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California State Disability Insurance for Health Care Providers 2010.

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Presentation on theme: "California State Disability Insurance for Health Care Providers 2010."— Presentation transcript:

1 California State Disability Insurance for Health Care Providers 2010

2 State Disability Insurance-What is it? oState Disability Insurance (SDI) is short-term, partial wage-replacement insurance plan for California workers currently in the labor market oSDI 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)

3 State Disability Insurance oSDI covers approximately 13 million California workers, and is funded through State-mandated payroll deductions oProvides partial wage replacement = approximately 55% of income for workers currently in the labor market oDOES NOT provide entitlement to leave, nor job security while on leave, as do the Family and Medical Leave Act and California Family Rights Act

4 oThere is a 7 day waiting period for both DI and PFL claims oClaims are payable starting on the 8 th day oWithin 14 days of receiving the completed claim, SDI will make an eligibility determination oClaimants must file a timely claim, within 48 days after the first day the disability began oEmployees are eligible to apply without regard to length of employment with current employer State Disability Insurance

5 State Disability Insurance Data State Fiscal Year 2009/2010 DIPFL Total claims filed 729,860190,743 Average weekly benefit amount $448$488 Total benefits authorized $4,615,628,827$474,589,252

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

7 oDisability 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 oImpairment An impairment is a condition which renders people less than 100% healthy or whole. This does not necessarily constitute a disability Disability vs. Impairment

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

9 oPaid Family Leave (PFL) is a component of SDI and applies to everyone covered by SDI oProvides up to 6 weeks worth of benefits within a rolling 12-months oPFL has two basic claim types: Bonding and Caregiving oPaid at the same rate as DI Paid Family Leave

10 Bonding oRequires written proof of a new child such as birth certificate, adoption papers, or foster care placement document oMust be claimed within 12 months of the child entering into the family oChild must be under 18 years old oNew fathers may apply Two basic PFL claim types

11 Care oTo care for a seriously ill spouse, registered domestic partner, parent, or child oRequires the Care Recipients Health Care Provider to certify to the serious illness/injury and a need for care oRequires the signature of person receiving care or his/her authorized representative Two basic PFL claim types

12 How Disability Insurance differs from Paid Family Leave Disability InsurancePaid 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 employees 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

13 SDI Claim Forms oThere are specific claim forms for DI and PFL oClaimants may obtain claim forms from SDI field offices, via the EDD website, or from their Health Care Providers oHealth Care Providers certification is a portion of the claim form

14 SDI Who can certify to a Disability? Physician (must be licensed) Chiropractor Podiatrist Optometrist Dentist Psychologist Licensed midwife, certified nurse midwife, or nurse practitioner Health Care Providers

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

16 Go to for more information about State Disability Insurance

17 General SDI Questions?

18 The Claim for Disability Insurance Benefits

19 The Doctors Certificate

20 Jayne Dough Identifying Information John L. Seagle A Main Street, # 678, Your Town, CA This top section identifies this as your patients claim form, and gives us your patients 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.

21 X X 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 patients progress.

22 E884 1 Supracondylar fracture of RT femur, open Codes and Diagnosis (or Detailed List of Symptoms if a Diagnosis Has Not Yet Been Determined) and Findings Complicated by laceration of popliteal artery, post-op infection, cellulitis leg 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.

23 Type of Treatment, Hospitalization, Surgery/Procedure Antibiotics, physical therapy Jun 1 & 4 09 ORIF, repair of arterial laceration 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.

24 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 Industrial Accidents and Occupational Diseases XXX Alcohol Recovery Homes and Drug-Free Residential Facilities Disclosure of Information to Patient 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. 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.

26 Jonathan L. Seagle June 15, 2009 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.

27 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 Extending the Recovery Date

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

29 The Claim for Paid Family Leave

30 The Doctors Certificate Required Only for Care Claims

31 J o h n N D o u g h The Claimants Information and Your Patient, the Care Recipients Information J a y n e N D o u g h 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.

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) 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 J a y n e N D o u g h X

33 Dates Related to Recovery and Care E 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.

34 Daily Hours of Care, Comments, and Disclosure of Information to the Care Recipient 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 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.

35 A J O H N L S E A G L E M a i n S t, # Y o u r T o w n CA M. D. O r t h o p e d i c Jonathan L. Seagle 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.

36 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. Extending the Recovery Date

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

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

39 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. Duration Management

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

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

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

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