Prepare Your Clients for NY PFL for Employees with a Sick Family Member

Topics: Agent Resources New York Paid Family Leave

Caring for a loved one who is seriously injured or ill can be a difficult and emotionally challenging time for a family. The New York Paid Family Leave (PFL) regulation ensures job-protected leave for employees to care for family members that qualify as seriously injured or ill.

As we’ve discussed in previous blog posts, including our NY State Paid Leave Client Prep Checklist for Success, this new policy will take effect on January 1, 2018. And you’ll want to help your clients get ahead of the game by putting a plan in place now so they don’t have to worry about taking care of employees while they’re out.

As a reminder, the new policy will guarantee New Yorkers paid family leave and job protection in the following circumstances:

  • When a new child is being welcomed into the home
  • When a loved one needs care due to a serious illness or injury
  • When someone in the family has been called for active military service

Keep reading to learn more about Paid Family Leave in the second instance, for taking care of a family member who has a serious medical condition like an injury or illness. Then contact the team at AmTrust North America to learn more about helping your clients cover costs with Statutory Disability Insurance.

What does “providing care” mean?

The definition of providing care has been designed to include different scenarios that an employee may face including physical care, emotional support, visitation, assistance in treatment, transportation, arranging for a change in care, assistance with daily living, and personal attendant services. 

New York State Paid Family Leave Client Prep Checklist

There are two qualifiers to this definition:

  • The covered employee providing care must be present at the same location as the family member during the majority of the employment period from which leave has been taken.
  • Any travel to obtain medication or to arrange care for the family member, or other deviations determined to be reasonably related to providing care, will be considered “providing care.”

What does "serious health condition" mean?

This means that an illness, injury, impairment or physical or mental condition involves either:

  • Inpatient care in a hospital, hospice or residential health care facility
  • Continuing treatment or continuing supervision by a doctor

What does "continuing treatment or supervision" mean?

The state regulations define this in a few ways:

1. More than three consecutive, full calendar days that a family member cannot work, attend school, perform regular daily activities or is otherwise incapacitated by illness, injury, impairment, or physical or mental conditions.

In addition, this includes any follow up treatment or incapacity caused by the same condition that also involves either:

  • Treatment two or more times by a doctor
  • Treatment at least once that results in a regimen of continuing treatment under the supervision of the doctor

2. Any period during which a family member is incapacitated due to a chronic serious health condition. This is a condition that:

  • Requires periodic visits for treatment by a health care provider
  • Continues over time (including recurring episodes of a single underlying condition)
  • May cause episodic rather than a continuing period of incapacity, such as epilepsy

3. A long-term or permanent period during which a family member is incapacitated, during which time (s)he must be under the continuing supervision of a doctor for a condition, such as a severe stroke.

4. A period during which a family member is incapacitated because (s)he is receiving treatment (including recovery time) by a doctor for:

  • Surgery after an accident/injury
  • Conditions such as cancer (chemotherapy and radiation), severe arthritis (physical therapy) or kidney disease (dialysis)
  • Dental or plastic surgery after an injury or removal of cancerous growths
  • Complications from mental illness or allergies

What conditions are not considered “serious” and will not be covered?

Cosmetic treatments such as most treatments for acne or plastic surgery (unless there are complications) are not covered under the new policy. In addition, the common cold, flu, ear aches, upset stomach, minor ulcers, headaches (other than migraine), routine dental or orthodontia problems, periodontal disease, etc. (unless there are complications) are also not covered.

Who is eligible to take this leave?

“Family member” can mean the following:     

  • Child - biological, adoptive or foster
  • Spouse
  • Domestic partner
  • Parent - birth, step, foster, in-law, legal guardian or the person to whom the stood as loco parentis (legal ward or court order) to employee
  • Grandchild - child of the employees’ child
  • Grandparent - parent of the employees’ parent

What are the required claim documents for this leave?

Health care provider form - state provided PFL-4 form

The employee must provide documentation of family member’s serious health condition from doctor that has the following information:

  • Name, address, telephone number, email address, license number and state of license of the doctor and the type of medical practice/specialization
    • Date that the serious health condition start and how long it may continue
    • Certification regarding the patient's health condition for which PFL is requested. The certification must be able to support the need for leave and have the diagnosis codes (ICD-10) that apply to the serious health condition
    • An estimate of the frequency and duration of the leave needed to care for the family member and whether it is continuing or on an intermittent basis

 A doctor may deny certification for family leave when the employee asking for the leave is the perpetrator of domestic violence or child abuse against the person receiving care.

Medical Certification and HIPAA Authorization Form - state provided PFL-3 form

This form includes the same stipulations outlined above. A doctor may also deny this certification for family leave when the employee asking for the leave is the perpetrator of domestic violence or child abuse against the person receiving care.

When certification is required, the employee must provide the carrier with a complete and sufficient certification or leave may be denied. The authorization, release or waiver completed by the person receiving care is subject to the authorization rules and exceptions outlined in the HIPAA Privacy Rule (45 C.F.R. parts 160 and 164 [2005]).

Learn More About PFL for an Ill or Injured Family Member

This type of family leave has been covered in the Family and Medical Leave Act, but was initially available only to those who work for an employer with 50+ employees. The expansion of this benefit to a larger population, combined with the financial and job security aspects of Paid Family Leave, means more opportunity for employees in New York State to utilize it.   

Help your clients prepare for the policy, which goes into effect on January 1, 2018, with a Statutory Disability Insurance Policy from AmTrust North America. To schedule a training webinar, please contact our Disabilities Insurance department.


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