Presentation on theme: "California State Disability Insurance for Health Care Providers"— Presentation transcript:
1California State Disability Insurance for Health Care Providers IntroductionThank you for having us hereGeneral 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 claimsRefer to packet and EVALUATIONS!2010
2State Disability Insurance-What is it? State Disability Insurance (SDI) is short-term, partial wage-replacement insurance plan for California workers currently in the labor marketSDI encompasses and provides coverage for two programs:Disability Insurance provides partial wage replacement benefits for up to 52 weeks per claimPaid 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 ServicesDisability Insurance (only) was added to CA Unemployment Insurance Code for non-industrial disabilities in 1946Paid Family Leave was added to the law in 2002
3State Disability Insurance SDI covers approximately 13 million California workers, and is funded through State-mandated payroll deductionsProvides partial wage replacement = approximately 55% of income for workers currently in the labor marketDOES NOT provide entitlement to leave, nor job security while on leave, as do the Family and Medical Leave Act and California Family Rights ActFunded by employees (unlike Workers Comp)Exemptions:Self-employed, Independent Contractors and Non-profit employeesMost public school entities, some municipalities, some domestic workers and some government employees are exemptPublic Government workers are not required to pay into SDI, but can elect to do soNon-profit employees, self-employed, independent contractorsIndividuals claiming religious exemptionsFunded through State-mandated payroll deductions2009 withholding rate of 1.1%2009 taxable wage limit = $90,6692009 max. yearly employee contribution =$997.35Earnings 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.
4State Disability Insurance There is a 7 day waiting period for both DI and PFL claimsClaims are payable starting on the 8th dayWithin 14 days of receiving the completed claim, SDI will make an eligibility determinationClaimants must file a timely claim, within 48 days after the first day the disability beganEmployees are eligible to apply without regard to length of employment with current employer7 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
5State Disability Insurance Data State Fiscal Year 2009/2010DIPFLTotal claims filed729,860190,743Average weekly benefit amount$448$488Total benefits authorized$4,615,628,827$474,589,252On average, we issue over $12 million dollars daily in DI benefits alone.WEEKLY BENEFITS RANGE FROM $50-987/WEEK
6Disability Insurance What is it? Disability Insurance (DI) is a component of SDI and provides up to 52 weeks worth of benefits per claimIt is a benefit for employees who cannot work due to a non-work related illness or injuryConditions may include: elective surgery, alcoholism, drug addiction, pregnancy, childbirth, or other related conditions
7Disability 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 workImpairmentAn impairment is a condition which renders people less than 100% healthy or whole. This does not necessarily constitute a disabilityWe 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
8Eligibility for DI To be eligible for DI, Employees must be: Unable to perform their regular and customary workUnder the care of a health care provider or a religious practitionerIn the labor market at the time the disability beganDocumentation and certification is required from the treating physician or practitionerEmployee must have qualifying wages in the base period
9Paid Family LeavePaid Family Leave (PFL) is a component of SDI and applies to everyone covered by SDIProvides up to 6 weeks worth of benefits within a rolling 12-monthsPFL has two basic claim types: Bonding and CaregivingPaid at the same rate as DIPFL, 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 LeaveJanuary 1, 2004 = Payroll deductions beganJuly 1, 2004 = Benefits beganEmployee Funded. No employer contributionReminder: PFL benefits are payable at the same rate as DI benefits using the same base period concept
10Two basic PFL claim types BondingRequires written proof of a new child such as birth certificate, adoption papers, or foster care placement documentMust be claimed within 12 months of the child entering into the familyChild must be under 18 years oldNew fathers may applyIn state fiscal year 08/09, approx. 88.8% of all PFL claims were “bonding claims”.Bonding claims do not require Medical CertificationAs 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)
11Two basic PFL claim types CareTo care for a seriously ill spouse, registered domestic partner, parent, or childRequires the Care Recipient’s Health Care Provider to certify to the serious illness/injury and a need for careRequires the signature of person receiving care or his/her authorized representativeIn 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
12How Disability Insurance differs from Paid Family Leave Up to 52 weeks worth of benefits per claimUp to 6 weeks worth of benefits per rolling 12-monthsBenefits are for employee’s illness, injury, or disabilityCaring for a seriously ill family member or to bond with a new childEmployers can not require employees to use vacation benefitsEmployers May require employees to use up to two weeks of their unused vacationBenefits are not reportable to IRS (unless in lieu of Unemployment Insurance)Benefits are reportable to IRSDI & PFL benefits are not reportable to the State of Calif.
13SDI 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 ProvidersHealth Care Provider’s certification is a portion of the claim formDI 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.
14SDI Who can certify to a Disability? Health Care ProvidersPhysician (must be licensed)ChiropractorPodiatristOptometristDentistPsychologistLicensed midwife, certified nurse midwife, or nurse practitionerWe 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 physiciansWhen 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 practiceAny post-partum conditions must be certified by the Physician or a psychologist or psychiatrist
15SDI Who can certify to a Disability? OthersAuthorized medical officer of a U.S. Government facilityRegistrar of California County HospitalAccredited religious practitioner
16Go 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.
17General 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.
18The 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.
19The Doctor’s Certificate The Doctor’s Certificate is the third page only.
20Identifying 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 DoughJohn L. Seagle A1234512345 Main Street, # 678, Your Town, CA
21Dates 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.XX
22Supracondylar fracture of RT femur, open Codes and Diagnosis (or Detailed List of Symptoms if a Diagnosis Has Not Yet Been Determined) and FindingsWe 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 1Supracondylar fracture of RT femur, openComplicated by laceration of popliteal artery, post-op infection, cellulitis leg
23Type 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/ProcedureThe type of treatment, hospital dates, and procedures also allow us to manager duration more effectively. Again, the more information the better.Antibiotics, physical therapyJun 1 & 4 ‘09 ORIF, repair of arterial laceration
24If 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 ClaimsIf your patient is filing a claim due to pregnancy, we need the expected date of delivery as well as any information about complications.
25X 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 InformationWorkers 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 DiseasesAlcohol Recovery Homes and Drug-Free Residential FacilitiesDisclosure of Information to PatientThese 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.XXX
26Medical Doctor Orthopedic California Your Practice and Specialty, the State in Which You Are Licensed, Your Original Signature, and Date SignedThe 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 CaliforniaThe 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
27Extending 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
28Extending 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 numberDiagnosis and ICD codeStatement that the patient is disabledEstimated recovery dateYour signature, license number, and date
29The 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.
30The 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
31The 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 hJ a y n e N D o u g h
32Whether 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)XJ a y n e N D o u g hWe 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 nE
33Dates 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
34This 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 RecipientThis 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 81 8C 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 nX
35Your 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.AJ O H N L S E A G L EM a i n S t , # 6 7 8Y o u r T o w n CAM. D O r t h o p e d i cHere 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
36Extending 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.
37Extending 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 numberDiagnosis and ICD codeStatement that the patient still hasn’t recovered, and still needs a caregiverEstimated date that the caregiver will no longer be neededYour signature, license number, and date
38Duration 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,
39Duration ManagementPatient 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.
40Legal 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.
41Legal 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.
42Legal 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.
43Please complete and turn in the Evaluation forms.