Jun 12, 2022
Welcome to the 15th episode of the Manager Minute. Joining Carol Pankow in the studio today is Cheryl Fuller, VR Division Director with the Texas Workforce Commission and also incoming CSAVR President. Today we will talk about Social Security's VR Cost Reimbursement program, which was authorized in 1981. The purpose of that program is to make State VR services more readily available to SSA beneficiaries with disabilities and to generate savings for the Social Security Trust Fund for SSDI beneficiaries and the General Revenue Fund for SSI recipients.
Learn how the Texas Workforce Commission uses technology and staff to maximize and track Social Security Reimbursements to help support their programs.
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VRTAC-QM Manager Minute: Everything is Bigger in Texas- Learn How Texas Leverages SSA Reimbursement
Speaker: Manager Minute brought to you by the VRTAC for Quality Management. Conversations powered by VR, one manager at a time, one minute at a time. Here is your host, Carol Pankow.
Carol: Welcome to the manager minute. I am so fortunate to have Cheryl Fuller, V.R. Division Director with the Texas Workforce Commission and also incoming CSAVR president, joining me in the studio today. And Cheryl, there certainly have been some very tragic things happening in your state and most recently the Uvalde School shooting. And my thoughts and prayers are with everyone affected. I know VR is typically filled with people with a lot of heart. We're kind of people people. So in light of all that's happening, how are you and your staff holding up?
Cheryl: First of all, thank you for thinking about us. This is something very much at the forefront of our minds and it's really on our hearts. And we have a field office in Uvalde about a block and a half from the school. And so it's a small community. Our staff knows everyone. I grew up in a small town myself, and I know just how wonderful it is to grow up in a small town with the support and the relationships, and that will be important for them going forward. And our agency, along with other agencies, immediately looked at what we can do, how can we help our community? Because it is our community. And we're looking at a couple of things. We're looking at some group skills training later this summer to help some of our students get ready to go back to school. And how can we do that? How can we help them think about going back to school and process that and think about some positive things that they look forward to about why they're in school, their career and growing up and getting ready to transition. And of course, we know adults also may need us. So we're redoubling our efforts to make sure that our community knows that our services are there to help them. If a few months from now they begin to have conditions that are preventing them from keeping their job. We're here to help, and we know that if we all do what we can, we will help our community work through this.
Carol: Well, I'm really glad you're at the helm because you bring that heart to it. That has just broken my heart. I'm thinking about you all. I'm praying for you guys every day. And I'm glad you're in that leadership role there to bring that to your staff and to your customers and that thought and thinking ahead for the next school year. That is so smart, so wise.
Cheryl: Well, that's our staff on the ground and it's our agency executive director. We're so fortunate to have an executive director that cares very much about our division, our programs, our customers and our staff, and was on the ground meeting with our staff and immediately asking what we can do and helping us be creative in thinking how can we help? We can do more. And so we're really fortunate to have.
Carol: I love that. That is so great to hear. Cheryl, I've known you since you started at the agency. And in fact, I don't think you probably remember this, but I was actually sitting behind you at your first CSAVR conference, and I remember thinking, Who is that lady? You were so sharp and you would ask questions like, I'm like, This gal is super intelligent. Like, Where's she come from? Because you were new to VR and you came out of the other side of the world. But I loved it because you participated right away and you've accomplished so much in your tenure. I've really always looked up to you and your leadership, not only in your agency but in the VR field as a whole. And so congrats on that new position as the incoming president of CSAVR. I know you're going to be spectacular at that job.
Cheryl: Thank you, Carol. You know, I've always looked up to you. In fact, we were following you around, as I recall, when you were president, as you tried to lead our association and lead our partnership with our federal agency to get more flexibility, which we so needed to serve students with disabilities. So I was in the group behind you going, Yeah, what Carol says.
Carol: So you are hilarious. Well, I never got to be CSAVR President, I was the NCSAB president. CSAVR Executive Committee.
Cheryl: Yeah, that's right.
Carol: I did a lot of that work through NCSAB, but you know, I was on both groups and so wow, definitely promoting those flexibilities and I'm glad they finally came through.
Cheryl: Well, thank goodness for your leadership there and your leadership with administrative changes like prior approval, I thought how has Carol already figured all of this out? And we're still trying to spell prior approval, so.
Carol: Oh, you are very sweet. Yeah, well, I'm still working on it to this day in my new role. Yes. But today we're going to talk about Social Security's VR cost reimbursement program, which was really authorized back in 1981. Right. And the purpose of that program is to make State VR services more readily available to SSI beneficiaries with disabilities and to generate savings for the Social Security Trust Fund for SSDI beneficiaries and the General Revenue Fund for SSI recipients. And so under that cost reimbursement program, the Social Security Administration will pay state VR agencies compensation in the form of reimbursement when beneficiaries served by State VR agencies enter the workforce and achieve nine continuous months of earnings. And those earnings must be at or above substantial gainful activity, and usually it's just referred to as SGA. I know for me that program income was really a game changer when I was at Minnesota Blind. I mean, it actually gave us some breathing room and we were able to do some really creative things and invest in. Our older individuals who are blind program. And so what I was thinking about who to talk to for this I of course I called Courtney. She was my person. I'm like, Courtney, what are the states out there that are doing really well with this? And you were at the top of the list. So when you look at those reimbursement levels, I know your state is out in the lead and being really efficient in getting every possible dollar. So let's dig into this. Can you give us a little picture about VR in Texas? Like what's your annual grant amount? Kind of how many staff do you have? How many customers do you serve? Paint a little picture for our listeners.
Cheryl: Sure. Our annual grant amount has been growing every year rather significantly. It's grown 23% since 2017. Wow. So our annual grant allotment is at about 300 million now. We're second to our sister state in California. Of course, California is bigger. And so we have certainly, as we've seen our grant grow, we are seeing it grow in significant part because of our population growth in Texas. We are expected to, if we haven't already surpassed the 30 million person point in Texas population, we were 27.4 in 2016 and we are now well into 30 million. In fact, I think we were leading the country in numeric growth from 2010 to 2020. Wow. Our state is growing in terms of population. Our economy is remaining strong and our grant is growing. I'll tell you our annual budget. So our grants are of course for two years, but our annual budget this year is about $276 million at the DSU level. And so when it comes to the number of folks that we're serving, if we just think about participants, which is how we now consider a number of customers serve in the most specific sense. So somebody with an IP who is also receiving services, last year it was about 65.5 thousand, so 65,514. To be specific, it's running 65 to 70000 a year is how many customers we're serving. We're doing that with a division that has about 744 positions. The vast majority of those are in the field. About 1663 of those positions are in the field. Almost 700 of them are counselors or transition VR counselors who work with students and youth, about 350 rehabilitation assistants to support them. And then we have other direct service delivery staff like our VR teachers, for example. We also have a residential training facility for individuals who are legally blind. Mark Driscoll Rehabilitation Center is in that direct service delivery group. And then of course we have regional and management unit staff also providing support oversight to our staff delivering services. So that's a picture of our system.
Carol: That's a bunch. I was doing the quick math, so I was looking at your 700 counselors divided by those 65,000 people. So you're sitting around 93 customers on average on a caseload.
Cheryl: On average.
Carol: Absolutely. I just have to ask, have you seen any changes as a result of the pandemic with individuals coming in starting to experience the long COVID or anything like that?
Cheryl: You know, we've seen just a handful. We have seen some. It's not big numbers. And I think as individuals experiencing long COVID work through what that is, what it means to them, whether it represents an impediment to their ability to keep a job or get a job or advance in their job. I think we may see more of that. And right now, it still seems like it's quite a new field of study. And these folks are trying to figure out where their resources are and how they're going to work through these symptoms that stay with them for a long time.
Carol: Yeah, absolutely. I'm just thinking that might end up coming your way given all that huge growth in population, for sure. That definitely is. People were all moving to Texas. I see it on Facebook all the time. I've had several friends moved down to Texas, so I get it.
Cheryl: Well, it's hot here right now, so they might be questioning that decision. It's supposed to be I think we're supposed to get to 107 over the weekend, so.
Carol: ]\Yeah, I saw that on the news. It's looking blistering, definitely. So tell me about what resources you've been able to put into your SSA reimbursement like both people and technology?
Cheryl: Well, we have had, I would say on the technology side, a game changer over ten years ago, and that is using the Morrow Ticket Tracker system. This system significantly improved not only our efficiency, but the number of claims we were able to successfully process. And for those of you who don't know, it's called the Vocational Rehabilitation Ticket to Work Reimbursement Tracker Program or Tracker. What it does is it tracks and processes traditional reimbursements and ticket to work payments. What the system does. For us as it collects data from our agency case management system. It connects that with external data, which is still internal to us in our agency, which is unemployment insurance, wage records, state verification and exchange information, other types of information. And what it does is it identifies cases that may be ready to be submitted as a claim, may be ready to be submitted as a claim is really important because that's where the other resource we have comes in that is so incredibly valuable to us. We have two dedicated staff in our finance division at the DSA level, and this is all these two staff. Do they use the systems that we have, including Ticket Tracker? They identify claims that may be eligible for us to submit for reimbursement and then they go over those claims with a fine tooth comb because they know the top reasons why a claim may be denied. And, so just because it pops up in that system doesn't mean you just send it in. You go over it with a fine tooth comb, and then they submit it for reimbursement, and then they follow through and then they double check payments when we receive them. And if they think we received a low payment and we can make a case for more of a reimbursement, they submit that for consideration, the level of rigor that these two staff apply to this process is why we have such a low denial rate and why we're able to be so successful. So I call them our secret sauce. They are fantastic. They also coach our counselors in how to help a customer with a ticket assignment. And so what to do with the ticket assignment? Our counselors can reach out to them for help. They're sleuths. They'll look at possible match and say, Wait a minute, I think this date of birth or season, we might need to make a correction here. And so they'll identify that and work with our staff, if necessary, to make data corrections. They are just incredible. And the combination of those two things has helped us be quite successful in submitting claims and receiving those reimbursements.
Carol: I'm really glad you mentioned both of those because I remember going to a conference, I think it was like in 2013 and there were poster sessions up and they had the moral ticket tracker and I'm going, What is this? Because we were doing this old pencil paper, we were getting maybe 400,000 a year or something. And once we got the tracker in, it was not a huge investment. I was super surprised it was a low dollar amount. We never went under $1,000,000 after that. We were a small agency. I'm like, What is happening was amazing, but I think you're right. Having a secret source like you had your two women that were your secret source. So I had Courtney. She was our secret. She was amazing at that. You know, I think you have to dedicate some resource. And I know there are definitely some agencies struggling right now, and I know there are a number of folks that are not actually submitting for reimbursement right now. They just haven't been able to land and figure that out. But those are two important pieces to the equation.
Cheryl: Very important and sharing. And I would tell you that because I asked them in preparing for this podcast, I talked to them and I said, Sherri and Annie, what would you recommend? And they said, Well, first ticket tracker.
Cheryl: And second, check every claim go through every detail of the fine tooth comb.
Carol: Got it. Good advice. That is good. Yes. So I know you've had some recent struggles with your SSA reimbursement and I understood some of the rules changed. You had some things that well, the rules change and it's impacted the amount of the recovery that you've been able to get. So can you talk a little more about that?
Cheryl: I can talk a little bit about it, and then I will make sure not to get out of my depth, because I did talk to Sherri and Annie about this extensively and it reminded me all over again why they're experts and why I'm doing what I'm doing. And so what I would say, kind of overall, as with any program rules, over time, SSA makes adjustments to submission, how we submit what is accepted. And so it's very important that we as well as all the other agencies that are participating in this program, stay on top of those changes and understand that our sister agencies at the federal level will also be making adjustments, and some of those may take some time for them and us. And in the meanwhile, that affects the rate at which you may be getting your claims paid. It may affect whether you're getting your claims paid. And one of the things that specifically has changed over time is what is accepted is proof of employment, particularly when somebody is working in another state. Right. So what used to be accepted is verification of that is no longer. And so we used to be able to show the information collected in our case management system as a valid submission for reimbursement. Now we need something more rigorous. And so we're working through how we connect with our Swiss data, because otherwise we would continue to lose valuable reimbursements for people working in other states, like a pharmacist in California. They could see it, but we needed that proof so that that claim could be paid. And. So it's really being and VR professionals are fantastic at this, but it's being on top of changes and being flexible to deal with them and really trying to work in partnership with our federal agencies to make sure we're all understanding what is required and doing our best to achieve that.
Carol: You might have to drive out to California and take a picture of that pharmacist, if that would be allowed.
Cheryl: I know, I know. I thought, man, what a fantastic outcome for VR, though, right?
Carol: Absolutely. That is incredible. Oh, gosh. I knew those changes had happened, but it was after I left, so I wasn't sure the nuances. So that makes some sense to me. Definitely. So I know you also had something really unique happen with your legislature and your SSA reimbursement, so tell us a little about that.
Cheryl: Well, in 2016, September 1st of 2016, our legacy agency, the Department of Assistive and Rehabilitative Services, was abolished, and the programs in our legacy agency were transferred by the legislature, either to the Texas Workforce Commission, which is where VR, older, blind, our Randolph Sheppard program, for example, all went. And then the other programs went to the Health and Human Services Commission that included our blind children's program. Our program for those that have traumatic brain or spinal cord injury, are deaf and hard of hearing services that we had, as well as independent living. So independent living part B, part C that went to Health and Human Services and they became the designated state entity for those programs. What we had done historically, though, at our legacy agency is that we had used our program income to expand and enhance our independent living services programs, including older lines. It was just an incredible value to us at our legacy agency that those dollars, because you can use your program income to support other programs funded by the Rehabilitation Act, that those dollars could really strengthen important programs in independent living. And so when we transferred to TWC from DAAS, the Legislature appropriated some of our program income back to the Health and Human Services Commission for continued support for those independent living services programs. That's really important because as we have changes in agency structure, we want to maintain the quality of service that we're providing to our customers, whether they're VR, old or blind, independent living, whatever the case may be. And this is not something that VR agencies may be accustomed to. We know you cannot appropriate vocational rehabilitation grant funds outside of the agency. Right. The VR agency. But with program income, the statute says the state. And so the legislature may appropriate that outside of the agency and did so, $8.5 million per year is appropriated in our appropriations bill pattern to the Health and Human Services Commission to provide continued support to those independent living services programs.
Carol: So how does that relate then to how much you get in program income? Wow.
Cheryl: We collect about $20 Million a year in program income. We have had years where it was higher significantly. So I think our highest year was 33 million. Wow. Sometimes that has to do with when claims are paid versus when you submit the claim. But we can look at about $20 Million a year. So it represents a significant part of our program income and it's also the largest method of finance for those independent living programs back at our sister agency.
Carol: That's pretty incredible. It's kind of it's a little scary to think that they designated a dollar amount versus saying we're going to take 20% or we're going to take a percentage, which would make it a little easier. As there's fluctuations, you're not held to that particular threshold.
Cheryl: Certainly that's something we keep our eye on. And I'm sure that our policymakers and appropriators were concerned about keeping the programs whole. So I understand why they would have been concerned to make sure our independent living programs remain strong and healthy. But we certainly do watch that pretty carefully.
Carol: Oh, I'm sure, absolutely. So I know you're also looking at doing some good stuff moving forward and expanding your older individuals who are blind program with the SSA dollars. So what are you thinking about with that?
Cheryl: Well, I have a lot of favorites. The older blind program is one of my favorites. It is such a gem of a program when we think about I think the number is one in six adults age 65 and over will experience some type of age related macular degeneration. And you think about the growing population in our state and the fact that that grant is a really small grant that stayed small for a long time. We and our stakeholders just want very much to serve more. We want to serve more. Seniors who are learning to live with less vision, experiencing that vision loss, and we want to provide more services for them. And one of the ways we can do that is looking at our program income, say, can we invest some of this program income in expanding this program? And we took a little step to do that last year to see how it's going. We added a few staff and we were able to increase our client services a little bit. And now we want to really move in the direction to maximizing that program income to expand that program, not only to add staff. Because in the state this size, our OIC grants was a little over 2 million, maybe 2.2 million a year and by the time we add our match funds, we're at about 2.5 million. That's very small for the population that could really benefit from these services. And so we would like to add more staff across the state so that we're present in more communities and there's not so much windshield time for our staff. But also we'd like to really enhance some of the services that we provide, including offering a one week residential program similar to what we might see in our Chris Cole Rehabilitation Center that's focused on VR. How could we have a one week residential program where a seniors could come and really get support and encouragement from other seniors experiencing vision loss and learn some of those skills where they can just focus on learning those skills in a group and in a supportive cohort and making friends and kind of working through some of the fear associated with vision loss and really gaining their confidence. We also want to do that on a daily basis. So if somebody doesn't want to go away for a week, they could go into a center in a day program. So we want to start working toward those kind of activities to really enhance the services as well as serving more people.
Carol: I love that. Well, the OIB program is near and dear to my heart, Too.
Cheryl: I just love that.
Carol: That was one of my places when stuff was all kind of going crazy. I'd go down and talk with the staff from there. I loved it and the stories they'd have, and I'd get these little sweet letters from some of the individuals that we helped to assist. It was lovely. I just think the work done there has been so important for quality of life for people in your later years. You know, yeah, I'm thinking about you with your $2 million. And I mean, my grant was like a half a million dollars. And we're in little, tiny Minnesota with 6 million people. And you've got 30 million people. Yeah, proportionately, it doesn't seem like a lot, but I think you're on the right track with that. We had a lot of success in doing group training with the seniors and like you say, developing that cohort and people to support each other. It really does work well. So I hope you have great success with that.
Cheryl: I hope so. It's such a fantastic program. My granddaddy was legally blind from a very young age and his sight got worse as he got older. And I just think about all the things if he had had access to a program like this, that could have made it easier for him.
Carol: Yep. I had a grandma. I had a grandma too. She lived in 98 with macular degeneration. I remember visiting her one day, went to her house and knocking on doors. She lived over in North Dakota. She's about 10 hours away, but she didn't know who I was, you know, because she couldn't see me. And so I'm talking to her for a long time that it took her while she's like, oh, you know, before she let me in the door, because, like, what's this strange lady doing at my door? Yes, but it would have been so great if I would have had one of our staff could have gone out and helped her and her house and all the bump dots and getting things situated for it would have made it so much easier. I completely understand. Absolutely.
Cheryl: That's what I think about.
Carol: Well, that's the beauty with that program income where you're able to help invest in a program like that. It really is important. Now, I know some other of your agencies are really struggling. They're not submitting their claims for reimbursement. They're not really putting this on the priority list. So what kind of what advice would you give to our listeners about SSA reimbursement if they're sitting back kind of going, wow, we haven't paid this much attention right now and we're doing other things. What advice would you give to them?
Cheryl: Well, first, I have all the sympathy in the world for our sister agencies. I don't know of one agency that doesn't have a full to overflowing plate. And we're all trying to figure out how we can improve our services, how we can be continuously improving, how we can adapt to the environment around us, which is changing so significantly just due to COVID. So, boy, I know we all have a lot on our plates, but this source of income for us is allowing us to expand a program that is really underfunded for the size of a state. We have just the incredible difference it can make in the lives of people who may have had their sight for years and years. And now they're losing it and they're scared to death and we can be there to help. And that's just one way we can think about using our program in. So I would encourage agencies that may not have tackled this yet or may have struggled with it in the past to just think through it, think through what the opportunity is, how much you might be leaving on the table, what you could do with those dollars. And there's help out there to figure out what you're doing if you need some systems. There are systems out there. The ticket tracker is a great system. There are people out there that can provide support and help you as you develop dedicated staff. But I would make sure if you want to jump in and I encourage you to get the system you need and get the people who make it a priority because it is what they do and you will benefit and you will be able to do with those programming dollars some innovative things to support your programs, whether it's VR or older, blind or independent living.
Carol: Well said. And I believe VR still has a cost reimbursement group. So they always had a little a group that got together and they do some specific training. I remember sending Courtney and other people out to that training and they developed quite a cohort themselves of folks to rely on. I remember her calling Virginia people, you know, different folks that she got to meet through the training. And so definitely that can be a resource as well.
Cheryl: That's the great thing about the VR world. I've learned so much from other states, from you, from some of my colleagues in other states. We are there for each other. CSAVR and NASAB are great avenues to pursue to make sure your staff are connected to other people who do that work and can support them.
Carol: Yeah, I love that. I love that. So I cannot leave this episode though, without asking you about your upcoming presidency on July 1st. It's CSA VR. So I just wondered, what are you hoping to accomplish next year? Do you have any things that you want to tackle?
Cheryl: Well, first of all, it's a big job and there have been some fantastic people in this role over the years. And so my goal would really be to continue the conversation that we began at CSA VR a couple of years ago and that we're having with each other as VR agencies at the association level offline and also with our federal partner. And that is how can we understanding the trends that are affecting the VR program nationally? And by that I mean fewer people applying, fewer people being determined eligible, fewer people achieving employment outcomes. How can we work together to understand what's driving those trends and to be innovative and collaborative as a system, as a national program about how we can address those trends. And I'm excited about the opportunity we have as an association to add value to the member agencies, because we're all working on some of these things. We're all working on recruiting and retaining staff because if you don't recruit and retain staff, you don't have people to serve your customers and making sure they're prepared and trained well so that you can serve your customers with the level of expertise that we all want to have at the table for the benefit of our customers. We're all looking at what we need to do to improve our processes. Our processes need to evolve just as all processes in businesses around the country. So how is the VR process evolving to meet the needs and expectations of the customers in 2022? And we're all working how we can be visible to our communities, be available, make sure they know we're here. How can we be doing outreach and communicating about the difference our program makes? These are things we can all work on together, and I think that CSA VR in partnership with CSA B and collaborating across states can really add some value to that conversation and support all of us out here in the States who are working hard to make our programs the best that they can be.
Carol: I love that. I look forward to following you this next year. It's going to be super fun, super fun to watch. So thanks for joining me, Cheryl. I know you're super busy and I really appreciate your time. I hope you have a great day.
Cheryl: Thank you, Carol. Thanks so much for having me.
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