State News

Overview

The California Division of Workers' Compensation (DWC) has adopted updated regulations governing the utilization review (UR) process under Labor Code § 4610. These regulations, effective April 1, 2026, do not alter the statutory framework itself but build a more detailed administrative layer on top of it — adding new procedural requirements for UR plans, approval and denial communications, and the IMR application process. The changes are designed to increase transparency, standardize decision communications, and tighten documentation requirements.

I. UR Plan Administration (§ 9792.7 and § 9792.7.1)

New UR-01 Cover Form. The DWC has introduced a standardized UR-01 form (§ 9792.7.1) that must be used as a cover page when establishing a new UR plan or submitting any plan modification. The form is available on the DWC's regulations page. Note that a "city" field was inadvertently omitted from the form and is expected to be corrected in April 2026; in the interim, city information should be included in the general address field.

Client List Maintenance. UR organizations are now required to keep their client lists current. Under the updated § 9792.7(c), UROs must identify the claims administrator clients for whom they perform any UR functions. This is a new affirmative obligation, UROs and the claims administrators who contract with them should confirm their processes account for this.

DWC Review and Approval Process. The updated regulations formalize a review and approval process for UR plans under § 9792.7. This is a newly added procedural layer, and organizations should review the regulation text for specific submission and compliance requirements.

II. UR Approval Letters (§ 9792.9.4)

The new regulations impose several additional content requirements for written UR approval decisions:

Documenting Prior Information Requests. If a request for additional information, testing, consultation, or examination preceded the approval, the approval letter must now include both the date the request for such information was made and the date the information was received. This creates a documented audit trail within the approval itself.

Generic Drug Substitution. When a treating physician requests a name-brand drug without specifying "do not substitute" or "dispense as written," the approval of the generic equivalent must affirmatively state "generic substitute authorized" or words to that effect. This standardizes language around formulary substitution and removes ambiguity.

Formulary-Exempt Drug Approvals. If the approved drug is exempt under the MTUS Drug Formulary, the decision must state "Exempt per MTUS Drug Formulary" or equivalent language.

30-Day Exempt Non-Drug Treatment. For approvals of non-drug treatment exempt under the 30-day rule (§ 9792.9.7), the written decision must identify the treatment as a "30-day exemption" or words to that effect.

Practical Impact: These are template-level changes, but they require updates to approval letter workflows. Claims administrators and UROs should audit their current letter templates against these requirements before April 1.

III. UR Denial and Modification Letters (§ 9792.9.5)

Responding to Treating Physician Opinions on Guidelines. This is a notable addition. When a requesting physician expressly includes in the RFA an opinion that prerequisite treatment or guideline criteria should be overlooked or deemed irrelevant, the reviewing UR physician must now provide a specific explanation of why the treating physician's rationale is insufficient. This goes beyond the existing requirement to cite guidelines and clinical reasoning, it requires direct engagement with the treating physician's stated position.

Identification of Liable URAC-Accredited Entity. Adverse UR decisions must now identify the URAC-accredited entity that is liable for the decision. This is a transparency measure and should be incorporated into denial/modification templates.

Updated IMR Appeal Rights Language. The template language in denial and modification letters regarding IMR appeal rights must be updated to conform with § 9792.9.5(e). The DWC has indicated that organizations should work directly with DWC UR staff to accomplish this through the UR plan modification process.

Denials After Extension of Time (Substantive Medical Necessity Finding). Where a denial is based on a substantive medical necessity finding after an extension of time was taken, the denial must now include: a description of the information that was needed, the dates and times the request was made, the manner of the request, and the date the missing information was first received.

Denials Based on Untimely Receipt of Information ("CNC" Denials). For denials issued because requested information, testing, or consultation results were not timely received, the letter must include: the reason for the decision, a specific description of the needed information, the date and time of attempts to contact the physician, and the manner of those attempts. The DWC notes that these requirements are already embedded in Labor Code § 4610(i)(5) and are being restated in the regulations to clarify their application in this context.

IV. IMR Application Updates

The DWC has updated the IMR application form with the following changes:

New Checkboxes. Three checkboxes have been added at the top of the form to categorize the type of dispute: (1) Medication Only – MTUS Formulary Drug List; (2) Retrospective for Exempt Treatment (Non-Drug); and (3) Retrospective for Exempt Treatment (Drug).

Mailing Date Field. A new field has been added under "Disputed Medical Treatment" for the mailing date of the UR determination letter.

Filing Deadline Designation. Claims administrators and UROs must now mark which IMR filing deadline applies. If the dispute involves only a drug listed on the MTUS Formulary Drug List, the deadline is 10 days from the mailing date of the UR determination letter. For all other disputes — including drugs not on the MTUS Formulary Drug List — the deadline is 30 days from the mailing date.

Known Form Errors. The DWC has acknowledged two omissions from the updated IMR application: the Authorized Designated Representative (ARD) form was inadvertently left out, and the "city" field was omitted from various address sections. Both are being corrected. In the interim, organizations should continue including the ARD form with adverse UR decision letters and note city information in the general address fields.

V. Action Items to Consider

The following steps should be evaluated before April 1, 2026:

1. Template Updates. Review and revise all UR approval, denial, and modification letter templates to incorporate the new content requirements, including generic substitution language, formulary exemption designations, 30-day exemption labels, and the identification of the liable URAC-accredited entity.

2. UR Plan Filings. Determine whether a UR plan modification is required and prepare the new UR-01 cover form. Coordinate with DWC UR staff regarding updated IMR appeal rights language.

3. Client List Compliance. UROs should confirm their client lists are current and establish a process for ongoing maintenance under § 9792.7(c).

4. IMR Application Workflow. Update internal processes to account for the revised IMR application, including the new checkboxes, mailing date field, and filing deadline designation. Continue including the ARD form despite its omission from the updated application.

5. Staff Training. Ensure UR physicians and reviewers understand the new requirement to substantively respond to a treating physician's express opinion that guideline prerequisites should be disregarded.

This summary is provided for informational purposes and highlights key operational changes under the DWC's updated UR regulations. It is not a comprehensive restatement of all new requirements. Organizations are strongly encouraged to review the full regulatory text and consult with legal counsel to ensure compliance.

Simon Anderson Law P.C.

701 Market Street, Suite 340, St. Louis, MO  63101

314-621-2828

MISSOURI WORKERS’ COMPENSATION CASE LAW UPDATE

January 2026 – March 2026

Claimant’s Fall Downstairs Not Compensable

Meyer v. National Hospice Management Beacon of Hope Hospice, Injury No. 24-001520

FACTS: The claimant worked as a team assistant and on the date of injury, there was a snow and ice storm. He received a text noting that there was going to be a delayed start possibly at 10:00 am but was advised not to leave home until he heard from his supervisor at 9:30 am to confirm. However, the claimant left for work and arrived in the office parking lot at 9:02 am and went into the office at 9:15 am. He realized he forgot his badge and went back to the car at 9:32 am and fell on snowy and icy stairs outside of the building. Afterwards he received a text at 9:47 am which called off the days’ work for all employees. The claimant admitted he knew the reasons for the delayed start was due to safety concerns of the employees and the hazardous weather conditions. He testified the parking lot at work does not have designated parking for any of the lessees of the building, and the claimant could park wherever he chose. He also noted there were multiple entrances to the building, but most employees used the entrance closest to their office suites. The office manager testified on behalf of the employer that the reason for the delayed start and ultimate cancellation of in person work was for the safety concerns of the employees due to hazardous weather. She did note the employer does not own, maintain, or control the common areas of the office building and the landlord is responsible for maintenance and snow removal from common areas. She also testified the building manager for the landlord contracts with the company for snow and ice removal on the property. The leased property for the employer only begins after entering the second set of doors on the outside of the office building and the snow and ice covered stairs are beyond any of the employer’s leased space. The lease showed that the area the employer leased did not include the outside steps and doors leading into the office building. There was no dispute that the claimant fell on the snow-covered steps in the common area of the building and not in an area leased by the employer.

HOLDING: The ALJ found that the evidence presented did not establish that the risk of falling on snowy and icy stairs was somehow exclusive to the claimant’s performance of work within the course and scope of his job as opposed to the risk source of any individual walking on snow- or ice-covered stairs, whether at work or not. The judge went on to note that the evidence showed that the employer did not own, maintain, or control the exterior of the common areas of the building and when they leased spaced and the landlord has the responsibility for maintenance of the steps, including snow and ice removal. Also, the judge did note that although not critical to the decision, the evidence established that the employer directed the claimant to not report to work until 10:00 am, however, the claimant’s actions were averse to these directions. The judge concluded that the claimant was not in the course and scope of his employment when he fell on the snowy and icy stairs and the extension of premises doctrine was not applicable to this case and therefore, the case was denied. The employer appealed and the Commission affirmed the decision.

Employer Not Responsible for Claimant’s Unauthorized Care as Claimant Did Not Give Employer Opportunity to Control It

Wills v. Fixture Contracting Company, Inc., Injury No. 17-099534

FACTS: The claimant, 41-year-old journeyman carpenter, began working for the employer in the fall of 2015 and his job duties included building cabinets, display fixtures, and countertops. He worked full time and his job required bending at the waist, stooping, lifting from the ground to the work bench, reaching overhead, and bending over to clean up. There was testimony on behalf of the employer showing that the claimant’s work was not as heavy or frequent as he testified but the employer’s evidence did establish the claimant lifted and bent throughout the workday. He developed low back pain in September of 2017, and he initially treated on his own with a chiropractor. He reported his pain and was directed to Concentra; he was signed in but never seen due to the wait. He then went and treated on his own at SSM Health. He was again advised by the employer that if the injury was work related, he had to follow her instructions. He continued to treat on his own and on December 22, 2017, he brought a letter drafted by his attorney to the employer advising that his doctors were talking about surgery and asked if they would pay for his treatment. The claim was reported to the insurance company and authorizations were forwarded and the attorney returned the same. However, the claimant continued to treat on his own and his attorney directed him to Dr. Levy who recommended surgery. The claimant also signed a notice of doctor’s lien on behalf of Attorney Hoffman. The attorney made another demand for treatment on February 8, 2018, and the claimant underwent surgery with Dr. Levy on his own on March 7, 2018. He underwent a second surgery on August 1, 2018. There was no evidence that the claimant requested the employer to offer the second surgery. The claimant did ask for an award for medical bills, which amounted to $248,116.98.

The employer obtained a report from Dr. Bernardi who did not believe that the claimant’s condition was related back to his job duties. The claimant’s attorney obtained a report of Dr. Volarich who did believe that the claimant’s job duties were the prevailing factor in causing his condition and he assessed 40% disability. Dr. DeGrange also testified that the claimant’s condition was work related, as did Dr. Levy.

FINDING: The ALJ did believe that the claimant’s job duties were the prevailing factor in causing his condition. The judge did not award medical as she determined that the claimant did not make a formal demand for treatment until February 14, 2018, when the claimant’s attorney requested the surgery, suggested by Dr. Levy and repeated the same over the next two weeks. The judge noted that the claimant knew the employer was actively collecting medical records but only one week after his last demand and three weeks after the first, the claimant underwent two surgeries with Dr. Levy, thus denying the employer to direct care. The ALJ noted the employer neither failed nor refused to provide treatment before the claimant had surgery. With respect to future medical, the judge noted that the mere possibility that the employee may require treatment in the future is inadequate to establish a right to such treatment. The ALJ found that there was no specific treatment recommended by the experts and that the claimant is not entitled to future medical treatment benefits because he did not establish there was a “reasonable probability” that future medical treatment will be necessary due to the alleged work-related injury. With respect to TTD, the judge did believe the claimant was entitled to TTD during the time he was unable to work, which was supported by Dr. Volarich’s opinion. She also awarded 30% disability referable to the low back. The case was appealed to the Commission, and the Award was affirmed.

Employer/Insurer Responsible for Full Amount of Medical Bills and Should be Paid Directly to Claimant

Chick v. City of Centralia and Treasurer of Missouri as Custodian of the Second Injury Fund, Case No. WD88273 (MO App. 2026)

FACTS: The claimant was an equipment operator for the City from 1995-2016. In February of 2014, he slipped and fell; he was seen by Dr. Runde and referred to an orthopedist. He saw Dr. Young who evaluated the claimant but did not provide treatment. He was sent back to Dr. Runde who suggested a second orthopedic referral but the City refused to authorize additional treatment. He sought treatment on his own with Dr. Mackinnon who performed two surgeries for plexus nerve damage. He also alleged a psychiatric component. He also treated for carpal tunnel syndrome and trigger finger syndrome. He was released from care. Dr. Schlafly provided a ten-pound lifting restriction and the claimant was terminated on April 18, 2026. At a hearing, the ALJ found that the work accident was the prevailing cause of the brachial plexus injury but did not connect the claimant’s carpal tunnel syndrome, trigger finger syndrome, or psychiatric conditions back to the work accident. The ALJ did not find the claimant PTD or the employer responsible for past or future medical. The claimant appealed.

The Commission confirmed that the claimant was not PTD but did believe that the employer was responsible for the treatment for the brachial plexus condition. The Commission noted that the claimant’s health insurance paid for most of the charges and therefore, it did not require the employer to pay the amount charged for the doctor’s treatment to the employee and his attorney but instead ordered the employer/insurer to resolve the charges with the doctor and hospital directly and hold the employee harmless in any collection attempts. The claimant appealed.

HOLDING: The claimant argued that the Commission acted in excess of its powers in directing the City to pay the Award of past medical expenses directly to the medical providers instead of the claimant and the Court agreed. The claimant argued that the Commission’s method provided a credit to his employer for payments made by a collateral source, in this instance the claimant’s private health insurance despite the fact that Section 287.270 expressly prohibits such a credit. The claimant further pointed out that the Commission’s method of reimbursement does not actually reimburse him for the out-of-pocket expenses he incurred, such as deductibles and copays, and therefore, the method of “reimbursement” was inadequate. The Court cited Farmer-Cummings, which addressed responsibility of past medical expenses. It noted that the case held that a claimant is not entitled to compensation for health care provider write offs and fee adjustments that extinguish the claimant’s liability as compensation for amounts for which the employe was not liable would amount to a windfall rather than compensation. The Court noted that the case was clear that any benefits from a collateral source that fell withing Section 287.270 were outside the scope of the defense and the case clarified that the employer was required to reimburse the employee for all medical expenses incurred and that the employer should not receive and advantage for failing to timely pay medical bills incurred at the employee's expense.

The Court noted that it was clear that the Commission considered payments made toward the claimant’s medical bills by the claimant and his private insurer. However, Section 287.270 forbids the Commission from considering and granting the City a credit against its liability for payments made by the claimant or his private insurance. The Court did note that there is support in case law for an approach in which the Commission directs unpaid medical bills for which the employer is liable directly to the medical provider. However, this was not the case here. Therefore, the Commission erred by directing the City to satisfy its liability for past medical in the amount of $32,526.48 to the claimant’s medical providers rather than to the claimant. The issue of attorney’s fees on the past medical was remanded to the Commission.

Commission Decided to Strike Employer/Insurer’s Brief Due to Bogus Citations

Daniel Justin Gazaway v. Nostrum Pharmaceuticals, LLC, Injury No. 22-074974

FACTS: The claimant was employed at the insured from August 2020 until March 25, 2022. He worked on three different machines which compounded calcium acetate. He alleged health problems due to being exposed to dust particles from the calcium acetate. The claimant did undergo various treatments and obtained medical reports concluding that the claimant’s symptoms, which included difficulties breathing, asthma, and sinusitis, were related back to his exposure. The employer did send him to Dr. Bhalla who noted that he really could not comment on causation. The ALJ found that the claimant met his burden in proving that his work was the prevailing factor in causing his condition based on the testimony of two of the claimant’s experts. The judge noted there was no evidence that any other factors contributed to the claimant’s condition. The ALJ assessed 35% disability, found the employer responsible for $114,439.35 in past medical, and did find the employer was also responsible for future medical treatment and past TTD. The employer appealed and the Commission set a briefing schedule.

HOLDING: In reviewing employer/insurer’s brief it noted several citations to non-existent cases, specifically three separate cases. The Commission noted that Missouri Courts have found that filing a brief with bogus citations represents a flagrant violation of duties of candor that all parties owe to a Tribunal. The Commission noted that per its rules the Commission upon its own motion can decline to consider any brief or any portion of a brief that is not filed within accordance with its rules. In light of the fictious references included in the employer/insurer’s brief, the Commission decided to strike the employer/insurer’s brief in its entirety on its own motion. The Commission urged all parties whether members of the bar or pro se to be cognizant that they are aware of this issue and will not permit fraud on the Commission. The Commission did find that the ALJ’s Award was supported by competent and substantial evidence and affirmed the same.

The Nebraska Workers' Compensation Court has announced plans to relocate its Lincoln office later this summer.

The Court will move from its current location at 1010 Lincoln Mall to Center on N, located at 1221 N Street in Lincoln. The new location is just a few blocks from the Court’s existing office.

At this time, the Office of the Court will continue operating from 1010 Lincoln Mall, Suite 100, until further notice. Court officials have indicated that additional updates—including any temporary service adjustments impacting scheduled hearings or trials—will be provided as more information becomes available.

Operations at the Hall of Justice in Omaha, as well as administrative personnel currently located at 1221 N Street, Suite 402, will remain unchanged.

The Court expressed its commitment to continuing to serve the public and looks forward to operating from its new location.

For additional information regarding workers’ compensation in Nebraska, visit the Court’s website or contact the Information Line at 402-471-6468 or 800-599-5155.

On January 1, 2026, the Delaware Family and Medical Leave Insurance Program began to accept claims.

The Delaware Department of Labor has created a forty-page Guide for Employers & Third Party Administrators that discusses eligibility, coverage, and reporting under the program.

The Guide is a helpful document for Employers to understand their responsibilities during the reporting and claims process.

We invite you to contact any attorney in our liability department for assistance in navigating this new administrative claims process in Delaware.

On February 13, 2026, The Alabama Court of Civil Appeals released its opinion in the matter styled Professional Education Services Group, LLC (“PESG”) v. Richard A. Ford., wherein it affirmed a PTD verdict, in part.  The case revolved around Ford’s claim that he sustained a left shoulder injury during his employment with PESG, which rendered him unable to return to his previous work or find other gainful employment. ​

Ford, a former HVAC mechanic, suffered a shoulder injury in June 2019 after tripping and falling at work. ​ Following surgery and treatment, he was assigned sedentary work restrictions, which were incompatible with his previous career in heavy-duty HVAC work. ​ A vocational expert concluded that Ford had a 100% vocational disability and was incapable of obtaining or maintaining competitive employment. ​ The trial court determined that Ford was permanently and totally disabled due to his shoulder injury, not his unrelated heart condition. ​ The court awarded Ford compensation for the remainder of his natural life. ​

PESG appealed the judgment, arguing that the evidence was insufficient to support the finding of permanent total disability. ​ PESG claimed that no medical or expert testimony explicitly stated Ford was incapable of gainful employment and that his heart condition, not his shoulder injury, was the cause of his disability. ​

The Court of Appeals affirmed the trial court’s finding that Ford was permanently and totally disabled due to his shoulder injury. ​ The court noted that Ford’s testimony about his pain and inability to work, combined with the vocational and medical evidence, constituted substantial evidence to support the trial court’s decision. ​ However, the portion of the judgment that awarded Ford PTD for the remainder of his natural life was reversed.  As the Court pointed out, compensation for PTD is limited to the duration of the disability, not the employee’s lifetime. ​

​My Two Cents:

Even with its opinion being release the day before Valentines Day, the Court refused to give much credence to matters of the heart.

About the Author:

This article was prepared by Mike Fish, an attorney with Fish Nelson & Holden, LLC, a law firm dedicated to representing self-insured employers, insurance carriers and funds, and third-party administrators in all matters related to workers’ compensation. Fish Nelson & Holden is a member of the National Workers’ Compensation Defense Network. If you have any questions about this article or Alabama workers’ compensation in general, please contact Fish by e-mailing him at mfish@fishnelson.com or by calling him directly at 205-332-1448.

CALIFORNIA 2026 NEWS

Beginning January 1, 2026, the following laws take effect for all injuries occurring on or after 1/1/26 unless otherwise noted:

·       SB 230 expands rebuttable presumptions for firefighters by extending coverage for cancer, PTSD, and other injuries to firefighters working at commercial airports. It also broadens presumptions for conditions such as pneumonia to firefighters serving at commercial airports, NASA installations, and U.S. Department of Defense facilities, further strengthening presumptive coverage for high-risk public safety work environments.

·       AB 1125 extends the heart injury presumption to peace officers employed by the State Department of State Hospitals, affording them the same presumptive benefits previously limited to officers at Atascadero State Hospital. The change recognizes the comparable occupational risks faced by these workers.

Beginning February 1, 2026, employers are required to provide a stand-alone written notice to current employees and new employees upon hire, in a manner the employer normally uses to communicate job or employment information, with information related to employee rights, including:

• Workers’ compensation benefits (including disability pay and medical care for work-related injuries or illness, and the contact information for the Division of Workers’ Compensation)
• Notice of inspection by immigration agencies. Labor Code 90.2
• Protection against unfair immigration-related practices against a person exercising protected rights. Labor Code 1019-1019.2.
• The right to organize a union or engage in a concerted activity in the workplace, and Constitutional protections when interacting with law enforcement at the workplace (i.e., fourth amendment protection against unreasonable searches and seizure, and fifth amendment protection against self-incrimination and right to due process)
• Rights when interacting with law enforcement at the work place, including immigration.  US Const 4^th and 5^th Amendment. 

D.C. Law 26-42. Parity in Workers’ Compensation Recovery Amendment Act of 2025.

            In July of 2025, the Parity in Workers’ Compensation Recovery Amendment Act of 2025 amended the District of Columbia Workers’ Compensation Act of 1979. This law allows claimants who received an award or payment of compensation in another state to receive compensation for the same injury or death in DC. However, if the claimant was already awarded compensation from the other state, D.C. will reduce the amount they already received from the other state.  This amendment applies to all claims that were still pending as of June 28, 2022 and all claims after that. This law became effective on October 1, 2025.

New D.C. Compensation Rates

The newest D.C. Compensation minimum temporary total disability and permanent partial disability rate as of 1/1/2026 are $463.02. The maximum temporary total disability and permanent partial disability rate as of 1/1/2026 is $1,852.07. Additionally, the maximum penalty for a late payment is now $7,500.

Minimum Wage

Beginning July 1, 2026, the minimum wage in D.C. will increase from $17.95 per hour to $18.40 per hour for all workers, regardless of the size of the employer. As of July 21, 2026, the base minimum wage for tipped employees will increase to $10.30 per hour. This affects workers’ compensation costs for employes because the higher their wages are, the more injured workers can receive. 

Nevada Workers’ Compensation Law Update
SB 7 (2025 Special Session): Expansion of First Responder Occupational Disease Presumptions

Nevada enacted Senate Bill 7 during the 2025 Special Session, significantly expanding occupational disease presumptions for first responders.

Senate Bill 7 expands workers’ compensation occupational disease presumptions for firefighters and other first responders, making it easier for them to establish that certain diseases are work-related. The law strengthens the presumption framework by shifting more of the evidentiary burden to employers and insurers.

SB 7 became effective immediately on November 29, 2025 and is structured to apply to claims that were pending and not finally adjudicated as of that date, not just future filings. As a result, active litigation and previously denied claims may be reevaluated under the expanded presumption standard.

https://www.leg.state.nv.us/App/NELIS/REL/36th2025Special/Bill/13004/Overview

• Average Weekly Wage: Based on wages earned in 52 weeks prior to the injury; $30 minimum.  Average annual earnings are equal to 50 times AWW (§102.11(1)(2)).
• Burial Expenses: Effective 05/01/10, maximum burial expense is $10,000 (§102.50).
• Death Benefit: Up to four years’ average annual wage (200 times average weekly wage but see secs. 102.46-51 Wis. Stats. for specific conditions).  Payments are paid weekly at TTD rate (§102.48(3)).  2026 maximum wage rate increases death benefit for fatal injuries occurring on or after January 1, 2026 to $412,500; Un-estranged parents benefit remains at $6,500.00; $20,000 payment into State Fund (§102.49)
• Disfigurement: Up to one year’s wages, subject to maximum ($102,125 max as of 01/01/26, §102.56); only applicable if Applicant does not return to work.
• Fractional Weeks: TTD benefits are paid for each day except Sunday, at the daily rate of one-sixth of the weekly rate (§102.11).
• Maximum Meal Allowance: Breakfast - $8; Lunch - $9; Dinner - $17.
• Medical Records: Health care providers must furnish certified copies of relevant records upon request.  Charges may not exceed the greater of $.45 per page or $7.50 per request, plus actual postage, or $26 per request for electronic records (§102.13(2)(b)).
• Medical Treatment: No limit on medical treatment reasonably and necessarily required to cure or relieve the injury (§102.42(1)).  Please note that Wisconsin does not have a fee schedule.
• Medicare Set Aside Thresholds:  If the Applicant has a “reasonable expectation” of Medicare entitlement within 30 months and the settlement exceeds $250,000 OR if the Applicant is currently a Medicare beneficiary and the settlement exceeds $25,000, a MSA can be submitted to CMS.   “Reasonable expectation” includes Applicants that are 62 ½ years old, or on Social Security Disability, or appealing a Social Security Disability determination.
• Mileage: As of 7/1/12 = $0.51 per mile
• Multiple Injury Variations: Benefits are increased if an injury causes more than one compensable permanent disability (see sec. 102.53, Wis. Stats.).  Schedule applicable to proximal injuries is reduced by disability resulting from more distal injuries (see DWD 80.50).
• Permanent Partial Disability (PPD): Rate is set by statute.  Maximum rate depends on injury date.  Unscheduled injuries are measured by functional limitations or loss of earning capacity, whichever is greater. 
• Statute of Limitations: *6 years prior to 01/01/78       *10 years as of 01/01/78     *12 years as of 05/13/80 *6 years for traumatic injuries as of 3/2/16 (occupational injuries remain at 12 years)

The statute of limitations has been eliminated for injuries resulting in loss or total impairment of hand or any part of rest of arm proximal to hand, foot or any part of rest of leg proximal to foot, any loss of vision, any permanent brain injury or any injury causing need for total or partial knee or hip replacement.  Said claims shall be covered under Work Injury Benefit Supplemental Fund under secs. 102.17(4) and 102.66(1)(2), Stats., if the last date of compensation or injury was before 4/1/06; otherwise, it is the carrier’s responsibility.

• Supplemental Benefits: Maximum benefit rate increased to $669 per week as of 03/02/16 (§102.44(1)).
• Temporary Partial Disability (TPD):  TPD rate is the ratio of actual wage loss during disability to average weekly wage times the TTD rate (i.e., an employee limited to half-time work receives one-half the TTD rate - §102.43(2)(3)).
• Temporary Total and Permanent Total Disability (TTD & PTD): Two-thirds of average weekly wage.  Maximum rate depends on date of injury; PTD benefits are paid for life (§102.11 & 102.44).
• Unreasonable Refusal to Rehire: Maximum penalty of up to one year’s wages. (§102.35(3)).
• Vocational Rehabilitation: TTD and travel expenses are paid during training.  For claims after 4/16/12, also responsible for tuition, books, and fees.  If training takes place away from the employee’s residence, actual and necessary maintenance expenses are also paid (§102.61).
• Vocational Rehabilitation Limit: The maximum annual limit for services provided by private vocational rehabilitation specialists is $2,183.00 (effective 01/01/26).
• Waiting Period: Three days.  If disability (temporary or permanent) exists after 7-calendar days from the date the employee leaves work as a result of the injury, benefits are paid for the waiting period (§102.43).