1. California State Disability Insurance for Health Care Providers
Introduction
Thank you for having us here
General Overview of State Disability Insurance - This presentation is not intended to make you an “Expert” on SDI, but instead give you general information on how the program works, and what your role as Health Care Provider means for SDI.
WIIFM? SDI claims relies heavily on the Health Care Provider’s Medical certification portion of the claims
Refer to packet and EVALUATIONS!
2010

2. State Disability Insurance-What is it?
State Disability Insurance (SDI) is short-term, partial wage-replacement insurance plan for California workers currently in the labor market
SDI encompasses and provides coverage for two programs:
Disability Insurance provides partial wage replacement benefits for up to 52 weeks per claim
Paid Family Leave provides partial wage replacement benefits for up to 6 weeks per claim (within a rolling 12-month period)
The Disability Insurance Branch is one of nine branches within EDD. Other branches include include Unemployment Insurance Branch, Tax and Workforce Services
Disability Insurance (only) was added to CA Unemployment Insurance Code for non-industrial disabilities in 1946
Paid Family Leave was added to the law in 2002

3. State Disability Insurance
SDI covers approximately 13 million California workers, and is funded through State-mandated payroll deductions
Provides partial wage replacement = approximately 55% of income for workers currently in the labor market
DOES NOT provide entitlement to leave, nor job security while on leave, as do the Family and Medical Leave Act and California Family Rights Act
Funded by employees (unlike Workers Comp)
Exemptions:
Self-employed, Independent Contractors and Non-profit employees
Most public school entities, some municipalities, some domestic workers and some government employees are exempt
Public Government workers are not required to pay into SDI, but can elect to do so
Non-profit employees, self-employed, independent contractors
Individuals claiming religious exemptions
Funded through State-mandated payroll deductions
2009 withholding rate of 1.1%
2009 taxable wage limit = $90,669
2009 max. yearly employee contribution =$997.35
Earnings above the taxable wage limit are not taxable (same concept as Social Security)
The contribution rate is announced every year for the following year, and can fluctuate.

4. State Disability Insurance
There is a 7 day waiting period for both DI and PFL claims
Claims are payable starting on the 8th day
Within 14 days of receiving the completed claim, SDI will make an eligibility determination
Claimants must file a timely claim, within 48 days after the first day the disability began
Employees are eligible to apply without regard to length of employment with current employer
7 day waiting period is UNPAID.
Determination = a completed claim meaning the medical documentation required is there – 14 days to process claim- issue payment, deny claim, etc. (this is in the UI code)
Claims are paid after the fact – in the past.
Good Cause Provisions

5. State Disability Insurance Data
State Fiscal Year 2009/2010 DI
PFL
Total claims filed
729,860
190,743
Average weekly benefit amount
$448
$488
Total benefits authorized
$4,615,628,827
$474,589,252
On average, we issue over $12 million dollars daily in DI benefits alone.
WEEKLY BENEFITS RANGE FROM $50-987/WEEK

6. Disability Insurance What is it?
Disability Insurance (DI) is a component of SDI and provides up to 52 weeks worth of benefits per claim
It is a benefit for employees who cannot work due to a non-work related illness or injury
Conditions may include: elective surgery, alcoholism, drug addiction, pregnancy, childbirth, or other related conditions

7. Disability vs. Impairment
According to the CA Unemployment Insurance Code, a disability is a physical or mental condition (sickness or injury) which renders people unable to perform their regular or customary work
Impairment
An impairment is a condition which renders people less than 100% healthy or whole. This does not necessarily constitute a disability
We need to recognize the difference between an impairment and a disability.
For example, a person who a receptionist looses hearing in one ear, but can use the other ear for the headset and answering the telephone. That is an impairment, not a disability, because the receptionist is still capable of doing his/her regular and customary work.
2nd example = Color Blindness

8. Eligibility for DI To be eligible for DI, Employees must be:
Unable to perform their regular and customary work
Under the care of a health care provider or a religious practitioner
In the labor market at the time the disability began
Documentation and certification is required from the treating physician or practitioner
Employee must have qualifying wages in the base period

9. Paid Family Leave
Paid Family Leave (PFL) is a component of SDI and applies to everyone covered by SDI
Provides up to 6 weeks worth of benefits within a rolling 12-months
PFL has two basic claim types: Bonding and Caregiving
Paid at the same rate as DI
PFL, originally known at the Family Temporary Disability Insurance program, took about 2 years to implement and began paying claims.
In 2002, Senate Bill 1661, created the Family Temporary Disability Insurance program to provide six weeks of benefits to workers (authored by Senator Sheila Kuehl)
In 2003, Senate Bill 727, was signed into law, provided clarifying and technical changes including referring to the program as Paid Family Leave
January 1, 2004 = Payroll deductions began
July 1, 2004 = Benefits began
Employee Funded. No employer contribution
Reminder: PFL benefits are payable at the same rate as DI benefits using the same base period concept

10. Two basic PFL claim types
Bonding
Requires written proof of a new child such as birth certificate, adoption papers, or foster care placement document
Must be claimed within 12 months of the child entering into the family
Child must be under 18 years old
New fathers may apply
In state fiscal year 08/09, approx. 88.8% of all PFL claims were “bonding claims”.
Bonding claims do not require Medical Certification
As a Health Care Provider, you are not required to fill out a form, but we would like you to at least make your patients aware of the PFL program.
Mothers who are on DI may elect to receive PFL benefits for bonding. They do not have to serve a second 7 day waiting period. (Considered same claim)

11. Two basic PFL claim types
Care
To care for a seriously ill spouse, registered domestic partner, parent, or child
Requires the Care Recipient’s Health Care Provider to certify to the serious illness/injury and a need for care
Requires the signature of person receiving care or his/her authorized representative
In state fiscal year 08/09, approximately 11.2% of all PFL claims were “care claims”.
Claimant must go to the Care Recipient's doctor, not their own doctor for the certificate

12. How Disability Insurance differs from Paid Family Leave
Up to 52 weeks worth of benefits per claim
Up to 6 weeks worth of benefits per rolling 12-months
Benefits are for employee’s illness, injury, or disability
Caring for a seriously ill family member or to bond with a new child
Employers can not require employees to use vacation benefits
Employers May require employees to use up to two weeks of their unused vacation
Benefits are not reportable to IRS (unless in lieu of Unemployment Insurance)
Benefits are reportable to IRS
DI & PFL benefits are not reportable to the State of Calif.

13. SDI Claim Forms There are specific claim forms for DI and PFL
Claimants may obtain claim forms from SDI field offices, via the EDD website, or from their Health Care Providers
Health Care Provider’s certification is a portion of the claim form
DI and PFL claim forms are in the folders.
DI claim form can be downloaded and both claim forms can be mailed out to potential claimants. The PFL form is not available online.
Claim forms and other informational materials on SDI can be ordered via the EDD website. There is no charge for these materials.

14. SDI Who can certify to a Disability?
Health Care Providers
Physician (must be licensed)
Chiropractor
Podiatrist
Optometrist
Dentist
Psychologist
Licensed midwife, certified nurse midwife, or nurse practitioner
We are currently engaged in ongoing discussions with appropriate stakeholders to identify and address how the provisions of SB 819 interact with other statutes and regulations governing the SDI programs, and all policies, procedures and processes that could potentially be impacted as a result of these provisions.
Including allopathic and osteopathic physicians
When certifying to a disability the Health Care Provider must be certifying within the scope of their practice.
Physician Assistant’s work under a Physician’s license. They Can fill out the form, but the actual physician has to sign.
Licensed & Certified Mid-wives & Nurse Practitioners can only sign the claim form for normal pregnancies and child births. No complications before or after delivery, no c-sections. Those have to be signed by a Physician.
Signing Nurse Practitioners must also have to be within the scope of their practice
Any post-partum conditions must be certified by the Physician or a psychologist or psychiatrist

15. SDI Who can certify to a Disability?
Others
Authorized medical officer of a U.S. Government facility
Registrar of California County Hospital
Accredited religious practitioner

16. Go to www.edd.ca.gov/ for more information about State Disability Insurance
Claim Forms and other materials such as brochures can be ordered free of charge here. Also there is a section under Disability for Medical Providers.
Phone numbers in English, Spanish and other languages are also available online.

17. General SDI Questions?
Conclusion: As Health Care Providers you have an opportunity to share your knowledge about SDI with your patients. We encourage you to help make your patients more aware of DI and PFL in their time of need. It can really make a difference in the lives of your patients.
General Program Questions? Claim Form specifics will be discussed momentarily by the OMD Analyst.

18. The Claim for Disability Insurance Benefits
The Claim for Disability Benefits consists of four pages. You have one in your packets; it has a blue cover sheet.

19. The Doctor’s Certificate
The Doctor’s Certificate is the third page only.

20. Identifying Information
This top section identifies this as your patient’s claim form, and gives us your patient’s file number, and your contact information, in case it is needed.
It also allows us to verify your licensure, and serves as an additional identification check.
This top section identifies this as your patient’s claim form, and gives us your patient’s file number, and your contact information, in case it is needed.
It also allows us to verify your licensure, and serves as an additional identification check.
Jayne Dough
John L. Seagle A12345
12345 Main Street, # 678, Your Town, CA

21. Dates of Care, and Dates of Disability
This indicates the dates of care, as well as the beginning and ending dates of the disability period. The ending date can be shortened or extended depending on your patient’s progress.
This indicates the dates of care, as well as the beginning and ending dates of the disability period. The ending date can be shortened or extended depending on your patient’s progress. X X

22. Supracondylar fracture of RT femur, open
Codes and Diagnosis (or Detailed List of Symptoms if a Diagnosis Has Not Yet Been Determined) and Findings
We need to know the disabling condition and corresponding codes. The findings allow us to do a more efficient job of duration management, so the more information you include here, the better we can adjudicate the claim.
We need to know the disabling condition and corresponding codes. The findings allow us to do a more efficient job of duration management, so the more information you include here, the better.
If a diagnosis hasn’t yet been made, we need a detailed list of symptoms.
E884 1
Supracondylar fracture of RT femur, open
Complicated by laceration of popliteal artery, post-op infection, cellulitis leg

23. Type of Treatment, Hospitalization, Surgery/Procedure
The type of treatment, hospital dates, and procedures also allow us to manager duration more effectively. The more information we get, the better we can adjudicate the claim.
Type of Treatment, Hospitalization, Surgery/Procedure
The type of treatment, hospital dates, and procedures also allow us to manager duration more effectively. Again, the more information the better.
Antibiotics, physical therapy
Jun 1 & 4 ‘09 ORIF, repair of arterial laceration

24. If your patient is filing a claim due to pregnancy, we need the expected date of delivery as well as any information about complications.
For Pregnancy Claims
If your patient is filing a claim due to pregnancy, we need the expected date of delivery as well as any information about complications.

25. X X X Additional Information
For patients in residential facilities for drug and/or alcohol addiction, the eligibility requirements and benefits are a little different.
Regarding the disclosure of information to your patients, if you check ‘Yes’ or skip this answer, we will not discuss the medical aspects of this claim with your patients.
Additional Information
Workers Compensation benefits are generally in conflict with SDI so if you check ‘Yes’ or skip this answer, we have to clear this issue. This can delay benefits to your patient.
Industrial Accidents and Occupational Diseases
Alcohol Recovery Homes and Drug-Free Residential Facilities
Disclosure of Information to Patient
These three sections are important. The first deals with Workers Compensation claims; Work Comp benefits are in conflict with SDI so if this is checked ‘Yes’ or simply skipped, we have to clear this issue. This can delay benefits to your patient.
The second section deals with referring patients to residential facilities for drug and/or alcohol addiction. The eligibility requirements and benefits are a little different for these patients. They have to be residents in licensed AND certified facilities pursuant to your referrals, and can generally only get 90 days of benefits.
The last section deals with the disclosure of information to your patients; if you check Yes or skip this answer, we will not discuss the medical aspects of this claim with your patients. X X X

26. Medical Doctor Orthopedic California
Your Practice and Specialty, the State in Which You Are Licensed, Your Original Signature, and Date Signed
The claim form must be signed by the treating physician except as we previously discussed. When you indicate what kind of provider you are, your specialty, and the state in which you are licensed, it helps us verify that the claim form is coming from you, and can assist duration management.
Medical Doctor Orthopedic California
The claim form must be signed by the treating physician except as we previously discussed. When you indicate what kind of provider you are, your specialty, and the state in which you are licensed, it assists us again in making sure that the claim form is coming from you, and helps with duration management.
Jonathan L. Seagle June 15, 2009

27. Extending the Recovery Date
A supplemental medical form or extension request is usually sent to the patient by EDD when the estimated recovery date is reached.
If your patient is still disabled and unable to return to his/her regular or customary work, you need to certify to a continued disability.
Your patient must return the completed signed extension request within 20 days of the issue date

28. Extending the Recovery Date
It is not necessary to use the DI extension form as long as you provide the following on your letterhead:
Patient’s name and Social Security number
Diagnosis and ICD code
Statement that the patient is disabled
Estimated recovery date
Your signature, license number, and date

29. The Claim for Paid Family Leave
Similar to the Disability Claim, the claim for Paid Family Leave is also four pages. You have one in your packets, inside a yellow cover sheet.
The form is printed in red as this form is scanned into our computers. This scanning serves to both capture certain data, as well as present us with an electronic image of the document.
The data capture assists in processing the claim.; for example the claimant’s name and Social Security numbers are captured and entered into the computer automatically.

30. The Doctor’s Certificate
Also as with the Disability Claim form, your portion of the Paid Family Leave form is just one page.
Required Only for ‘Care’ Claims

31. The Claimant’s Information and Your Patient, the Care Recipient’s Information
This top section identifies the care-giver and your patient, the care recipient. Please note that the can be more than one care-giver – and so more than one PFL claim – at a time – for a particular care recipient.
This section shows the claimant – this is the person who will be giving care to your patient.
J o h n N D o u g h
J a y n e N D o u g h

32. Whether the Care Recipient Requires a Care Provider, and
Diagnosis (or Detailed List of symptoms if a Diagnosis Has Not Yet Been Determined), and Code(s) X
J a y n e N D o u g h
We need to know that the care is necessary, and we need the diagnosis and corresponding codes. Again, if there has been no diagnosis yet, we need a detailed list of symptoms.
S u p r a c o n d y l a r F X o f R t F em u r, O p e n E

33. Dates Related to Recovery and Care
This section gives us the date you anticipate the care recipient will recover, and how long you believe the care recipient will need the care-giver.
This section gives us the dates you anticipate your patient will be disabled, and how long you believe your patient will need the care-giver. E

34. This lets us know how many hours the care-giver will be needed each day, and allows some brief comments regarding these hours.
We need to know whether the disclosure of the medical information would be detrimental to the care recipient.
Daily Hours of Care, Comments, and Disclosure of Information to the Care Recipient
This lets us know how many hours the care-giver will be needed each day, and allows you to give us some brief comments regarding these hours.
Again, we need the information regarding the disclosure of medical information.
If more than 8 hours of care is needed daily, your patient could have more than one care giver.
If less than 8 hours care is needed, the benefits to the claim provider can be pro-rated downwards.
1 8
1 8
C a n n o t p e r f o r m A D L’ s , I n s e v e r e p a i n X

35. Your Practice and Specialty, the State in Which You Are Licensed, Your Original Signature, and Date Signed.
The claim form must be signed by the treating physician except as we previously discussed. When you indicate what kind of physician you are, your specialty, and the state in which you are licensed, it helps us verify that the claim form is coming from you, and can assist duration management. A
J O H N L S E A G L E
M a i n S t , # 6 7 8
Y o u r T o w n CA
M. D O r t h o p e d i c
Here you give us information so that we can verify your identity and licensure, as well as get contact information in case it’s necessary.
Jonathan L. Seagle

36. Extending the Recovery Date
A supplemental medical form or extension request is usually sent to the care provider by EDD when the estimated recovery date is reached.
If your patient has not yet recovered and is still in need of a care provider, you need to certify that recovery has not yet occurred and that care is still required.
Your patient must return the completed signed extension request within 20 days of the issue date.

37. Extending the Recovery Date
It is not necessary to use the PFL extension form as long as you provide the following on your letterhead:
Patient’s name and Social Security number
Diagnosis and ICD code
Statement that the patient still hasn’t recovered, and still needs a caregiver
Estimated date that the caregiver will no longer be needed
Your signature, license number, and date

38. Duration Management SDI relies on information provided by:
Health Care Providers including diagnosis(es), ICD codes, findings, treatments, comorbid conditions,
MDGuidelines, created by The Reed Group,

39. Duration Management
Patient Contact in person when they visit an office, by telephone or mail,
Health Care Provider Contact by telephone or mail,
Independent Medical Exam (IME)
Other sources as appropriate.

40. Legal Basis for Requesting IME’s
According to Title XXII, Section 2627( C ) – 1, these are the reasons for which we can require reasonable IME’s:
Medical information from a claimant’s physician does not conform with the guidelines established by the Medical Director regarding normal duration and the claimant’s physician doesn’t provide any objective medical findings to alter the expected duration.
Inadequate medical information to support the existence of a disability.

41. Legal Basis for Requesting IME’s
Conflicting medical information concerning the claimant’s disability is received.
Reports of the claimants’ activities conflict with reports on the claimant’s disability.
Additional medical evidence is requested to support a continued claim for disability benefits cannot be secured without an additional fee to the claimant.

42. Legal Basis for Requesting IME’s
Additional medical information is necessary to confirm that the claimant is disabled.
Please see Title XXII for the complete verbiage of this section.

43. Please complete and turn in
the Evaluation forms.

44. Any questions?

45. Thank You
Any questions?
Thank you.