PPT - Ticket to Work

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Ticket to Work: All EN Payments Call
Part II
April 29, 2014
EN Payment Rules and Application
Part I
Phase 1/Phase 2
Milestones
• Benefits
• Attainment
Month
• Payment
Request
Form
Part II
Phase 1/Phase 2
Milestones
• Earnings
• 18-Month
Lookback Rule
• State VR agency
involvement
• EN Certification
of Services
• Outcome
Phase 1/Phase 2 Milestones -Earnings
3
Phase 1/Phase 2 Milestones - Earnings (cont.)
EN submits a Payment Request for an Social Security Disability Insurance (SSDI) (T2) beneficiary for
a PH2/M1 for the claim month 01/2011. The pay stubs (2) submitted show:
Pay stub # 1
Pay Period Beginning:01/10/2011
Pay Period Ending:01/23/2011
Pay Date:01/28/2011
Gross amount:$530.20
Pay stub # 2
Pay Period Beginning:01/24/2011
Pay Period Ending:02/06/2011
Pay Date:02/11/2011
Gross amount:$660.80
Determination: The P2M1 claim is denied.
Denial Reason: Earnings Amounts Do Not Meet Criteria for Payment
Comments: Evidence of earnings submitted are below SGA for 2011= $1,000
4
Phase 1/Phase 2 Milestones- Earnings (cont.)
Explanation: SSDI (T2)
•
If an EN submits a Payment Request for a
beneficiary receiving SSDI (T2), we will
determine the amount of earnings earned in
the month (from the 1st day of the month to
the last day of the month) for Ph1/Ph2
Milestones and for Outcome payments. If
the evidence of earnings for the claim month
requested is overlapping the following
month, we will prorate the earnings for each
month.
•
•
•
$660.80 / 14 (days in the pay period) =
$47.20 X 8 (days 01/24-01/31) = $377.60
Then: $530.20 (pay stub #1) + $377.60 (8
days in 01/2011, pay stub # 2) = 907.80
The PR submitted by the EN for Ph2/M1 for
the claim month of 01/2011 will be denied
due to total earnings amount is below
Substantial Gainful Activity (SGA) (SGA for
2011=$1000.00).
5
Phase 1/Phase 2 Milestones- Earnings (cont.)
6
Phase 1/Phase 2 Milestones - Earnings (cont.)
• Supplemental Security Income (SSI) (If beneficiary was
SSI or T16)
• If an EN submits a Payment Request for a beneficiary
receiving T16, we will determine the amount of earnings
paid in the month (pay dates may fall on any day of the
month) for Ph1/Ph2 Milestones and for Outcome
payments. Even if a pay stub shows that the days are
overlapping the following month, we will consider only
the pay date.
7
Phase 1/Phase 2 Milestones - 18-MLB Rule
8
Phase 1/Phase 2 Milestones - 18-MLB Rule (cont.)
EN submits a Payment Request for a P1M1 with an attainment date of 01/2013. The beneficiary’s
Ticket was assigned 12/10/2012. The EN supplied copies of pay stubs with earnings that met were
above Trial Work Level (TWL) to meet the criteria for a Phase 1 Milestone. The EN also submitted a
Look Back form and indicated the beneficiary had earnings at or above TWL for 10/2012 and 11/2012.
Determination: The P1M1 claim is denied.
Denial Reason: Not Eligible for Payment Due to Look Back Earnings
Comments: Earnings above TWL exist prior to the Ticket assignment date. EN is not entitled to
receive P1M1 payment.
The timeframe use to calculate Phase 1 Milestones that may be unavailable is listed below:
Phase 1 Milestone #
Timeframe of TWL Earnings
1
1 Month before Ticket assignment
2
3 out of 6 Months
3
6 out of 12 Months
4
9 out of 18 Months
9
Phase 1/Phase 2 Milestones - 18-MLB Rule (cont.)
In the example above, 18 months prior to 12/2012 is 06/2011. If the beneficiary has
earnings ≥ TWL:
3 months between 06/12 and 12/12; Phase 1 Milestone 2 would be excluded
6 months between 12/11 and 12/12; Phase 1 Milestone 3 would be excluded
9 months between 06/11 and 12/12; Phase 1 Milestone 4 would be excluded
10
Phase 1/Phase 2 Milestones – State Vocational
Rehabilitation (VR) Involvement
11
Phase 1/Phase 2 Milestones –
State VR agency Involvement (cont.)
EN submitted a Payment Request for Phase 1 Milestones 1-3. The Ticket
assignment date was 01/10/2011. The attainment dates were 03/11, 05/11 and
08/11. The EN supplied pay stubs with earnings above Substantial Gainful
Activity (SGA) for the 6 months and filled out Section V of the PR with a
summary of services and dates of services between each Phase 1 milestone.
Determination: Phase 1 Milestones 1- 4 were denied.
Phase 2 Milestones 1- 6 paid.
Denial Reason: Due to VR services Phase 1 Milestone cannot be paid.
Comments: Ticket assignment to a State VR agency under Cost
Reimbursement was closed successfully. No Phase 1 Milestone payments can
be made.
12
Phase 1/Phase 2 Milestones –
State VR Involvement (cont.)
According to §411 Code of Federal Regulations:
(iii) If a beneficiary had a ticket that otherwise was available for
assignment and chose to receive services under an IPE from a State
VR agency that elected the VR cost reimbursement option, payment of
Phase 1 Milestones to an EN or a different VR agency acting as an EN
with respect to the same ticket is precluded if the State VR Agency
that elected the VR cost reimbursement option achieved an
employment outcome (as described in 34 CFR 361.56) before case
closure.
13
Phase 1/Phase 2 Milestones – EN Certification of
Services
14
Phase 1/Phase 2 Milestones – EN COS (cont.)
EN submitted a PR for a Phase 2 Milestone 11 claim with an attainment month
of 03/13. The beneficiary was in a current pay payment status and earnings
posted in Social Security’s system were above SGA for 03/13. Phase 2
Milestone 10 had been paid for attainment month 02/13.
Determination: The P2M11 is paid. EN Payments staff request PHD to submit
a request to the EN for an EN COS for P2M11.
Explanation: The beneficiary met the criteria for payment of the P2 M11;
however, ENs should submit an EN COS when submitting PRs for:
Phase 1 Milestone 4
Phase 2 Milestone 11
Outcome 11
Outcome 22
15
Outcomes - Benefits
16
Outcomes – Benefits (cont.)
•
EN submits a Payment Request for Outcomes for attainment months 03/13
– 04/13. EN submitted pay stubs with earnings above Substantial Gainful
Activity (SGA) for 03/13 – 04/13. The beneficiary is a concurrent beneficiary
(SSDI and SSI).
•
•
•
Determination: Outcomes for attainment months 03/13 - 04/14 are denied.
Denial Reason: Benefits not suspended or terminated due to work
Comment: Benefits are in current pay status for 3/13 - 4/13. Outcome
payments cannot be processed when beneficiary is receiving Federal cash
benefits.
17
Outcomes – Benefits (cont.)
Explanation: The beneficiary has earnings above SGA and his SSI (T16)
record indicates the beneficiary has been placed in a non-pay payment status
due to work and earnings. However, the beneficiary’s SSDI (T2) record
indicates the beneficiary is in current pay payment status (receiving a Federal
cash benefit). To be eligible for outcome payments, a concurrent beneficiary
must be in a non-pay or suspense payment status under both programs (SSDI
and SSI) and the reason for non-pay or suspense under at least one of the two
programs must be due to work and earnings. This beneficiary had been in an
outcome period (i.e. non-pay due to work and earnings) under both SSDI and
SSI previously. Therefore, the only payments available for this beneficiary are
outcomes. Since the beneficiary is not in a non-pay or suspense payment
status under both programs (and one of the two non-pay reasons are due to
work and earnings), outcome payments are not available.
18
Outcomes - Availability
19
Outcomes – Availability (cont.)
The EN has chosen the Outcome Only payment method and submitted a PR
for an outcome 1 payment with an attainment month of 02/13. The Ticket
assignment date was 02/13/2013. The EN submitted pay stubs with earnings
for 02/13 well above SGA. The beneficiary is an SSI beneficiary and is in
suspense due to work and earnings.
Determination: Outcome #1 for attainment months 02/13 is denied.
Denial Reason: Can not pay until month after first assignment
Comment: Claim not payable until first month after Ticket assignment date.
Explanation: The EN submitted a claim for the same month the Ticket was
assigned; 02/13. The first month available for payment is the first month after
Ticket assignment. In this case, the first month available for payment is 03/13.
20
Outcomes – SGA Levels
21
Outcomes – SGA Levels (cont.)
An EN submitted a PR for an outcome payment and pay stubs with earnings
well over SGA ($1240) for the attainment month 12/10. The Ticket was
assigned 06/10 and the SSDI beneficiary was in a suspense payment status
due to work and earnings.
SGA Levels
Year
T
SGA Non-Blind
W
SGA Blind
Determination: Outcome was denied.
2008
$940
$1,570
Denial Reason: Earnings amounts do not
2009
$980
$1,640
meet criteria for payment
2010
$1,000
$1,640
Comment: Evidence of earnings submitted
2011
$1,000
$1,640
are below Blind Substantial Gainful Activity
2012
$1,010
$1,690
for 2010 = $1,640.
2013
$1,040
$1,740
Explanation: The earnings requirement for
outcome payments for this particular beneficiary was Blind SGA instead of
normal SGA. The requirement for Blind SGA earnings is higher than non-blind
SGA.
22
Outcomes – Payment/Denial Decision
EN Payments Specialists make payment/denial decisions based on the
information posted on Social Security databases at the time claims are
processed. This information can change; therefore Payments Specialists save
all information used (i.e., a snapshot of status, earnings and other information
at the time claims processed) to make a determination.
An EN submitted a PR for a claim (no specific type of claim) and submitted pay
stubs for the attainment month 11/12. The beneficiary had a Ticket assignment
date of 06/10. The EN Payments staff created and denied an outcome claim
with a Denial Reason: Insufficient earnings. The EN resubmitted the claim with
the same pay stubs and EN Payments staff created a P2M10 and denied the
P2M10 claim with a Denial Reason: Insufficient earnings.
The EN submitted an inquiry and wanted to know:
1. Why was the claim created as an outcome the first time and a Phase 2
Milestone claim the second time.
2. Why was the claim denied for insufficient earnings because pay stubs
23
exceeded SGA based on her calculation of $1,001.93?
Outcomes – Payment/Denial Decision (cont.)
Explanation: The first time the claim was correctly created and processed as
an outcome claim. The beneficiary’s pay status at the time the claim was
processed was: Suspended Due to Work and Earnings. The Social Security
field office had placed the beneficiary in and out of suspense beginning 09/11 –
12/12. For the month of 11/12, the field office posted the beneficiary in a
suspense pay status due to work and earnings. This is the correct pay status of
an outcome claim.
24
Outcomes – Payment/Denial Decision (cont.)
The second time the claim was correctly created and processed as a Phase 2
Milestone 10 claim. At the time this claim was processed the Social Security
field office retroactively placed the beneficiary in a current pay payment status
(i.e., receiving a monthly Federal Benefit) with NO outcome periods since the
beneficiary’s disability award was approved. The beneficiary remained in a
current pay status, so a Phase 2 Milestone payment was appropriate. The last
payment processed under the beneficiary’s Social Security Number was a
Phase 2 Milestone 9; therefore, the current claim created for a Phase 2
Milestone 10 was appropriate.
ISSUE OF INSUFFICIENT EARNINGS - EN Payments staff review of pay
stubs submitted resulted in agreement with the EN’s calculation of $1,001.93.
However, SGA for 2012 was $1,010. When informed the EN realized that she
had not updated tables of earnings for 2012 and made the necessary changes.
25
Outcomes – Notification Policy Changes
EN Payments Staff resumed processing payment denials for Universal Auto
Pay and all claims submitted by ENs.
In February 2013 the EN Payments Staff stopped processing payment denials
for auto pay claims since ENs did not request these payments. EN Payment
staff only created and processed claims for payment from the Universal Auto
Pay file. During this time, EN Payments staff also grouped denials under one
work case number when a large number of denials were processed for the
same reason and provided an explanation in the comments section of the EN
Payment Status Report. This process made it more difficult for ENs to reconcile
their account receivable balances. Therefore, EN Payments Staff resumed the
process of creating payment denials for these claims in August 2013.
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Contact Us
Website:
www.yourtickettowork.com
Email:
[email protected]
Payments Helpdesk
• Toll Free Line:
1.800.949.3687
• Email:
[email protected]
Questions
28
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