CMS recognizes that work is a fundamental part of adult life for people with and without disabilities. It provides a sense of purpose, shaping who we are and how we fit into our community. Work has also been associated with positive physical and mental health benefits; meaningful work is also part of building a healthy lifestyle as a contributing member of society. Because it is so essential to people's economic self sufficiency, as well as self esteem and well being, people with disabilities and older adults with chronic conditions who want to work should be provided the opportunity and support to work competitively within the general workforce in their pursuit of health, wealth and happiness. All individuals, regardless of disability and age, can work — and work optimally with opportunity, training, and support that build on each person's strengths and interests. Individually tailored and preference based job development, training, and support should recognize each person's employability and potential contributions to the labor market.

In conjunction with the administration's initiative to promote The American with Disabilities Act, the Centers for Medicare & Medicaid Services (CMS) is committed to providing  program supports that enable individuals with disabling conditions to live and work in the community. People with disabilities living in the community, who are working, or want to work, need the supports and services to ensure that they have the chance to fulfill their potential and contribute to our nation. In response, CMS has developed policies and implemented a number of initiatives to help increase employment across America for those who are disabled.

CMS supports the competitive employment of workers with disabilities by providing Medicaid services to eligible individuals, that enable workers with disabilities to gain and maintain employment. Optional Medicaid eligibility groups, such as the Medicaid Buy-In, allow workers with disabilities to have higher earnings and maintain their Medicaid coverage. As of December 31, 2010, more than 150,000 individuals in 42 States were covered under this new eligibility group.

Additionally, CMS also administers the Medicaid Infrastructure Grant (MIG) program authorized by the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA). Finally, there are Medicaid services that enable employment such as Personal Assistance Services, Supported Employment, and Peer Support Services. These programs and services are briefly described below.

Ticket to Work and Work Incentives Improvement Act

1. Medicaid Buy-In. Section 201 of TWWIIA governs the provision of health care services to workers with severe disabilities by establishing a Medicaid state plan buy-in optional eligibility groups. In addition, the Balanced Budget Act of 1997 (BBA) created a separate optional Medicaid eligibility group for working individuals with disabilities. Currently, 42 States provide Medicaid eligibility through the TWWIIAA Buy-in, the BBA Buy-in, or a Section 1115 waiver.
2. Medicaid Infrastructure Grants (MIG). Section 203 of TWWIIAA provides grants to States to develop state infrastructures to support working individuals with disabilities. For eligibility under this grant program, a State must offer personal assistance services statewide within and outside the home to the extent necessary to enable an individual to be engaged in full-time competitive employment. As of 2011, 42 States and the District of Columbia are participating in this program.
3. Demonstration to Maintain Independence and Employment. This demonstration, funded under TWWIIA, was designed to test the hypothesis that, by providing health care and other services early in the progression of a disease may, delay the loss of a person's ability to be self-sufficient and the onset of cash assistance. The DMIE grant program enabled States to provide the full Medicaid benefits package to those who are not disabled (according to the SSA definition of disability) but who had a potential disabling condition and or significant medical impairment. Demonstration participants included those who had a specific physical or mental impairment that, in absence of the provision of Medicaid or Medicaid-like services, could reasonably be expected to lead to a disability. The demonstration will measure the effect of providing this early intervention and the ability of demonstration participants to retain competitive employment. This demonstration ended in September, 2009

Medicaid Services that Support Employment

1. Personal Assistance Services. Personal Assistance services are a range of services, provided by one or more persons, designed to assist an individual with a disability to perform daily activities on and off the job that the individual would typically perform if the individual did not have a disability. Such services shall be designed to increase the individual's control in life and the individual's ability to perform activities on and off the job. [Ticket to Work and Work Incentives Improvement Act of 1999, Pub. L. No. 106-170, § 203 (b)(2)(B)(ii)].
2. Supported Employment. Supported employment is assistance in obtaining and keeping competitive employment in an integrated setting. CMS sponsored a Promising Practices in Home and Community Based Services Issue Brief on Supported Employment.
3. Peer Support Services. Peer support providers are a distinct provider type for the delivery of counseling and other support services to Medicaid eligible adults with mental illnesses and/or substance use disorders. CMS recognizes that the experiences of peer support providers, as consumers of behavioral health care services, can be an important component in a State's delivery of effective treatment. CMS issued guidance about peer support services in the State Medicaid Directors Letter #07-011, dated August 15, 2007
4. Other Medicaid Services. Medicaid also provides other medical services that are essential to treating a condition or illness and enabling individuals to work in the community. These can include clinic services, rehabilitation, pharmaceutical, and other medical benefits that some individuals require in order to obtain or maintain employment.

CMS also conducts research to identify factors that contribute to a person's ability to work or maintain employment. Data from individuals returning to work under the Medicaid by-in, mentioned above, is used to develop policies and programs that support employment.

Employment and HCBS

States can provide specific employment supports to individuals through Home and Community Based Services (HCBS) under Section 1915(c) waivers or Section 1915(i) State-plan services. 1915(c) waivers provide long-term care for individuals who would receive institutional care without a waiver. 1915(i) services provide HCBS to individuals who meet a State-defined criteria.

Services available through HCBS are more comprehensive than those available in standard Medicaid benefits packages. HCBS services provide States with the opportunity to offer services that specifically support an employment goal or outcome, through what are called habilitation services. Habilitation services are covered as part of HCBS in both 1915(c) and 1915(i) benefits. Supported employment services may be furnished as an expanded habilitation service under the provisions of §1915(c)(5)(C) of the Act. It may be offered to any target group for whom the provision of these services would be beneficial in helping them to realize their goals of obtaining and maintaining integrated community employment.

CMS defines habilitation as "services designed to assist participants in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings." Habilitation services are flexible in nature, and can be specifically designed to fund services and supports that assist an individual to obtain or maintain employment. It is important, however, to note that employment services available to an individual through other programs, such as Vocational Rehabilitation, cannot be provided through Medicaid.

Self directed service delivery models can also be used to provide employment supports. In a self-directed model, individuals may hire their own job coaches and employment support staff, rather than relying exclusively on agency based staffing models. This may be particularly useful as individuals seek to expand the pool of people who can provide employment supports and services to include friends, family members, co-workers and other community members that do not view themselves as part of the traditional Medicaid agency based employment supports workforce.