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Recognizing that work is at the heart of the American Dream, President Clinton signed the federal Ticket to Work and Work Incentives Improvement Act (TWWIIA) into law in December, creating several new benefits critical to disabled individuals eager to enter the workforce. TWWIIA was the last bill signed into law by a U.S. President in the 20th century.

The new law should increase consumer choice in obtaining rehabilitation and vocational services, remove barriers that require people with disabilities to choose between health care coverage and work, and give more Americans with disabilities the opportunity to participate in the workforce and lessen their dependence on public benefits.

Despite its promise, the TWWIIA promises to add complexity to already complex programs, given its multiple components, numerous qualifications, varying effective dates, and the requirement that states agree to participate in efforts to extend Medicaid coverage to the working disabled through sliding-scale premiums (the so-called state option "buy-in").

The Ticket to Work provisions of the new law will allow adults with severe mental illnesses on Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) to seek vocational rehabilitation and employment services from providers of their own choice (government or private sector) after January 2001. The federal Social Security Admini-stration (SSA) is expected to phase-in the Ticket to Work program over a three-year period through test sites across the country. Perhaps most important for consumers seeking to enter the workforce are provisions to expand eligibility for Medicare and Medicaid health insurance benefits.

For Medicare beneficiaries, TWWIIA provides a 4.5 year extension beyond the current four year maximum Medicare coverage for disabled individuals returning to work and earning more than $700 per month. Medicare currently has no outpatient prescription drug benefit and a 50% co-payment for outpatient services. Medicaid provisions expand the options available to states since passage of the 1997 Balanced Budget Act (BBA) to extend Medicaid coverage to working individuals with disabilities, otherwise ineligible because of income, by letting them "buy-in" to Medicaid through sliding-scale premiums. Under BBA, states could offer a Medicaid buy-in for individuals with incomes of 250% of the poverty level who would be otherwise eligible for Medicaid except for their income. TWWIIA expands the scope of the buy-in option by letting participating states offer a sliding scale Medicaid premium to disabled individuals earning between 250 and 450% of poverty level (not to exceed 7.5% of total income). States can set resource limits up to $14,000. States will also be allowed to cover individuals with disabilities who have lost eligibility for SSI or SSDI because their medical condition has improved.

Critical to the success of the TWWIIA is the willingness of states to participate by offering the Medicaid "buy-in" option. New York is among those states that has decided not to participate in the Medicaid "buy-in" program available under the BBA of 1997 because of concerns over the possible impact on the state Medicaid budget. A coalition of advocates is currently at work to promote passage of legislation to require New York State to offer the TWWIIA Medicaid "buy-in."

Consumers should be aware that New York State currently offers Medicaid to certain working individuals with disabilities under the so-called "1619 program," which permits earnings from work up to $28,736 per year. Additionally, several new protections will be available to SSDI recipients. Effective January 2001, individuals whose benefits have been previously terminated due to earnings from work will be able to request an immediate reinstatement of benefits. Effective January 2002, the Social Security Administration is prohibited from using work activity as the basis for a continuing disability review for SSDI recipients who have been on SSDI for at least two years. But termination of cash benefits can still occur for individuals who exceed the earning threshold from work activity. TWWIIA also includes provisions to support a variety of demonstration projects and efforts to enhance the infrastructure to serve individuals with disabilities.