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Medicaid Involvement in Employment-Related Programs- Findings from the National Survey of State Systems and Employment for People with Disabilities

Research to Practice 33


Originally published: 3/2003

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Recent legislation such as the Balanced Budget Act of 1997 (BBA), the Workforce Investment Act of 1998 (WIA), and the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) has emphasized collaboration and participation of multiple agencies in working toward better employment outcomes for people with disabilities. One of the more unconventional partners drawn in by these programs is Medicaid. Because the potential loss of health benefits is a barrier to workforce entry for people with disabilities, Medicaid plays an important role in opening up work opportunities.

WIA, TWWIIA, and the BBA offer several opportunities for state Medicaid agencies to broaden their scope and become more involved in employment issues. Each state has taken its own approach to involving Medicaid in these initiatives.

WIA emphasizes collaboration at the local level, with multiple partners involved in networks of local One-Stop Career Centers (One-Stops) as well as local Workforce Investment Boards. In addition to these local efforts, WIA also involves collaboration at the statewide level, both in state Workforce Investment Boards and in multi-agency working groups to develop state Workforce Investment Act Plans (WIA Plans). A number of states have involved Medicaid in the One-Stop system: for example, offering Medicaid eligibility determinations or referrals through One-Stops. Some have involved Medicaid in state Workforce Investment Boards and the state planning process for WIA. TWWIIA, in addition to involving Vocational Rehabilitation and Social Security in the Ticket to Work program, also involves Medicaid and Medicare in extending health insurance coverage to working adults with disabilities. The BBA also provides for such "Medicaid Buy-In" programs. Different state Medicaid agencies are in various stages of planning and implementation of Buy-In under both the BBA and TWWIIA.

This brief uses data from the 2001 National Survey of State Systems and Employment for People with Disabilities to explore Medicaid agencies' involvement with employment programs. It describes survey responses regarding prioritization of employment issues by state Medicaid agencies, as well as Medicaid involvement in BBA, WIA, and TWWIIA implementation.

About the survey

The National Survey of State Systems and Employment for People with Disabilities was a survey of state agency directors conducted by the Institute for Community Inclusion in summer and fall 2001. The survey addresses state agency activities and interagency collaboration related to employment opportunities for people with disabilities. Data were gathered from 265 respondents representing state Vocational Rehabilitation agencies, Commissions for the Blind, Mental Retardation/Developmental Disability agencies, Mental Health agencies, Temporary Assistance for Needy Families (TANF) agencies, Medicaid agencies, and Workforce Development Offices (One-Stop Career Centers).

Prioritization of employment

One of the questions in the ICI survey asked respondents if increasing competitive labor market job placement for people with disabilities was a priority goal for their agency and other agencies in the state. Close to three-quarters of Medicaid agency respondents indicated that increasing job placement for people with disabilities was indeed a priority goal for their agency. This high number of positive responses indicates that there is a lot of interest in employment outcomes at Medicaid agencies, despite the fact that competitive employment of people with disabilities is not part of the primary mission of Medicaid.

Medicaid involvement with WIA

While some agencies are mandatory partners in WIA, participation by Medicaid is voluntary. The survey explored three main mechanisms through which Medicaid can be involved in WIA: representation on state Workforce Investment Boards (WIBs), participation in the development of state WIA Plans, and involvement with state level One-Stops.

Workforce Investment Boards and WIA plans

Statewide WIBs are responsible for developing and coordinating workforce investment activities such as the One-Stop network and the statewide performance measurement system, as well as for reviewing local plans and activities.

Half the Medicaid agencies that responded to the survey were represented in some way on their state WIB. Of those who were represented on the WIB, three-quarters were represented directly by the agency's chief administrator or a delegate, while one-quarter had their interests represented by another agency. About the same proportion of respondents (around 40%) was involved in the development of the WIA Plan as was directly represented on the WIB.

One-Stop Career Centers

In some states, Medicaid is a partner in the One-Stop Career Center system. To assess collaboration with the One-Stop system, the survey asked state Medicaid agencies about their use of seven specific methods of collaboration with the state One-Stop entity: cross-agency awareness training, multi-agency working groups, physical co-location, sharing of computer networks, sharing of client tracking databases, sharing of client intake information, and sharing of the costs of direct services. A considerable number of respondents (about 40%) indicated that they participated in cross-agency awareness training and/or multi-agency working groups with the One-Stop entity. Other measures of collaboration had very low levels of implementation, with only zero to 15% of respondents using them. In fact, of the six agencies about which the survey asked, the lowest use of most types of collaboration by Medicaid was with the One-Stops. These low levels of collaboration seem to indicate that Medicaid does not participate much in the One-Stop system. Medicaid involvement may, however, be underrepresented by these figures because the questions were asked about collaboration at the state level and the real activity of One-Stops takes place at the local level. Also, confidentiality issues may prevent more sharing of client information.

Relationship between involvement with WIA and prioritization of job placement

The survey data indicate that those Medicaid agencies that are involved in WIA implementation are more likely to also consider job placement for people with disabilities an agency priority. Eight of the nine Medicaid agencies directly represented on state Workforce Investment Boards considered job placement a priority, as compared to seven of the fourteen agencies not represented on the WIB at all. Likewise, 79% of those involved in WIA Plan development considered job placement a priority, while only 60% of those not involved in the WIA Plan did. A similar difference can be seen between those who used at least one measure of collaboration with One-Stops and those who did not.

Figure 1: Collaboration with One-Stop entities by Medicaid

Type of Collaboration %
Multi-agency working groups (n=28) 42.9
Physical co-location (n=32) 0
Sharing a computer network (n=30) 13.3
Sharing a client tracking database (n=29) 3.4
Sharing intake information (n=25) 8
Sharing the costs of direct services (n=26) 15.4

Figure 2: Prioritization of job placement by WIB representation


Figure 3: Prioritization of job placement by WIA representation


Figure 4: Prioritization of job placement by collaboration with One-Stop centers


Medicaid activities under TWWIIA and BBA

State Medicaid agencies can also become involved in advancing employment of people with disabilities by implementing the optional Medicaid Buy-In provision under TWWIIA and BBA. The expansion of eligibility criteria offered under Medicaid Buy-In programs allows people with disabilities to continue their Medicaid coverage even if they earn more than the usual Medicaid income limits, thus removing potential loss of insurance as a barrier to employment.

States offering Medicaid Buy-In

Almost half the Medicaid survey respondents (15 of 36) had some kind of Buy-In program, while another third (11) had a Buy-In program planned but not yet implemented.

Based on ICI's survey findings and on the latest findings from the National Association of State Medicaid Directors's Center for Workers with Disabilities, fifteen states currently have Buy-In programs under TWWIIA, which is the most recent Buy-In legislation. Twelve states offer Buy-In under the BBA. Massachusetts's Buy-In program is authorized by Section 1115 of the Social Security Act, which provides waivers for Medicaid "research and demonstration projects" that can include expansion of coverage.

Relationship between Buy-In and prioritization of employment

Unlike the case with WIA involvement, there is no association between considering job placement for people with disabilities a priority and implementing Medicaid Buy-In. In fact, the proportion of respondents indicating that job placement is a priority for the Medicaid agency actually is highest for the states that do not have any Buy-In program and lowest for those that have already implemented Buy-In.

Figure 5: State Implementation of Medicaid Buy-In*

Section 1115 Demonstration Project MA
Currently offered under the Balanced Budget Act [AK], CA, IA, [ME], MS, [NE], [NM], [OR], SC, UT, VT, WI
Currently offered under TWWIIA AR, [AZ], [CO], CT, MN, NH, NJ, [OK], [TX], WA
** Plans enacted but not implemented CO, FL, [ID], IL, IN, KS, LA, MO, NV, OK, PA, TX
Not being considered at this time AL, DC, DE, GA, HI, ID, MT, NC, RI, WV

*States in brackets were non-responders to the survey; data are taken from the Center for Workers with Disabilities (August 2002), http://disabilities.aphsa.org/Resource%20Directory/MedicaidBuyIn.htm
**IL, IN, KS, MO, and PA have all begun implementation of their Buy-In programs since the survey date. FL has rescinded its Buy-In program since the survey date (M. Cheek, 9/5/02)

Figure 6: Prioritization of job placement by Buy-In implementation


Conclusions and Implications

The findings presented here indicate a moderate level of involvement by Medicaid agencies in employment-focused efforts such as WIA and TWWIIA. One-third to one-half of the Medicaid agencies that responded to the survey are involved in state WIBs, participating in WIA planning at the state level, collaborating with One-Stops, and/or implementing Medicaid buy-in programs.

While these numbers indicate significant progress, they also show that there is still room for much expansion of Medicaid's role. On any particular measure, over half of Medicaid agencies are not taking advantage of that particular opportunity for involvement. These are significant levels of non-participation, particularly considering that 72% of Medicaid agencies report that employment of people with disabilities is an agency priority.


The authors would like to thank Michael Cheek of the National Association of State Medicaid Directors' Center for Workers with Disabilities and Peter Baird of the Connecticut Bureau of Rehabilitation Services for reviewing this brief and Scott Cinsavich, Jennifer Bose, and Danielle Dreilinger for their contributions to the survey design and implementation.

For more information, contact:

Susan Foley, PhD
Center on State Systems and Employment
Institute for Community Inclusion
UMass Boston
100 Morrissey Boulevard
Boston, Massachusetts 02125
617.287.4364 (v); 617.287.4350 (TTY)

This is a publication of the Center on State Systems and Employment (RRTC) at the Institute for Community Inclusion. The center is funded by the National Institute on Disability and Rehabilitation Research (NIDRR) of the US Department of Education (grant #H133B980037). The opinions contained in this publication are those of the grantees and do not necessarily reflect those of the US Department of Education.

This publication will be made available in alternate formats upon request.

ICI: promoting inclusion for people with disabilities