28 Tex. Admin. Code § 130.104 - Determination of Entitlement or Non-Entitlement for Subsequent Quarters
(a) Subsequent Quarter Determination. After
the Division has made a determination of entitlement or non-entitlement for
supplemental income benefits for the first quarter, the insurance carrier shall
make determinations for subsequent quarters consistent with the provisions
contained in §
130.102 of this title (relating to
Eligibility for Supplemental Income Benefits; Amount). The insurance carrier
shall issue a determination of entitlement or non-entitlement within 10 days
after receipt of the Application for Supplemental Income Benefits for a
subsequent quarter.
(b) Application
for Supplemental Income Benefits. An injured employee claiming entitlement to
supplemental income benefits for a subsequent quarter must send the insurance
carrier an Application for Supplemental Income Benefits as required under this
section. With the first monthly payment of supplemental income benefits for any
eligible quarter and with any insurance carrier determination of
non-entitlement, the insurance carrier shall send the injured employee a copy
of the Application for Supplemental Income Benefits and the proper address to
file the subsequent application. On the Application for Supplemental Income
Benefits sent by the insurance carrier, the insurance carrier shall include:
(1) the number of the applicable
quarter;
(2) the dates of the
qualifying period;
(3) the dates of
the quarter;
(4) the deadline for
filing the application with the insurance carrier; and
(5) the minimum number of work search efforts
required by §
130.102(d)(1) and
(f) of this title (relating to Eligibility
for Supplemental Income Benefits; Amount) during the next qualifying
period.
(c) Filing the
Application for Supplemental Income Benefits. The employee shall file the
Application for Supplemental Income Benefits and any applicable documentation
with the insurance carrier by first class mail, personal delivery or electronic
transmission. Except as otherwise provided in this section, the Application for
Supplemental Income Benefits shall be filed no later than seven days before,
and no earlier than 20 days before, the beginning of the quarter for which the
injured employee is applying for supplemental income benefits. If the
Application for Supplemental Income Benefits is received by the insurance
carrier more than 20 days before the beginning of the quarter, the insurance
carrier shall return the form to the injured employee with detailed
instructions on when the form is required to be filed. Any form returned to the
injured employee because the form was filed early shall not be subject to the
provisions of §
130.108 of this title (relating to
Contesting Entitlement to Supplemental Income Benefits).
(d) Date-Stamp. Upon receipt, the insurance
carrier shall date-stamp all Application for Supplemental Income Benefits forms
with the date the insurance carrier received the form.
(e) Notice of Determination. Upon making
subsequent quarter determinations, the insurance carrier shall issue a notice
of determination to the injured employee. The notice shall be sent by first
class mail, personal delivery or electronic transmission and shall contain all
the information required in the Notice of Entitlement or Non-entitlement
portion of the Application for Supplemental Income Benefits. The notice of
determination of non-entitlement shall contain sufficient claim specific
information to enable the employee to understand the reason for the insurance
carrier's determination. A generic statement such as "failure to satisfy the
compliance standards of Labor Code §
408.1415", "not a direct
result", or similar phrases without further explanation does not satisfy the
requirements of this section.
(f)
Accrual date. If the injured employee is entitled to supplemental income
benefits for a subsequent quarter, the benefits begin to accrue on the later
of:
(1) the first day of the applicable
quarter; or
(2) the date the
Application for Supplemental Income Benefits is received by the insurance
carrier, subject to the provisions of §
130.105 of this title (relating to
Failure to Timely File Application for Supplemental Income Benefits; Subsequent
Quarters).
(g) Changes
in Amount. A change in the monthly amount of supplemental income benefits from
one quarter to the next does not constitute a dispute subject to §
130.108 of this title (relating to
Contesting Entitlement to Supplemental Income Benefits). An insurance carrier
that does not contest the entitlement to supplemental income benefits for a
subsequent quarter, but determines a different monthly amount is due, shall:
(1) send the notice as required in subsection
(e) of this section;
(2) include
instructions about the procedures for contesting the insurance carrier's
determination as provided by §
130.108 of this title (relating to
Contesting Entitlement to Supplemental Income Benefits); and
(3) issue payment based on the newly
calculated amount.
Notes
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