounded in an approach that equates impairment
with inability to work. This approach exists despite medical advances and
economic and social changes that have redefined the relationship between
impairment and the ability to work. The disconnect between SSA's program
design and the current state of science, medicine, technology, and labor
market conditions, along with similar challenges in other programs, led
GAO in 2003 to designate modernizing federal disability programs,
including DI and SSI, as a high-risk area urgently needing

14

attention and transformation.

The Ticket to Work and Work Incentives Improvement Act of 1999 amended the
Social Security Act to create the Ticket to Work and Self-Sufficiency
Program (Ticket Program). This program provides most DI and SSI
beneficiaries with a voucher, or "ticket," which they can use to obtain
vocational rehabilitation, employment, or other return-to-work services
from an approved provider of their choice. The program, while voluntary,
is only available to beneficiaries after the lengthy eligibility
determination process. Once an individual receives the ticket, he or she
is free to choose whether or not to use it, as well as when to use it.
Generally, disability beneficiaries age 18 through 64 are eligible to
receive tickets. The Ticket Program has been implemented in phases and is
to be fully implemented in 2004.

The Social Security Advisory Board15 (Advisory Board) has questioned
whether Social Security's definition of disability is appropriately
aligned with national disability policy. The definition of disability
requires that individuals with impairments be unable to work, but then
once found eligible for benefits, individuals receive positive incentives
to work.16 Yet

14GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.: Jan. 1,
2003).

15The Social Security Advisory Board is an independent, bipartisan board
created by the Congress and appointed by the President and the Congress to
advise the President, the Congress, and the Commissioner of Social
Security on programs and matters related to SSA.

16In addition to the Ticket Program, SSA also offers other work incentives
to disability beneficiaries aimed at encouraging work. For SSI recipients,
these work incentives include such things as earned income exclusions
(which are intended to make work more enticing since some earned income is
excluded from countable income), a deduction for impairment-related work
expenses, and continuation of SSI, which allows beneficiaries to work and
continue receiving benefits until their countable income exceeds the SSI
limit.

the disability management literature has emphasized that the longer an
individual with an impairment remains out of the workforce the more likely
the individual is to develop a mindset of not being able to work and the
less likely the individual is to ever return to work.17 Having to wait for
return-to-work services until determined eligible for benefits may be
inconsistent with the desire of some individuals with impairments who want
to work but still need financial and medical assistance. The Advisory
Board, in recognizing that these inconsistencies need to be addressed, has
suggested some alternative approaches. One option they discussed in a
recent report is to develop a temporary program, which would be available
while individuals with impairments were waiting for eligibility
determinations for the current program. This temporary program might have
easier eligibility rules and different cash benefit levels but stronger
and more individualized medical and other services needed to support a
return to work.18

SSA has also realized that one approach may not work for all
beneficiaries, and in recent years it has begun to develop different
approaches for providing assistance to individuals with disabilities. One
example of these efforts is the proposed Temporary Allowance
Demonstration, which would provide immediate cash and medical benefits for
a specified period to individuals who meet SSA's definition of disability
and who are highly likely to benefit from aggressive medical care. SSA is
also in the process of developing the Early Intervention Demonstration.
This demonstration project will test alternative ways to provide
employment-related services to disability applicants. Although both of
these demonstration projects only cover the DI program, SSA also has the
authority to conduct other demonstration projects with SSI applicants and
recipients.

17GAO, SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C.: July 11,
1996).

18Social Security Advisory Board, The Social Security Definition of
Disability, (Washington, D.C.: Oct. 2003).

  TANF Recipients with Impairments Are Encouraged to Apply to SSI; Impact on SSI
  Caseload Growth Is Inconclusive

Estimates from our nationwide survey of county TANF offices indicated that
almost all offices reported that they refer at least some recipients with
impairments to apply for SSI. But the level of encouragement these
individuals receive from their local TANF office to apply for SSI varies,
with many offices telling the individual to apply for SSI and some offices
helping the recipient complete the application. Because TANF offices are
referring individuals to SSI, these referrals will have some effect on the
SSI caseload. However, findings regarding the impact that these SSI
referrals from TANF have on SSI caseload growth are inconclusive, due to
data limitations.

    Nearly All County TANF Offices Refer Recipients with Impairments to Apply
    for SSI, but the Level of Encouragement Varies

Based on estimates from our survey, 97 percent of all counties refer at
least some of their adult TANF recipients with impairments to SSA to apply
for SSI. As table 1 shows, 33 percent of county TANF offices said that it
is their policy to refer to SSI only those adults whose impairments are
identified as limiting or preventing their ability to work. However,
another 32 percent of county TANF offices said that it is their policy to
refer all TANF recipients identified with impairments to SSI for
eligibility determinations.

Table 1: County TANF Office Policies for Referring Adult Cash Recipients
to SSI

                                 Policy Percent

Refer all recipients with impairments

Refer based on criteria from SSI eligibility determination process

Refer only those who are work limited

No policy

Source: Percentages are estimated from GAO survey of county TANF offices.

Note: Respondents were also given the option of indicating that their
policy was something other than those listed above, and 2 percent of
respondents indicated other.

TANF offices reported that they rely on several methods to identify an
individual's impairment and assess whether the individual could work or
should be referred to SSI. Estimates from our survey indicated that all
county offices rely on the applicant to disclose his or her impairment. In
addition, 96 percent of all counties rely on caseworker observation, about
57 percent use a screening tool, and about 60 percent use an intensive
assessment.

Once recipients are identified as having impairments, TANF offices need to
decide which individuals to refer to SSI. As table 2 shows, many

counties rely on multiple forms of documentation or other information to
make this decision, rather than referring all individuals with
impairments. Specifically, 94 percent of all counties reported that they
use documentation from a recipient's physician, and 95 percent reported
that they use self-reported information from the recipient.

Table 2: Information Used by County TANF Offices to Determine Whether to
Refer Adult Recipients to SSI

                              Information Percent

Documentation from recipient's physician

Documentation from medical professional other than a physician

    Evaluation by an on-site or vendor medical professional 31 Evaluation of
    recipient's ability to work by state vocational rehabilitation worker 70

Informal evaluation by caseworker or social worker

Documented evaluation by caseworker

Behavior observed by caseworker

Self-reported information from recipient

Source: Percentages are estimated from GAO survey of county TANF offices.

While nearly all county TANF offices reported that they refer at least
some individuals with impairments to SSI, the level of encouragement such
individuals receive from their local TANF office appears to vary. About 98
percent of county TANF offices reported that they tell these recipients to
call or go to SSA to apply for SSI. About 61 percent reported that they
will also assist a recipient in completing the SSI application, and about
74 percent reported that they follow up to ensure the application process
is complete. Some of the variation in the level of encouragement may be
explained by the fact that some states are work first states. Officials we
interviewed in four states acknowledged that they try to get all TANF
recipients to work, including recipients with impairments. Therefore,
while they make referrals to SSI, officials in these work first states
told us that they try to encourage work more than the SSI application
process.19 However, officials in all five of the states we visited stated
that if they feel an individual has a severe impairment, they would have
the individual apply for SSI.

19The labor market may also be a contributing factor in deciding to refer
an individual with an impairment to SSI.

    Findings About How SSI Caseload Growth Has Been Affected by Referred TANF
    Recipients with Impairments Are Inconclusive due to Data Limitations

Since county TANF offices refer individuals with impairments to SSI, these
referrals will have some effect on the SSI caseload. To determine the
magnitude of the effect that these TANF referrals have had on SSI caseload
growth, SSA would need to know who among their applicants are TANF
recipients. However, SSA headquarters officials told us that the agency
does not know who is referred or how people are referred because it does
not collect those data. Although the SSI application specifically asks
whether the applicant is receiving TANF, this information is combined with
other income assistance based on need in SSA's database. Therefore, while
the working age (18-64) SSI caseload has increased 33 percent over the
last decade, SSA does not have an easy way to accurately determine the
magnitude of the effect that the TANF referrals have had on the growth of
the SSI rolls. 21

Also, in a study funded by SSA and conducted by The Lewin Group,
researchers found little, if any, evidence that TANF had increased
referrals to SSI. 22 Only one of the five states the researchers visited
remarked of a perceptible increase in transitions to SSI. The authors
noted that the likely reason for not finding a significant increase in
referrals due to welfare reform is the fact that referrals to SSI had
already been occurring under AFDC, and that the full impact of the welfare
reform changes would not be known until the time limit for benefit receipt
had elapsed.23 However, to date there have not been any studies that
looked at this issue.

In addition to SSA not knowing the magnitude of the effect that TANF
referrals have had on SSI caseload growth, TANF officials we interviewed
stated that they generally do not have historical data on SSI referrals,
approvals, and denials. But officials in most states that we visited said
they are in the process of improving their data collection in this
respect,

20In order for SSA to obtain this information, special processing runs are
required. Based upon recent work, SSA determined that 95 percent of the
reported income based on need was from TANF.

21Over the last few years, the percentage of the SSI caseload age 18 to 64
that received income assistance based on need prior to becoming eligible
for SSI has remained fairly stable at 25 percent. While this does not give
an accurate estimate of the portion of SSI recipients who were TANF
recipients, it does provide an upper bound.

22Cornell University and The Lewin Group, Policy Brief: Transitions from
AFDC to SSI Prior to Welfare Reform, (Ithaca, NY: Feb. 1, 2000).

23HHS pointed out that recipients in all states have reached the 5-year
national time limit. However, all states are under the 20 percent limit on
extensions, so there is no reason to expect a sharp increase in referrals
to SSI.

  TANF Offices Differ in Their Exemptions from Work Requirements, but
  Utilization of Noncash Services Is Generally Low

including tracking methods to determine the status of an SSI application,
which should provide them with better data in the future.

TANF offices vary in whether they make work requirements mandatory for
their adult recipients with impairments awaiting SSI eligibility
determinations. Even though estimates from our survey showed that 83
percent of county TANF offices reported offering noncash services to TANF
recipients with impairments who are awaiting SSI eligibility
determinations, these services may not be available or are not fully
utilized. Reasons for this low service utilization may include exemptions
from the work requirements and an insufficient number of job training or
related services.

    Work Requirements Are Not Always Mandatory for Those TANF Recipients with
    Impairments Awaiting SSI Eligibility Determinations

Estimates from our survey showed that about 86 percent of county TANF
offices have policies that always or sometimes exempt from the work
requirements adult TANF recipients with impairments who are referred to
SSI for eligibility determinations. Also, about 31 percent of county TANF
offices consider the number of times a recipient is denied and appeals an
SSI decision as a factor when deciding to exempt recipients from the work
requirements.

Our survey further found that 82 percent of counties reported exempting
recipients, in part, on the basis of the degree to which the impairment
limits the recipient's ability to work. In addition, about 69 percent of
county TANF offices reported that the severity of the impairment was a
major factor in their decisions to exempt people with impairments who are
awaiting SSI determinations from work requirements. One TANF official we
interviewed told us that the recipients' impairments were too great to
participate in work activities.

However, some of the state and county TANF officials we interviewed
explained that they have developed alternative practices to help
recipients with impairments participate in work activities. TANF officials
from two of the states we visited told us that they have developed a
modified work requirement for adult TANF recipients with impairments.24 A
TANF official

24A modified work policy, for example, allows TANF recipients with
impairments to work fewer hours than the federal work requirement without
being sanctioned. Modified work policies are defined by the state and are
not federally approved.

from one of these states said that the modified work requirements
encourage individuals with impairments to work, but they do not expect
that these individuals will be able to work in a full-time capacity. One
county TANF official we interviewed explained that the work requirements
and services provided for their recipients with impairments are very
individualized, based on recommendations of the doctors who meet with the
recipients. However, in all of the states and counties we visited, TANF
officials said that individualized services can be costly. One state
official said that his state's program does not have the funds to pay for
the training needed by people with learning disabilities. The official
added that when people with impairments need substantial help, there were
limits as to what could be funded in a work first state.

    A Broad Range of Services Are Offered to Recipients Awaiting SSI
    Determinations, but Utilization Is Low

Even though about 51 percent of county TANF offices do not require adult
TANF recipients awaiting SSI determinations to participate in any type of
job services, education services, work experience programs, or other
employment services, 83 percent of county TANF offices reported that they
are still willing to provide work-related or support services to this
population. One state official we interviewed reported that the services
provided are the same for persons with or without impairments. Officials
in this state explained that these services include transportation, child
care, medical assistance, tuition assistance, vocational rehabilitation,
and assistance with obtaining SSI benefits.

Even though county TANF offices may be willing to offer noncash services
to their recipients, among those counties that could provide us with
information on service utilization, utilization of these services tended
to be low. While the low utilization of services may be due to exemptions
from the work requirements, service availability may also be an issue.
Estimates from our survey showed that 40 percent of county TANF offices
reported one of the reasons adult TANF recipients with impairments, who
are awaiting SSI eligibility determinations, are not participating in work
activities is that there are an insufficient number of job training or
related services available for them to use. In addition, some TANF
officials that we interviewed cited not only limited funding, but also
their offices' own TANF policies as factors that might explain why
services may not be available to recipients with impairments. For example,
a state TANF official we interviewed said that state budget cuts have
resulted in trimming of support services made available to recipients.
Another state official explained that adult recipients with impairments
who are placed in an exempted status are allowed access to medical
services but not workrelated support services, such as transportation,
clothing, or vehicle

repairs. The official further explained that those services are limited to
those individuals who are in work activities.

In addition, estimates from our survey showed that 50 percent of county
TANF offices reported recipients' motivation to apply for SSI was one of
the conditions that might challenge or hinder their offices in providing
employment services. Some state and county TANF officials we interviewed
also believe that one of the main reasons why there is low utilization of
services is recipients' fear of jeopardizing their SSI applications. While
participation in a work activity does not necessarily preclude an
individual from obtaining disability benefits from SSA, estimates from our
survey showed that 41 percent of county TANF offices reported that their
recipients with impairments, awaiting SSI eligibility determinations, are
unsure whether or not the demonstration of any work ability would hinder
or disqualify their chances for SSI eligibility. State and county TANF
officials we interviewed explained that recipients applying for SSI or
awaiting an SSI decision fear participating in work activities. Some of
the county TANF officials we interviewed explained that this population
does not want to participate in work-related services for fear of
jeopardizing their applications. These officials noted that compounding
recipients' fears are attorneys who may be attempting to protect their
clients' interests by sending TANF offices notices saying that any work
activity could jeopardize their clients' SSI applications. These fears
have led to TANF workers having some difficulty in getting their
recipients with impairments to explore work options during the time they
are applying for SSI. One state TANF official we interviewed pointed out
that conversations with their recipients about work activities have
generally occurred because the recipients want to volunteer for such
activities. A county TANF official explained that there is a challenge in
providing work services to this population, as the recipients are so
focused on getting on SSI that it is difficult to get them to focus on
anything else.

Yet another reason for the low use of noncash service is that some of the
county TANF officials we interviewed expressed some uncertainty as to how
to best serve their adult TANF recipients with impairments, explaining
that they are sending mixed signals when it comes to encouraging work. One
county TANF official we interviewed said that on one hand, recipients are
being told about using TANF services to obtain employment, and then, on
the other hand, recipients are being told to apply for SSI benefits, which
require an applicant to focus on his or her inability to work. Some TANF
offices also allow TANF recipients with impairments to count applying for
SSI as a work activity. Estimates from our survey showed that about 30
percent of county TANF offices reported

  Some Interaction Between County TANF Offices and SSA Exists, but Opportunities
  Exist for Improvement

that they consider the SSI application process an activity that satisfies
the work requirement. Also, another county official we interviewed stated
that if a client goes into an exempted status, the client must participate
in at least one activity a week, but not necessarily a work activity. It
can be any service the TANF office has to offer, including physical
therapy or assistance in completing the SSI application.

Some county TANF offices have developed interactions with SSA offices, but
such interactions have been of a limited nature and have focused on the
SSI application process. Estimates from our survey indicated that some
TANF offices have some form of interaction with SSA. Estimates from our
survey also showed that two frequently reported forms of interaction
between county TANF offices and SSA include having a contact at SSA with
whom to discuss cases and following up with SSA regarding applications for
SSI.

In describing his office's interactions with SSA, one state TANF official
we interviewed said that his office, SSA, and DDS have a good working
relationship, which includes cross training between the agencies and
discussions concerning the SSI application process. However, estimates
from our survey showed about 95 percent of county TANF offices reported
that they would like to develop a relationship, or improve their
relationship, with their local SSA field office with regard to adult TANF
recipients applying for SSI. One state TANF official that we interviewed
said that his office does not have much of a relationship with SSA. He
noted that he had no contacts within SSA but would like to develop a
formal relationship with DDS so that they could make faster determinations
for the deferred TANF caseload. A county TANF official we interviewed said
that her office's communication with SSA is largely one-sided. This TANF
official explained that even though her office sends documentation that
supports a recipient's SSI application, SSA does not inform them of any
eligibility decisions it makes with TANF applicants. As a result, TANF
staff must rely on their recipients telling them about decisions or on a
computer system that indicates if an individual is receiving benefits.
Finally, in all of the states we visited, TANF officials told us that they
interact with SSA to assist their TANF recipients with impairments get
onto SSI. Estimates from our survey also showed that 64 percent of
counties reported that their interactions were TANF officials following up
with SSA regarding a recipient's SSI application, and 53 percent reported
having a contact at SSA to discuss cases.

TANF offices identified a number of ways they would like to improve
interactions with SSA, but most of these focused on making the SSI
application process more efficient and not on working together to assist
TANF recipients with impairments toward employment and selfsufficiency.
Estimates from our survey showed about 57 percent of the county TANF
offices said that they would like to receive training from SSA regarding
the SSI application process and eligibility requirements, 50 percent said
they would like to have a contact at SSA with whom to discuss cases, and
41 percent said they would like to have regular meetings or working groups
with SSA regarding interactions and other issues related to serving
low-income individuals with impairments. In addition, one TANF official we
interviewed would like interactions with SSA to be improved and thinks
they could be if he knew what DDS was looking for in the application
process, such as what it requires for evidence. In contrast, only 6
percent of county TANF offices reported that they would like to improve
interactions with SSA specifically related to providing SSA with
information on employment-related services received while on TANF.

Although TANF offices reported an interest in developing a close working
relationship with SSA, based on their interactions with SSA, some state
and county TANF officials believed that they had to take the lead in
developing these relationships. For example, one TANF official we
interviewed explained that he had attempted to make contact with SSA to
discuss a potential partnership and address some of the county's issues
with the SSI application process but received no response. The county
official then wrote a letter to a top SSA regional official asking about
partnering opportunities. In response, the regional official instructed
the SSA area director, along with the local SSA and state DDS office, to
meet with county officials.

One SSA headquarters official we interviewed told us there is no SSA
policy that directs or encourages their field offices to interact with
TANF offices. The official also told us that SSA would consider such a
partnership with TANF offices but would want assurances of what the
benefits would be for SSA. In addition, the official said that the agency
does not want to start up a partnership that would overly tax its already
high workloads. The official further said that if it were to develop a
relationship with TANF offices, SSA would then have to develop a training
program and then administer it to all operations personnel. The official
noted that developing and administering such a training program would not
be a small task. SSA officials did state that if a TANF office makes a
request for training sessions, SSA would be willing to provide training on

the application process. However, about 27 percent of county TANF offices
reported that they were discouraged in their attempts to establish a
relationship with SSA because the local SSA field office told the TANF
office that SSA did not have the time or the interest.

While officials at SSA headquarters stated that they are largely unaware
of any partnerships or interactions between TANF offices and local SSA
field offices, some local SSA officials have found such relationships
beneficial. In particular, one SSA official has found his office's
relationship with the local TANF office to be a form of outreach for SSA
by helping his office identify people who would qualify for SSI. He
explained that his local SSA office does not always have the time or staff
to conduct outreach. He further explained that TANF case managers can
explain the benefits and provide assistance to the TANF recipient applying
for SSI. Thus, when a letter comes from the DDS that initially denies the
claim, the individual is less likely to throw it away, as he or she is
more aware of the process. This could save SSA time and money as the
applicant knows that he or she must appeal within a certain amount of
time, thereby reducing the need to start over because of missed deadlines.

While 34 percent of those county TANF offices that provide services to
recipients awaiting SSI eligibility determinations reported interacting
with SSA in some manner to serve adult TANF recipients with impairments, a
much higher proportion reported receiving assistance from other agencies
or programs. For example, as table 3 shows, 91 percent of county TANF
offices reported that at least some of their recipients awaiting SSI
determinations received assistance from the state vocational
rehabilitation agencies, and 86 percent of all offices reported that at
least some of their recipients received assistance from the state or local
mental health agency. Further, in all of the states we visited, TANF
offices reported working with other agencies, such as the Department of
Education and the Department of Labor, to help TANF recipients with
impairments find work.

Table 3: Agencies or Programs That Support TANF Offices by Providing Services to
At Least Some Adult TANF Cash Recipients Awaiting SSI Eligibility Determinations

                                Agencies Percent

                        State Vocational Rehabilitation

Other U.S. Department of Education Programs

Social Security Administration

U.S. Department of Labor

State or Local Mental Health Agency

Community Programs

Other

None

Conclusions

Source: Percentages are estimated from GAO survey of county TANF offices.

With the new emphasis on work and self-sufficiency taken by TANF and SSI,
and the overlap in the populations served by both programs, opportunities
exist to improve the way these two programs interact in order to help
individuals with impairments become more self-sufficient. While some
interactions between TANF offices and SSA do exist, they are often limited
to how best to assist a TANF recipient with impairments become eligible
for essentially permanent cash benefits under SSI. Moreover, the practice
by most TANF offices of exempting individuals from work requirements while
awaiting SSI eligibility determination, as well as SSA's policy of
offering return-to-work services and incentives only after a lengthy
eligibility process, undermines both programs' stated goals of promoting
self-sufficiency. In addition, this practice runs counter to the
disability management literature that has emphasized that the longer an
individual with an impairment remains out of the workforce the less likely
the individual is to ever return to work. In recognition of this, SSA is
planning demonstration projects that will test alternative ways to provide
benefits and employment supports to DI applicants. However, TANF
recipients with impairments, because of their low income and assets, are
more likely to apply and qualify for SSI. Moreover, TANF recipients with
impairments often receive assessments of their conditions and capacity to
work while on TANF. Since SSA cannot easily identify who among its
applicants are TANF recipients, SSA is also unable to systematically
identify the types of services that the SSI applicant may have received
through TANF or know whether the SSI applicant has been assessed as having
the capacity to work or not. Being able to identify the receipt of TANF
benefits, as well as the noncash services received through TANF, may help
SSA accomplish its mission of promoting the employment of

beneficiaries with impairments. By sharing information and establishing
better working relationships with TANF agencies, SSA could identify, among
its applicants who are or were TANF recipients, those individuals capable
of working and could then target them for employment-related services and
help them achieve self-sufficiency or at least reduce their dependency on
cash benefits. Although the disconnect in work requirements between TANF
and SSA's disability programs and the timing of when employment-related
services are provided to SSI recipients could be barriers to establishing
a continuity of services, the earlier provision of employment-related
services, as part of a demonstration project, could mitigate these
potential barriers.

While some county TANF officials we interviewed have developed working
relationships with their local SSA office, other counties have not or may
be unaware of the possibilities for interactions with SSA and how to go
about establishing these relationships. Sharing best practices about how
TANF agencies can distinguish, among the recipients they have referred to
SSI, those individuals without the capacity to work from those with the
capacity to work and who could benefit from employment-related services
could help ensure that those individuals with work capacity be given the
assistance they need to help them obtain employment. Moreover, sharing
best practices for establishing useful interactions with SSA could help
ensure that employment-related services could continue after the person
becomes eligible for SSI.

To help individuals with impairments become more self-sufficient and to
address the gap in continuous work services between the TANF and SSI
programs, we are recommending that SSA, as part of a new demonstration
project, work with TANF offices to develop screening tools, assessments,
or other data that would identify those TANF recipients with impairments
who while potentially eligible for SSI may also be capable of working.
Once these recipients have been identified, the TANF offices and SSA could
work together to coordinate aggressive medical care and employment-related
services that would help the individual obtain employment and achieve or
at least increase self-sufficiency.

In order to facilitate and encourage a sharing of information among TANF
offices regarding the development of interactions with SSA that might
increase self-sufficiency of recipients with impairments, we are
recommending that HHS provide space on its Web site to serve as a
clearinghouse for information regarding best practices and opportunities
for TANF agencies to interact with SSA. This would allow state and county

  Recommendations

  Agency Comments
  and Our Response

TANF officials to share information on what they are doing, what works,
and how to go about establishing relationships with SSA. It would also
provide states and counties with access to the research of federal
agencies, state and county offices, and other researchers that they may
need in order to develop a strong functional relationship with SSA and
help TANF recipients with impairments move toward economic independence.
HHS should be able to minimize its work and expense by using its Web site
to share this information.

We provided a draft of this report to HHS and SSA for comment. Both
agencies generally agreed with our recommendations and indicated that they
look forward to working together to help low-income individuals with
impairments become more self-sufficient. Specifically, SSA stated that it
would be pleased to work with HHS on the planning and design of a
demonstration project. Likewise, HHS stated that it would be pleased to
have its staff work with SSA to develop a process or criteria for
identifying individuals who could benefit from employment services.

In addition, in response to the findings of our report, SSA said it would
take immediate measures to ensure that it responds to all requests from
TANF offices for training on SSA's programs.

Also in its comments, SSA suggested that we include in our report the fact
that states may exempt up to 20 percent of their caseload from the time
limits and that many states waive work requirements for persons applying
for SSI. In both the draft we sent to SSA and the final version, we
included a footnote explaining the time limit exemptions, and in the body
of the report we discussed the issue of work requirement exemptions for
persons applying for SSI.

HHS' comments appear in appendix II and SSA's comments appear in appendix
III. In addition, both HHS and SSA provided technical comments, which we
have incorporated as appropriate.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution until 30 days after the date of
this letter. At that time, we will send copies to the Secretary of HHS,
the Commissioner of Social Security, appropriate congressional committees,
and other interested parties. The report is also available at no charge on

GAO's Web site at http://www.gao.gov. If you have any questions about this
report, please contact me or Carol Dawn Petersen on (202) 512-7215. Other
staff who made key contributions are listed in appendix IV.

Cynthia M. Fagnoni Managing Director, Education, Workforce, and Income
Security Issues

                         Appendix I: Scope and Methods

To determine the extent that Temporary Assistance for Needy Families
(TANF) recipients with impairments are encouraged to apply for
Supplemental Security Income (SSI), whether work requirements are imposed,
the range of services provided during the period of SSI eligibility
determination, and the extent that interactions exist between the SSI and
TANF programs, we conducted a nationally representative survey of 600
county TANF administrators from October 14, 2003, through February 20,
2004.

For the most part, TANF services are provided at the county level, so we
selected a random probability sample of counties for our survey. We
derived a nationwide listing of counties from the U.S. Bureau of the
Census's county-level file with 2000 census data and yearly population
estimates for 2001 and 2002. We selected a total sample of 600 counties
out of 3,141 counties. To select this sample, we stratified the counties
into two groups. The first group consisted of the 100 counties in the
United States with the largest populations, using the 2002 estimates. The
second group consisted of the remaining counties in the United States. We
included all of the 100 counties with the largest populations in our
sample to ensure that areas likely to have large concentrations of TANF
recipients were represented. From the second group, consisting of all the
remaining counties, we selected a random sample of 500 counties.

After selecting the sample of counties, we used the American Public Human
Services Association's Public Human Services Directory (2002-2003) to
determine the name and address of the TANF administrator for each county.
In states with regional TANF programs, we asked the regional director to
fill out a questionnaire for each county in the region. We obtained
responses from 527 of 600 counties, for an overall response rate of about
88 percent.1 The responses are weighted to generalize our findings to all
county TANF offices nationwide. Sample weights reflect the sample
procedure, as well as adjusting for nonresponse.

Because we followed a probability procedure based on random selections,
our sample is only one of a large number of samples that we might have
drawn. Since each sample could have provided different estimates, we
express our confidence in the precision of our particular sample's results

1The response rate for the stratum consisting of the 100 counties with the
largest populations was 92 percent. The response rate for our sample of
the remaining U.S. counties was 87 percent.

Appendix I: Scope and Methods

at a 95 percent confidence level at an interval of plus or minus 5
percentage points. This is the interval that would contain the actual
population value for 95 percent of the samples we could have drawn. In
other words, we are 95 percent confident the confidence interval will
include the true value of the study population.

In addition to the reported sampling errors, the practical difficulties of
conducting any survey may introduce other types of errors, commonly
referred to as nonsampling errors. For example, differences in how a
particular question is interpreted, the sources of information available
to respondents, or the types of people who do not respond can introduce
unwanted variability into the survey results. We included steps in both
the data collection and data analysis stages for the purpose of mitigating
such nonsampling errors.

Appendix II: Comments from the Department of Health and Human Services

Appendix II: Comments from the Department of Health and Human Services

Appendix II: Comments from the Department of Health and Human Services

Appendix II: Comments from the Department of Health and Human Services

Appendix III: Comments from the Social Security Administration

Appendix III: Comments from the Social Security Administration

Appendix IV: GAO Contacts and Staff Acknowledgments

GAO Contacts 	Carol Dawn Petersen, (202) 512-7215 Michael J. Collins,
(202) 512-7215

Staff 	In addition to those named above, David J. Forgosh, Cady Summers,
Megan Matselboba, Christopher Moriarity, and Luann Moy made key

  Acknowledgments contributions to this report.

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