CaliforniaState Disability Insurance for Health Care Providers

2010

State Disability Insurance-What is it?

o State Disability Insurance (SDI) is short-term, partial wage-replacement insurance plan for California workers currently in the labor market

o 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)

State Disability Insurance

o SDI covers approximately 13 million California workers, and is funded through State-mandated payroll deductions

o Provides partial wage replacement = approximately 55% of income for workers currently in the labor market

o 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

o There is a 7 day waiting period for both DI and PFL claims

o Claims are payable starting on the 8th dayo Within 14 days of receiving the completed claim,

SDI will make an eligibility determinationo Claimants must file a timely claim, within 48

days after the first day the disability began o Employees are eligible to apply without regard to

length of employment with current employer

State Disability Insurance

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

o Disability Insurance (DI) is a component of SDI and provides up to 52 weeks worth of benefits per claim

o It is a benefit for employees who cannot work due to a non-work related illness or injury

o Conditions may include: elective surgery, alcoholism, drug addiction, pregnancy, childbirth, or other related conditions

Disability Insurance What is it?

o DisabilityAccording 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

o ImpairmentAn impairment is a condition which renders people less than 100% healthy or whole. This does not necessarily constitute a disability

Disability vs. Impairment

To be eligible for DI, Employees must be: o Unable to perform their regular and customary

worko Under the care of a health care provider or a

religious practitionero In the labor market at the time the disability

begano Documentation and certification is required from

the treating physician or practitionero Employee must have qualifying wages in the

base period

Eligibility for DI

o Paid Family Leave (PFL) is a component of SDI and applies to everyone covered by SDI

o Provides up to 6 weeks worth of benefits within a rolling 12-months

o PFL has two basic claim types: Bonding and Caregiving

o Paid at the same rate as DI

Paid Family Leave

Bondingo Requires written proof of a new child such as

birth certificate, adoption papers, or foster care placement document

o Must be claimed within 12 months of the child entering into the family

o Child must be under 18 years old

o New fathers may apply

Two basic PFL claim types

Careo To care for a seriously ill spouse, registered

domestic partner, parent, or child

o Requires the Care Recipient’s Health Care Provider to certify to the serious illness/injury and a need for care

o Requires the signature of person receiving care or his/her authorized representative

Two basic PFL claim types

How Disability Insurance differs from Paid Family Leave

Disability Insurance Paid Family LeaveUp 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

SDI Claim Forms

o There are specific claim forms for DI and PFL

o Claimants may obtain claim forms from SDI field offices, via the EDD website, or from their Health Care Providers

o Health Care Provider’s certification is a portion of the claim form

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

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

Go to www.edd.ca.gov/ for more information about State Disability Insurance

General SDI Questions?

The Claim for Disability Insurance Benefits

The Doctor’s Certificate

001 555 12 1234 Jayne Dough

Identifying Information

John L. Seagle 530 555 1212 A12345

12345 Main Street, # 678, Your Town, CA 91234

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.

06 01 09 06 12 09 X

X

Dates of Care, and Dates of Disability

06 01 09 12 21 09

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.

821 23 682 6 904 41 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.

Type of Treatment, Hospitalization, Surgery/Procedure

Antibiotics, physical therapy

Jun 1 & 4 ‘09 ORIF, repair of arterial laceration

06 01 09 06 14 09

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.

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.

Industrial Accidents and Occupational Diseases

X X X

Alcohol Recovery Homes and Drug-Free Residential Facilities

Disclosure of Information to Patient

Additional InformationFor 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.

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.

•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

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

Extending the Recovery Date

The Claim for Paid Family Leave

The Doctor’s Certificate

Required Only for ‘Care’ Claims

9 9 9 9 9 9 9 9 9 J o h n N D o u g h

The Claimant’s Information and Your Patient, the Care Recipient’s Information

0 7 0 4 1 9 7 6

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.

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

8 2 1 2 3 6 8 2 6 9 0 4 4 1 E 8 8 4 1

0 7 0 4 1 9 7 6

J a y n e N D o u g h

X

Dates Related to Recovery and Care

8 2 1 2 3 6 8 2 6 9 0 4 4 1 E 8 8 4 1 0 6 0 1 2 0 0 9

0 6 0 1 2 0 0 9 1 2 2 1 2 0 0 9 0 8 3 1 2 0 0 9

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.

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

1 81 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.

A 1 2 3 4 5

J O H N L S E A G L E

1 2 3 4 5 M a i n S t , # 6 7 8

Y o u r T o w n CA 9 1 2 3 4

M. D. O r t h o p e d i c

5 3 0 5 5 5 1 2 1 2 0 6 1 5 2 0 0 9Jonathan 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.

•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

•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

Extending the Recovery Date

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

•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

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.

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.

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.

Legal Basis for Requesting IME’s