What is a disability?
The definition of a disability can differ among plans. Please consult your plan documents for the applicable definition of a disability.
What is the difference between an impairment and a disability?
The definitions of impairments and disabilities can differ by plan. Consult your plan documents for specific definitions, as well as the criteria to qualify for disability benefits.
What are the differences between workers compensation and disability?
Work injuries are not necessarily disabilities. Worker’s compensation may be received if you are injured at work, whereas disability insurance can be used when you become ill or are injured away from work and are no longer able to work at your regular job.
What is the difference between Short Term Disability (STD) and Long Term Disability (LTD)?
If your employee becomes disabled and is unable to work, Aetna’s Short Term Disability insurance benefits help him or her meet his or her financial responsibilities. Eligible employees who become ill or injured generally receive an amount of base pay for up to 25 weeks of certified disability after a waiting period (the number of weeks that an employee could receive STD will vary by the plan). The amount of base pay depends on the employee’s length of service at the time he or she becomes disabled. STD checks are issued on a weekly basis.
Aetna also provides Long Term Disability insurance coverage that provides a total monthly benefit equal to 50 percent of your employee’s eligible pay. Your employee may be eligible to receive LTD benefits after a 26-week period of certified short-term disability. In addition to company-paid LTD benefits, your employee may elect to purchase an additional 10 percent of LTD coverage for a total of 60 percent of his or her eligible pay. LTD checks are issued on a monthly basis.
Under what criteria does your employee qualify for short-term disability benefits?
Aetna will obtain objective medical findings to make sure your employee’s condition meets the definition of disability and supports his or her inability to perform the material and substantial duties of one’s regular occupation. Your employee may be asked to assist Aetna in obtaining the necessary documentation to make this determination. A note from the employee’s physician is not considered sufficient medical evidence to ascertain whether or not he or she qualifies for short-term disability benefits.
Be sure to reference plan specific documents to determine the applicable definition of a disability.
How does STD and LTD insurance work?
Each employee’s insurance benefits plan will differ. However, you should understand some common terms that you will see as part of a typical insurance plan:
- Benefit waiting period: The period of time that must elapse before benefits are payable under a group insurance contract.
- Self-insured: Some employers offer self-insured insurance plans as opposed to a fully-insured plan. An employer who chooses to run their own insurance plan is offering a self-insured plan. In this case, the employer pays the insurance carrier to manage and administer the plan that they have tailored to their employees and the employer assumes the financial risk of paying all claims from its employees. Some employers choose this option as a way to reduce costs.
- Fully-insured: A fully-insured insurance plan is the traditional method of administering disability insurance. The employer allows the insurance carrier to both administer and pay claims
How can your employee get in contact with State Disability?
- California: your employee can call the local EDD office to obtain an application for benefits. The main number in Sacramento is (916) 227-0220 or 800-480-3287. They will help you identify the number to your local EDD office/Web site: http://www.edd.ca.gov/disability/
- Rhode Island: your employee should contact the State TDI office at (401) 222-3287 to apply for benefits/Web site: www.dlt.state.ri.us
- Puerto Rico: your employee should contact the Department of Labor and Human Resources 787-754-2146
- New Jersey: your employee should contact the Division of Disability Insurance Service at 609-292-2681 to apply for benefits
- New York: your employee should contact the Workers' Compensation Board Disability Benefits Bureau at 518-474-6681 to apply for benefits
- Hawaii: your employee should contact the Disability Compensation Unit at 808-586-9188 to apply for benefits
Do Social Security Disability Insurance (SSDI) and the American Disability Association (ADA) differ from an employer's disability plan?
Your employee must meet different criteria for different types of insurance coverage.
In order to be eligible for SSDI, your employee (the claimant) must meet the following criteria:
- The claimant must have current insured status with Social Security
- A claimant must have 40 quarters of coverage in order to be insured for SSDI.
- A claimant must have 20 of those 40 quarters within the last 10 years from date of disability.
- Claimant must meet Social Security's definition of disability, which is:
- An individual who is unable to engage in substantial gainful activity (SGA) by reason of a medically determinable physical or mental impairment(s) which has lasted or is expected to last at least 12 continuous months or result in death.
- A person must be not only unable to do his previous work but cannot, considering age, education and work experience, engage in any other kind of substantial work that exists in the national economy. It is immaterial whether such work exists in the immediate area, or whether a specific job vacancy exists.
- Claimant must be able to prove legal residency.
According to the ADA, a disability is defined as follows:
- An individual has a disability if that individual either
- has a physical or mental impairment which substantially limits one or more of that person's major life activities
- has a record of such an impairment
- is regarded as having such an impairment
- Temporary impairments and pregnancy are excluded
How can your employee contact Aetna?
Your employee can contact Aetna by checking with your Human Resources department to find the appropriate claim office
File a claim
When should your employee call Aetna to file his or her claim?
Your employees must file their claims by the third consecutive day of their absences. All employees who have a planned absence should file their claims within two weeks prior to their anticipated first day of absence.
Are there any forms that your employee must complete?
Yes, he or she must complete a Medical Release Form. It is imperative that this form is promptly completed to make sure Aetna has immediate access to his or her medical records. Timely completion of this form will help expedite the claim process. Download forms now.
What is the role/responsibility of Aetna in claim processing?
During the claim initiation, Aetna accepts claim notification via toll free number, web-based customer portal or paper. During the initial intake, a member’s STD eligibility is verified. When members are identified as having both Aetna medical and Aetna disability coverage, IHD Secure Voice Authorization (HIPAA compliance) is performed during telephonic intake. A member’s consent is required for our IHD services. Paper and web claimants receive the HIPAA consent form in the mail. Additionally, during telephonic intake, the employee is educated about the claim process.
To ensure claims are properly prepared or “Completed,” our trained and experienced intake staff conducts a three-point contact. Three-point contact includes outreach to: the employee to obtain any missing information not included in the initial claim submission, the employer to verify eligibility and confirm information about the employee’s job duties and the attending physician to obtain relative disability related medical information.
If your employee has a surgery scheduled, when should he or she contact Aetna to file a claim?
Aetna should be notified of all planned absences, including scheduled surgery, two weeks before the surgery date. Your employee can contact Aetna by checking with his or her Human Resources department to find the appropriate claim office.
If your employee is pregnant, when should she file her claim with Aetna?
Your employee may file her claim two weeks before her estimated delivery date. She may also file a claim if her doctor decides to take her out of the workplace before her delivery date for medical reasons that can be supported by objective medical findings.
How long does it take for your employee’s claim to be processed?
The claim process can take up to 14 calendar days for processing depending on how quickly Aetna receives your employee’s medical information. Your employee can help make sure the process is not delayed by promptly completing the Medical Release Form.
What will happen if Aetna's claims examiner doesn't receive your employee’s medical information from his or her treating physician?
Aetna will contact your employee if we are unable to obtain, within seven calendar days, the objective medical information that supports the employee’s absence. The employee will be requested to lend assistance in obtaining records that may include lab results, X-rays, various reports and office visit notes. If Aetna has not received the necessary medical information within 14 calendar days, benefits cannot be authorized. Aetna will send your employee a letter to notify him or her of what to do next in the claim process.
What can your employee do if Aetna denies his or her claim?
Aetna has an appeals process if your employee feels his or her claim has been incorrectly denied. If the claim is denied, your employee will receive a letter from your claims examiner that will explain the reasons for the denial and describe the appeals process. The employee can also contact your claims examiner for additional information.
Managing your employee’s disability
What are the roles/responsibilities of the manager/supervisor during an employee’s disability?
Education is the most important part to managing your employee’s disability. You should educate your employees about their options in dealing with their disability, where they can find help, and the need for a provider. Submitting job description to Aetna at FDA is also important.
What are some disability options that you should discuss with your employee?
If you’re dealing with work related issues or problems with your employees, these are not disabilities. You should set aside time to discuss the issues accordingly. If one of your employees has a mental health issue, consult an Employee Assistance Program (EAP) if needed. As an employer, you should discuss a return to work plan prior to disability. No matter what type of disability your employee is leaving on, (e.g. pregnancy, elective/planned surgery), a return to work plan should be put into place.
What is a disease management program?
Disease management programs aim to help people living with chronic conditions successfully self-manage their diseases by helping them better understand their conditions and their doctor-prescribed treatment plans. Aetna offers specific disease management programs tailored to specific disease needs. For example, here are a few specific conditions for which there are disease management programs: Asthma, Chronic Heart Failure, Chronic Kidney Disease, Coronary Artery Disease, Diabetes and Lower Back Pain.
How can disease management impact/assist your employee prior to his or her disability leave?
A disease management program is designed to help manage your employee’s disease through:
- Self-care skills
- Physician support
How can I find or identify disease management programs that are available to my employees?
There are many resources available online to find disease management programs for your employees. To enroll in Aetna’s Disease Management program, log in to the secure Aetna Navigator® at www.aetna.com. Click on Take Action on Your Health and then Treating Illness. Select Enroll in Aetna Health ConnectionsSM Disease Management and complete and submit the short survey form. You should receive a response from a program representative within two weeks.