OhioBWC - Basics: (Policy library) - File

Living Maintenance

Policy Name:

Living Maintenance Compensation

Policy #:

CP-12-03

Code/Rule Reference:

R.C. 4121.63; R.C. 4123.57(B); O.A.C 4123-18-04; O.A.C. 4123-18-05(E)

Effective Date:

02/04/2025

Approved:

Shawn Crosby, Chief Operations Officer

Origin:

Claims Policy

Supersedes:

Policy #CP-12-03, effective 10/07/2019

History:

Previous versions of this policy are available upon request

 

Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

IV. POLICY

A.          LM Compensation

B.          Payment of LM During Vocational Rehabilitation Plan Interruptions

C.          Stopping and Resumption of LM

V. PROCEDURE

A.          General Claim Note and Documentation Requirements

B.          Establishing LM

C.          Payment of LM

D.          SC in Lieu of LM

E.           Ongoing Management of LM

F.           Interruptions and Stopping of LM

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that BWC appropriately pays living maintenance compensation (LM) to an injured worker (IW) who is actively participating in a BWC-approved vocational rehabilitation plan.

 

II. APPLICABILITY

 

This policy applies to BWC Claims Services staff, specifically disability management coordinators (DMC) and claims service specialists (CSS).

 

III. DEFINITIONS

 

See Vocational Rehabilitation Definitions.

 

IV. POLICY

 

A.      LM Compensation

1.      LM and Temporary Total Disability

a.      It is BWC’s policy to pay an IW LM compensation in place of temporary total compensation (TT) when the IW is actively participating in a vocational rehabilitation plan.

b.      An IW receiving LM is considered temporarily totally disabled and will not receive any other compensation while collecting LM, except for scheduled loss, as provided in R.C. 4123.57(B).

c.       BWC will allow the payment of salary continuation (SC) in lieu of LM in the same way BWC allows the payment of SC in lieu of TT. For additional information, see the Salary Continuation policy.

2.      LM Payment Timeframes

a.      LM payments will begin on the date that the IW begins to actively participate in an approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan service; and

b.      Must not exceed more than a total of six months, unless BWC determines that the IW will benefit from an extension.

3.      Rate of Payment of LM

a.      LM payments will not exceed the amount the IW would receive if receiving TT, including any offsets that would be applied to TT; or

b.      Will be paid at 50% of the current statewide average weekly wage (SAWW) if the amount determined is less than 50% of the current SAWW.

c.       See the Temporary Total Compensation policy for further information about offsets.

4.      If an IW is paid for activities while participating in a vocational rehabilitation plan, they are required to endorse that paycheck over to BWC for deposit into the State Insurance Fund. If the IW does not endorse the payment over to BWC:

a.      Such payment will be deducted from LM; or

b.      Deducted as an overpayment from any future compensation that the IW receives if the IW is no longer receiving LM.

c.       See the Overpayment of Compensation policy for more information.

 

B.      Payment of LM During Vocational Rehabilitation Plan Interruptions

1.      It is BWC’s policy to recognize three types of interruptions to an approved vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan service:

a.      Non-medical interruptions beyond the IW’s control;

b.      Medical interruptions; and

c.       Interruptions without good cause.

2.      BWC may suspend or stop LM in the event of these interruptions.

3.      See Section V.F of this procedure for more information.

 

C.      Stopping and Resumption of LM

1.      LM will not be paid for any period during which an IW has returned to work while the IW’s vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan remains open, other than as part of a gradual return-to-work plan.

a.      LM may resume if the IW:

i.        Subsequently stops working while the plan is still open; and

ii.      Resumes active services in the plan.

b.      BWC will stop LM upon the closure of the IW’s vocational rehabilitation assessment plan or comprehensive vocational rehabilitation plan, pursuant to OAC 4123-18-05(E).

2.      The suspension or stopping of LM will not affect the IW’s right to any other workers’ compensation or benefits to which they may be entitled.

 

V. PROCEDURE

 

A.      General Claim Note and Documentation Requirements

1.      BWC staff will  refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2.      Must follow any other specific instructions for claim notes and documentation included in this procedure.

 

B.      Establishing LM

1.      The DMC must evaluate an IW’s ability to participate in vocational rehabilitation, pursuant to the Referrals, Eligibility, and Feasibility policy and procedure, and issue an order that addresses both:

a.      The IW’s ability to participate in vocational rehabilitation; and

b.      The IW’s entitlement to the payment of LM.

2.      When an IW’s participation in vocational rehabilitation (including LM) has been approved by order, by either BWC or the Ohio Industrial Commission (IC):

a.      The DMC must:

i.        Enter the plan into the claims management system; and

ii.      Create a work item for the CSS to begin LM on the date the DMC identifies as the first day the IW begins to actively participate in the plan.

b.      The DMC must:

i.        Consider “actively participating” in an original plan as the first day the IW attends their first approved plan service (e.g., work conditioning); and

ii.      Not consider “actively participating” in an original plan as any of the following:

a)      The date of referral to vocational rehabilitation services;

b)     The date the IW signs the plan; or

c)      The date of any pre-plan activities.

 

C.      Payment of LM

1.      The CSS will issue payment of LM at the rates described in Section IV.A.3 of this policy, unless the IW has chosen to receive SC (see Section V.D below for further guidance).

2.      The CSS will apply the same offsets to LM as would be applied to TT, pursuant to the Temporary Total Compensation policy and procedure.

 

D.      SC in Lieu of LM

1.      If the employer of record offers SC, the IW may choose to receive SC or LM unless the IW has already received TT or LM in the claim, in which case the IW will receive LM.

2.      The DMC or CSS must contact the IW to determine if the IW chooses to receive SC or LM during participation in the plan.

3.      The DMC will develop and manage the plan with SC in the same manner as a plan in which LM is provided.

4.      After the plan is completed, the DMC and CSS will assist an IW that has received SC in obtaining other workers’ compensation benefits the IW may be eligible to receive (e.g., living maintenance wage loss compensation).

5.      For additional information, see the Salary Continuation policy.

 

E.      Ongoing Management of LM

1.      The DMC must provide ongoing LM-qualifying dates to the CSS prior to the end of the current benefit plan.

2.      When an IW is paid for activities while participating in a plan service (e.g., work adjustment):

a.      The DMC must instruct the IW to:

i.        Submit a personal check, cashier’s check, or money order for the net amount of their paycheck in cases where the IW receives a direct deposit; or

ii.      Endorse the paycheck over to BWC in cases where the IW receives a paper paycheck; and

iii.    In either case:

a)      Include the claim number and contact information with the check; and

b)     Forward the check for deposit to:

BWC Cash Control

PO Box 15487

Columbus, OH 43215-0487

b.      If the IW does not forward such payment to BWC and is receiving LM for that period:

i.        The DMC will issue an order declaring the deduction;

ii.      The DMC must notify the CSS of the payment; and

iii.    The CSS will deduct the payment from LM if the IW is receiving LM for that period.

c.       If the IW does not forward such payment to BWC and is no longer receiving LM for that period:

i.        The DMC will notify the CSS;

ii.      The CSS will issue an order declaring the overpayment; and

iii.    Process as an overpayment from any future compensation that the IW receives once the order is final (see the Overpayment of Compensation policy for more information).

 

F.      Interruptions and Stopping of LM

1.      Non-Medical Interruptions Beyond the IW’s Control

a.      The DMC may continue to authorize LM up to a total of seven calendar days when an IW is unable to actively participate in the plan due to non-medical circumstances beyond the IW’s control (e.g., death in the family).

b.      If the non-medical interruption extends beyond a total of seven calendar days, the managed care organization (MCO) and DMC will consider and decide if the plan should be closed, and LM stopped.

2.      Medical Interruptions

a.      The DMC will continue to authorize LM for a maximum of 30 calendar days in an open plan when an IW is unable to actively participate in the plan due to medical instability.

b.      The DMC will notify the CSS to suspend payment of LM in an open plan when the IW continues to be unable to actively participate in the plan due to medical instability and this timeframe will exceed the 30 calendar days referenced above.

c.       The DMC must issue an order suspending LM, which includes:

i.        The effective date of the suspension;

ii.      The reason for the suspension;

iii.    What conditions are required to resume LM; and

iv.     The IW’s right to compensation or benefits for which the IW may otherwise qualify.

d.      During a medical interruption, the CSS must assist the IW in obtaining other workers’ compensation benefits the IW may be eligible to receive.

e.      When an IW resumes active participation in a plan following a medical interruption, the DMC must:

i.        Issue an order restarting LM; and

ii.      Notify the CSS to resume payment of LM.

3.      Interruptions Without Good Cause

a.      When the DMC is notified that the IW has failed to participate in their plan without good cause, the DMC must review the allegation. If, after review, the DMC finds that the IW did, in fact, fail to participate in their plan without good cause and:

i.        The IW is still receiving LM for that period:

a)      The DMC will issue an order declaring the deduction;

b)     The DMC must notify the CSS of the deduction; and

c)      The CSS will deduct one-seventh of the weekly amount of LM for each full day the IW failed to participate in their plan.

ii.      The IW is no longer receiving LM for that period:

a)      The DMC will notify the CSS;

b)     The CSS will issue an order declaring the overpayment; and

c)      The CSS will declare the IW overpaid by one-seventh of the weekly amount of LM for each full day the IW failed to participate in their plan as an overpayment from any future compensation that the IW receives (see the Overpayment of Compensation policy for more information).

b.      In both cases the order must include:

i.        That a deduction/overpayment is being made for the identified dates;

ii.      Why the deduction/overpayment is being made; and

iii.    That the deduction/overpayment does not affect the IW’s right to compensation or benefits for which the IW may otherwise qualify.

4.      Stopping LM

a.      The DMC must notify the CSS to stop payment of LM upon the earlier of:

i.        The IW returning to work, other than as part of a gradual return-to-work plan; or

ii.      When the IW’s plan has been closed.

b.      When the CSS receives notification from the DMC to stop payment of LM, the CSS must assist the IW in obtaining other workers’ compensation benefits the IW may be eligible to receive.