1. Temporary Total and Temporary Partial Incapacity Benefits - The Basics
Compensation for Incapacity
Temporary Total and Temporary Partial Incapacity Benefits - The Basics
Rev 3/4/2013

2. Payment with Prejudice
Order or award of compensation. OR
Employer/Insurer accepts the claim.
MOP Box 20(A)
Creates a compensation payment scheme.
Compensation payment scheme means the procedure whereby an employer is required to provide compensation or other benefits under the Act to an employee. Explain that “with prejudice” means there is basically no opportunity to reduce or discontinue benefits without an order from the Board (unless the employee RTW and then they can reduce or discontinue under A), and that MOP box 20-B affords the opportunity to proceed with payment of the claim as if it was accepted without forfeiting the opportunity reduce or discontinue benefits without an order from the Board (unless the employee RTW and then they can reduce or discontinue under A).

4. Section 204: Waiting period; when compensation payable
Compensation for incapacity to work is not payable for the first 7 days
Exception – firefighters not subject to waiting period
In a broken period of incapacity, the waiting period may be determined by wages lost, or by benefits lost.

5. Waiting period; when compensation payable
Forms and Petitions Manual Appendix D
AWW Method
Employee loses wages because of the injury which cumulatively equal or exceed the employee’s pre-injury AWW.
Ordinarily expedites the obligation to pay.
Comp Rate Method
Employee loses wages because of the injury that would otherwise require the insurer to pay one week of benefits (equal to or greater than the employee’s WCR).
Used by the Board’s Audit Division.
Other methods may be acceptable
Appendix G shows a good example of how the AWW method expedites the obligation to pay. If the claim goes on for more than a certain number of weeks, the amount owed is the same for both methods.

6. Waiting period; when compensation payable
Example 1: A broken period of incapacity (Temporary Total Disability)
Injured 1/29/13, paid ½ day
OOW 1/29/13 – 1/31/13
RTW 2/1/13
Back out of work 2/15/13 – ongoing
When is the 7 day waiting period met?

7. Waiting period; when compensation payable
Example 1 Calculations
1/29/13: When an employee is paid 1/2 day or more wages on the date of injury, the date of injury will not be considered a day of incapacity (Section 212 and Rule 8.3).
1/30/13 – 1/31/13: 2 calendar days
2/15/13 – ongoing: 5 calendar days = 2/19/13
Waiting period met 2/19/13; first day of compensability after waiting period is met (MOP Box 22) is 2/20/13.

8. Waiting period; when compensation payable
Example 2: Temporary Partial Disability
DOI 3/11/13 (filing status not relevant)
Pay period Sunday – Saturday
Pre-injury AWW $650 / WCR $433.33
Post-injury actual earnings $450 / WCR $300.00
Partial rate = $ $ = $133.33

9. Waiting period; when compensation payable
Example 2 Calculations
First day of compensability after waiting period is met (MOP Box 22): 4/6/13
Partial Weekly Benefit Rate
Cumulative Partial Weekly Benefit Rate
Weekly Benefits Due
3/10-3/16/13
133.33
3/17-3/23/13
266.66
3/24-3/30/13
399.99
3/31-4/6/13
533.32
99.99
Be sure to inform them that if the carrier is able to calculate the exact day that the employee met the waiting period, they can use that. However, payment of benefits would be due 6 days from the first day of compensability after waiting period is met. Otherwise, the audit department uses the last day in the pay period where the employee met the waiting period. Also note that 8/6/11 is acceptable but 8/7/11 is not.
$ – $ waiting period rate = $99.99

10. Waiting period; when compensation payable
In case incapacity continues for more than 14 days, compensation is allowed from the date of incapacity.
Must pay for the waiting period.

11. Waiting period; when compensation payable
Example 2 Calculations (cont.) (WCR $433.33) (2 x WCR $866.66)
Partial Weekly Benefit Rate
Cumulative Partial Weekly Benefit Rate
Weekly Benefits Due
3/10 - 3/16/13
133.33
3/17 - 3/23/13
266.66
3/24 - 3/30/13
399.99
3/31 - 4/6/13
533.32
99.99
4/7 - 4/13/13
666.65
4/14 - 4/20/13
799.98
4/21 - 4/27/13
933.31
566.66
4/28 - 5/4/13

12. Benefit payment Section 205 and Rule 1.1
The first payment of compensation is due and payable within 14 days of notice or knowledge of a claim for incapacity or death benefits, on which date all compensation then accrued must be paid.
In the previous example, the first day of compensability after the waiting period is met is 4/6/13 (8th day); first payment due 4/12/13.
Discuss: Provisional payments may be required. Also discuss that the first payment is due 6 days from the first day of compensability after the waiting period is met. This may be greater than 14 calendar days from the notice or knowledge of a claim for incapacity or death benefits.

13. Benefit payment Section 205 and Rule 8.4
Subsequent incapacity payments must be made weekly (every 7 days) and directly to the employee entitled to that compensation at that employee’s last known mailing address, or at any place that employee designates.
Discuss provisional payments may be required. Also discuss that weekly means every 7 days, not 6 days and then 8 days unless there is a Holiday.

14. Discontinuance or reduction of payments Section 205.9 and Rule 8.11
Section A – employee must return to work with the employer of injury.
Reductions and discontinuances must be based on the employee’s actual earnings unless the employee returns without restrictions or limitations.

15. Discontinuance or reduction of payments Section 205.9
Section B – all circumstances other than the employee’s return to work with the employer of injury.
Payment without prejudice (voluntary payment) – must file WCB-8.
Payment with prejudice (order or award of compensation or compensation payment scheme) – must petition the Board.

16. Discontinuance or reduction of payments Section 205.9 and Rule 8.15
RTW with a different employer and employer/insurer is filing a 21-day certificate of discontinuance/reduction (WCB-8):
Actual documented earnings must be provided by the employee or their representative to the employer/insurer within 7 days of their RTW (to substantiate the discontinuance/reduction)
The employer/insurer must include, with the 21-day certificate, form WCB-231A (with a statement)
Within 14 calendar days after the expiration of the 21-day period, the employer/insurer shall file with the Board the documentation it has received along with an amended 21-day certificate which shall also include any necessary adjustments based on the documentation received by the employer/insurer.
Make it clear that only clerical corrections that do not affect the employee’s rights are accepted (i.e. box 22).

17. Discontinuance or reduction of payments Examples
RTW with the employer of injury
Jane $600 AWW / RTW earning $620
WCB-4 Discontinuance (with or without restrictions or limitations)
Julie $600 AWW / RTW no restrictions or limitations earning $560
WCB-4 Discontinuance (maintain proof of full duty release on file)
Janice $600 AWW / RTW with restrictions or limitations earning $560
WCB-4 Modification (to partial)
If reduced earnings are strictly due to economic conditions (i.e. overtime no longer available), may discontinue with a WCB-8
Joslyn $600 AWW / RTW without restrictions or limitations according to her treating health care provider, but there are conflicting medical records from another health care provider with respect to the lack of restrictions or limitations, earning $560
WCB-8 (21 Day) Discontinuance

18. Discontinuance or reduction of payments Examples (continued)
RTW with the employer of injury
Judy $600 AWW / RTW earning $560 because she chooses not to work optional overtime which she worked prior to the injury
If RTW was with restrictions or limitations, WCB-8 (21 Day) Discontinuance
If RTW was with no restrictions or limitations, WCB-4 Discontinuance (maintain proof of full duty release on file)
RTW with a different employer
Joyce $600 AWW / RTW with different employer and with restrictions or limitations earning $560
WCB-8 Modification (to partial)

19. Maximum benefit levels Section 211
Adjusted annually on July 1 – adjust on that day. File a modification.
Date of Injury prior to 1/1/ % of the state average weekly wage as determined by the Department of Labor.
Date of injury on/after 1/1/ % of SAWW

20. Compensation for total incapacity Section 212
Date of injury prior to 1/1/ weekly compensation equal to 80% of the employee’s after-tax average weekly wage, but not more than the maximum benefit under section 211.
Date of injury on or after January 1, 2013, 80% after tax computation is replaced with two-thirds of the AWW (AWW divided by three, times two).

21. Compensation for partial incapacity Section 213 and Rule 8.8
Date of injury prior to 1/1/ difference between 80% of the injured employee’s after-tax average weekly wage before the injury and 80% of the after-tax average weekly wage after the injury, but not more than the maximum benefit under section 211.
Date of injury on/after 1/1/ the 80% after tax computation is replaced with two-thirds of the AWW.

22. Compensation for partial incapacity Section 213 and Rule 8.8
Things to remember:
Employers must be notified of their obligation to promptly furnish all post-injury information necessary to facilitate timely indemnity payments (need weekly information even if the pay cycle is different).
Match partial benefit calculations to the employer’s pay cycle.
There is no such thing as a partial week of partial benefits.
Reference the Recordkeeping Requirements under the Fair Labor Standards Act (FLSA). To be compliant with FLSA, the employer must maintain total hours and wages for each workweek. 

23. Modifications from TTD to TPD or from TPD to TTD
When an employee is both partially
and totally incapacitated in the same week:
Calculate and pay TTD benefits due for the days of total incapacity.
Calculate TPD benefits due for the week.
Deduct TTD benefits paid during the week for which partial benefits were calculated and pay the difference.
If the result is a negative amount, no additional indemnity benefits are due for the week.
Explain that you always calculate TPD benefits for the whole week, not just for the days where TTD was not paid.

24. Modifications from TTD to TPD or TPD to TTD
Example 1: John is injured 3/2/13, he is paid for half a day on that day
Pay period Sunday – Saturday
Pre-injury AWW $800
OOW 3/2 - 3/13/13, RTW 3/14/13 with restrictions
Post-injury actual earnings $300

25. Modifications from TTD to TPD or TPD to TTD
March 2013
Sun
Mon
Tue
Wed
Thu
Fri
Sat 1 2
Paid ½ day 3
TTD 4 5 6 7 8 9 10 11 12 13 14
TPD 15 16

26. Modifications from TTD to TPD or TPD to TTD
Example (cont.)
Pre-injury AWW $800
WCR $533.33/Daily Rate $76.19
TTD 3/2 - 3/13/13
3/2/13 paid ½ day; not considered a day of incapacity
Calculate TTD 3/3/13 - 3/9/13 ($76.19 x 7 days = $533.33)
Waiting period, do not pay yet
Pay TTD 3/10 - 3/13/13 ($76.19 x 4 days = $304.76)
Calculate Partial benefits for week ending 3/16/13

27. Modifications from TTD to TPD or TPD to TTD
Example (TPD 3/10/13 - 3/16/11 cont.)
Pre-injury AWW $800
Determine the WCR – 2/3 of AWW (WCR $533.33).
Post-injury weekly earnings $300
Determine the WCR – 2/3 of $ (WCR $200.00).
Employee’s TPD benefits for the transition week = $333.33
The difference between the pre-injury rate and the post-injury rate is the partial benefit amount.
Less TTD paid during the transition week ($304.76)
Employee owed $28.57 TPD in addition to
the $ TTD already paid
Pre-injury WCR $ Post-injury WCR $ = $333.33
TPD $ $ TTD already paid = $28.57 TPD due for the transition week

28. Modifications from TTD to TPD or TPD to TTD
Example 2:
Jack is Injured 3/5/13, not paid ½ day
Pay period Sunday - Saturday
Pre-injury AWW $750
OOW 3/5/13 - 3/13/13, RTW 3/14/13 with restrictions
Post-injury actual earnings $350

29. Compensation for partial incapacity Section 213 and Rule 8.8
March 2013
Sun
Mon
Tue
Wed
Thu
Fri
Sat 1 2 3 4 5
Not Paid ½ day 6
TTD 7 8 9 10 11 12 13 14
TPD 15 16 17 18 19 20 21 22 23

30. Compensation for partial incapacity Section 213 and Rule 8.8
Example 2 (cont.)
Pre-injury AWW $750
WCR $500.00/Daily Rate $71.43
TTD 3/5/13 - 3/13/11
Calculate TTD 3/5/13 - 3/13/13 (one week plus 2 days = $642.86)
Do not pay 7 day waiting period 3/5/13 - 3/11/13 ($500.00)
Pay TTD 3/12/13 - 3/13/13 ($71.43 x 2 days = $142.86)
Calculate Partial benefits for week ending 7/16/11

31. Modifications from TTD to TPD or TPD to TTD
Example 2 (cont.)
Pre-injury AWW $750
Determine the WCR – 2/3 of the AWW (WCR $500.00).
Post-injury weekly earnings $350
Determine the WCR – 2/3 of $350 (WCR $233.33).
Employee’s TPD benefits for the transition week = $266.67
The difference between the pre-injury rate and the post-injury rate is the partial benefit amount.
Less TTD owed during the transition week (4 days or $285.72).
$ (TPD due) minus $ (TTD due) is less than zero, so no additional benefits are due.
Pre-injury WCR $ Post-injury WCR $ = $266.67
TPD $ $ TTD already due ($ payable now) = ($19.05) < zero, no additional due

32. Modifications from TTD to TPD or TPD to TTD
Example 2 (cont.)
Pre-injury AWW $750
Determine the WCR – 2/3 of the AWW (WCR $500.00).
Post-injury weekly earnings $350
Determine the WCR – 2/3 of $350 (WCR $233.33).
Employee’s TPD benefits for the w/e 3/23/13 = $266.67
The difference between the pre-injury rate and the post-injury rate is the partial benefit amount.
Be sure to pay for the waiting period in addition to TPD the following week if incapacity continues for more than 14 days (2 x WCR).

33. Waiting period; when compensation payable
Example 2 Calculations (cont.)
WCR = $500.00, 2 x WCR = $ )
Partial Weekly Benefit Rate*
Cumulative Partial Weekly Benefit Rate
Weekly Benefits Due
Notes
3/5/13 - 3/9/13
357.14
*TTD Benefits
3/10/13 - 3/13/13
285.72
642.86
142.86
3/10/13 - 3/16/13
No additional due
3/17/13 - 3/23/13
266.67
909.53
3/24/13 - 3/30/13
766.67
$ $266.67
3/31/13 - 4/6/13

34. QUESTIONS???