Proposed Rule(s) Filing Form

Transcription

1 ~ ~-- Department of State Division of Publications 312 Rosa L. Parks Avenue, 8th Floor Snodgrass/TN Tower Nashville, TN Phone: Fax: reg For Department of State Use Only Sequence Number: Rule D(s): File Date: Effective Date: Proposed Rule(s) Filing Form Proposed rules are submitted pursuant to T. C.A , in lieu of a rulemaking hearing. t is the intent of the Agency to promulgate these rules without a rulemaking hearing unless a petition requesting such hearing is filed within sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. To be effective, the petition must be filed with the Agency and be signed by twenty-five (25) persons who will be affected by the amendments, or submitted by a municipality which will be affected by the amendments, or an association of twenty-five (25) or more members, or any standing committee of the General Assembly. The agency shall forward such petition to the Secretary of State ~ - Agen9/B~a!~l~(?m_~i~~io!1: Dep-9_rt_m_en!_ of L lbo_r a~~ \f\!orkforc~ D~~~lq~ment. Djvisio~: Bu~ea!:J of Workers' Q_ompensation. Contact Person: _roy _l::lale3_y _ Address:. 220 French Landing Drive Side 1-B, Nashville.Tennessee Zip: Phone: (615) '. froy.haley@tn.go v Revision Type (check all that apply): x Amendment New Repeal Rule(s) Revised (ALL chapters and rules contained in filing must be listed here. f needed, copy and paste additional tables to accommodate multiple chapters. Please enter only ONE Rule Number/Rule Title per row) Chapter Number Chapter Title Mediation and Hearing Procedures Rule Number Rule Title Forms SS-7038 (October 2017) RDA 1693

2 (Place substance of rules and other info here. Statutory authority must be given for each rule change. For information on formatting rules go to Amendments Rule is amended by adding the following: Chapter Mediation and Hearing Procedures (1) Pursuant to T.C.A , the following statistical data form is to be used for settlements approved by the court of workers' compensation claims involving injuries occurring on or after July 1, 2014: Tennessee Bureau of Workers' Compensation 220 French Landing Drive, -B Nashville, TN STATSTCAL DATA FORM FOR NJURES ON/AFTER JULY 1, 2014-Form SD-2 EMPLOYEE NFORMATON Docket# State File# *Date of njury Employee Last Name First Name M SSN Date of Birth Year of Hire Education Level D Less Than High School D High School D More than High School CLAM/NJURY NFORMATON ~~~~~~~~== =~~~~~~ Employer s Employer Self-nsured? 0 Yes 0 s Employer a member of the Bureau's Tennessee Drug Free Workplace Program? (select one) D Yes D No nsurer TPA njury occurred in TN D Yes 0 No County of njury First date out of work Date of return to work Total # of days lost No Date of MM ATP mpairment Rating% Average Weekly Wage Was claim denied? D Yes O No Compensation Rate f yes, basis of denial?o Statute of limitations D Notice D Not Work-Related Vocational Assessment performed? D Yes D No D ntoxication!+ Drug Test 0 0ther (Specify) Nature of Primary njury/body Part Occupational lllness D Yes D No Chiropractic Treatment? D Yes D No Physical Therapy? D Yes D No Case Manager? D Yes D No Was there an Employee ME?O Yes D No Was there an Employer ME?O Yes D No f yes, mpairment Rating% f yes, mpairment Rating% SETTLEMENT/ HEARNG NFORMATON ~ Type of Conclusion: D Compensation Hearing D Settlement Approval SS-7038 (October 2017) 2 RDA 1693

3 Was Bureau Mediation conducted? D Yes D No f yes, was dispute resolved in mediation? D Yes D No f concluded by a Compensation Hearing: Style of Case Date ofhearing Name of Approving/Hearing Judge Date of Settlement Approval mpairment Rating % used to settle the claim Has nitial Compensation Period expired? O Yes 0 No fno, insert date this Period will expire PPD increased benefits awarded? 0 Yes 0 No Vocational mpairment for ncreased Benefits f yes, check all that apply: D Did not return to work D 40+ years old D County Unemployment Rate D Education level Was there a trial for increased benefits 0 Yes 0 No Was there a judgment for increased benefits? 0Yes 0No Was there a judgment for the Employer? D Yes O No f yes, what was the basis: O statute oflimitations 0 Notice D Not work related D No permanency D ntoxication 0 Willful Misconduct Other Did Employee return to work for any Employer? 0 Yes D No f yes, was return to work pay D Less D same D Higher Was claim settled pursuant to T.C.A (e)? D Yes 0 No SECOND NJURY FUND NFORMATON Was there a judgment entered against the Subsequent njury and Vocational Recovery Fund? D Yes 0 No fthere was a judgment against the Subsequent njury and Vocational Recovery Fund, how was the settlement apportioned? Employer% # of Weeks Subsequent njury and Vocational Recovery Fund% # of Weeks Permanent Total Disability (including those to be paid)! i ncreased PPD Benefits Death Benefits (including those to be paid) Burial Benefits Medical Benefits MONETARY AMOUNTS PAD Temporary Total Disability # of weeks, or $! # of days Temporary Partial Disability # of weeks, or $ i # of days Permanent Partial Disability PPD% # of days i PTO% J : # of weeks, or $ l # of weeks, or $ ' i # of days i - $ 1 $ $ SS-7038 (October 2017) 3 RDA 1693

4 Future Medical Expenses Closure Date closed i After prior settlement? $ ) 0Yes 0No ---- Lump Sum per (e) Amount of Settlement Paid in Lump Sum: $ (SSA requirement) ( do not include this amount in total) ' $ Total Paid for all above columns $ Date Settlement Lump Sum Paid: Employee's Attorney Fee$ % of Settlement Was fee approved by Court? D Yes D No Employer's Attorney Fee Range D Under $1,500 O$1,501-$3,000 D $3,001-$10,000 D Over $10,000 Certification and Signatures: By providing my BPR Number and my signature, hereby certify that have read the contents of the form and the information provided is true and correct to the best ofmy knowledge. Printed name of Employee Signature Date Printed name of Employee's Attorney BPR# Signature Date Printed name of Adjuster Signature Date Printed name of Employer's Attorney BPR# Signature Date Authority: T.C.A , , SS-7038 (October 2017) 4 RDA 1693

5 * f a roll-call vote was necessary, the vote by the Agency on these rules was as follows: Board Member Aye No Abstain Absent Signature (if required) certify that this is an accurate and complete copy of proposed rules, lawfully promulgated and adopted by the (board/commission/other authority) on ll/ /01/7 (date as mmlddlyyyy), and is in compliance with the provisions of T.C.A The Secretary of State is hereby instructed that, in the absence of a petition for proposed rules being filed under the conditions set out herein and in the locations described, he is to treat the proposed rules as being placed on file in his office as rules at the expiration of sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. Date: Signature: Name of Officer: Title of Officer: _A_d_m_in_is_t_ra_t_or~, _B_u_re_a_u_o_f_W_o_rk_e_r_s'_C_o_m_, pe_n_s_a_ti_o_n Notary Public Signature: - ~---~cl{ Subscribed and sworn to before me on: _4"1 ~--.---~-l-~--+f -o)_o_l-_l ~ = _'.'.Ul\l ~----, My commission expires on: ;;;,/'-t_c,,_.l_'a! _D All proposed rules provided for herein have been examined by the Attorney General and Reporter of the State of Tennessee and are approved as to legality pursuant to the provisions of the Administrative Procedures Act, Tennessee Code Annotated, Title 4, Chapter 5. Department of State Use Only -divj.w- tl&~ Attorney ener and~ eporter J,O({ Date ',! : r'""'. l.n l CD w Li... w r'- "'(:J.: f--cf) if) ;,i~ Lt... c- r=., ;=. Filed with the Department of State on: Effective on:, Tre Hargett Secretary of State SS-7038 (October 2017) 5 RDA 1693

6 Regulatory Flexibility Addendum Pursuant to T.C.A through , prior to initiating the rule making process as described in T.C.A (a)(3) and T.C.A (a), all agencies shall conduct a review of whether a proposed rule or rule affects small businesses. 1. The type or types of small business and an identification and estimate of the number of small businesses subject to the proposed rule that would bear the cost of, or directly benefit from the proposed rule: The rule will affect small employers that fall under the Tennessee Workers' Compensation Laws, which would be employers with at least five employees, or for those in the construction industry at least one employee. There should be no additional costs associated with these rule changes. 2. The projected reporting, recordkeeping and other administrative costs required for compliance with the proposed rule, including the type of professional skills necessary for preparation of the report or record : There is no additional record keeping requirement or administrative cost associated with these rule changes. 3. A statement of the probable effect on impacted small businesses and consumers: These rules should not have any impact on consumers or small businesses..4'. A description of any less burdensome, less intrusive or less costly alternative methods of achieving the purpose -': and objectives o'f the proposed rule that may exist, and to what extent the alternative means might be less burdensome to small business: There are no less burdensome methods to achieve the purposes and objectives of these rules. 5. Comparison of the proposed rule with any federal or state counterparts: None. 6. Analysis of the effect of the possible exemption of small businesses from all or any part of the requirements contained in the proposed rule: None. SS-7038 (October 2017) 6 RDA 1693

7 mpact on Local Governments Pursuant to T.C.A and "any rule proposed to be promulgated shall state in a simple declarative sentence, without additional comments on the merits of the policy of the rules or regulation, whether the rule or regulation may have a projected impact on local governments." (See Public Chapter Number 1070 ( us/sos/acts/106/pub/pc1070. pdf) of the 2010 Session of the General Assembly) This proposed rule will have little, if any, impact on these entities. SS-7038 (October 2017) 7 RDA 1693

8 Additional nformation Required by Joint Government Operations Committee All agencies, upon filing a rule, must also submit the following pursuant to T.C.A (i)(1 ). (A) A brief summary of the rule and a description of all relevant changes in previous regulations effectuated by such rule; This form (SD-2), as promulgated, is a simplified version of the pre-reform SD-1 form that has been in both prereform and post-reform settlements. The SD-2 form will be used in workers' compensation settlements that are a roved b the Court of WC Claims in est-reform cases in uries occurrin on/after 7/1/14. (B) A citation to and brief description of any federal law or regulation or any state law or regulation mandating promulgation of such rule or establishing guidelines relevant thereto; T.C.A (a) requires the development or alternation of the bureau's statistical data form to be promulgated by rule, pursuant to the Uniform Administrative Procedures Act, compiled in Tennessee Code Annotated, title 4, chapter 5. (C) dentification of persons, organizations, corporations or governmental entities most directly affected by this rule, and whether those persons, organizations, corporations or governmental entities urge adoption or rejection of this rule; Employees and employers may be affected by the promulgation of this form, which is a simplified version of an existin form. No entit has ur ed ado tion or re ection of these rules. (D) dentification of any opinions of the attorney general and reporter or any judicial ruling that directly relates to the rule; None (E) An estimate of the probable increase or decrease in state and local government revenues and expenditures, if any, resulting from the promulgation of this rule, and assumptions and reasoning upon which the estimate is based. An agency shall not state that the fiscal impact is minimal if the fiscal impact is more than two percent (2%) of the agency's annual budget or five hundred thousand dollars ($500,000), whichever is less; The effect of the rule change will be negligible. (F) dentification of the appropriate agency representative or representatives, possessing substantial knowledge and understanding of the rule; Troy Haley, Director of Administrative Legal Services and Legislative Liaison (G) dentification of the appropriate agency representative or representatives who will explain the rule at a scheduled meeting of the committees; Troy Haley, Director of Administrative Legal Services and Legislative Liaison (H) Office address, telephone number, and address of the agency representative or representatives who will explain the rule at a scheduled meeting of the committees; and Tennessee Bureau of Workers' Compensation 220 French Landing Drive, Floor 1-B, Nashville TN (615) trov.halev@tn.qov () Any additional information relevant to the rule proposed for continuation that the committee requests. SS-7038 (October 2017) 8 RDA 1693

9 None SS-7038 (October 2017) 9 RDA 1693

10 Department of State Division of Publications 312 Rosa L. Parks Avenue, 8th Floor SnodgrassrrN Tower Nashville, TN Phone: Fax: For Department of State Use Only Sequence Number: Rule D(s): File Date: Effective Date: Proposed Rule{s) Filing Form Proposed rules are submitted pursuant to TC.A , in lieu of a rule making hearing. t is the intent of the Agency to promulgate these rules without a rulemaking hearing unless a petition requesting such hearing is filed within sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. To be effective, the petition must be filed with the Agency and be signed by twenty-five (25) persons who will be affected by the amendments, or submitted by a municipality which will be affected by the amendments, or an association of twenty-five (25) or more members, or any standing committee of the General Assembly. The agency shall forward such petition to the Secretary of State. Agency/Board/Commission: Division: Contact Person: Address: Zip: Phone: Department of Labor and Workforce Development Bureau of Workers' Compensation Troy Haley 220 French Landing Drive Side 1-B, Nashville, Tennessee (615) troy. haley@tn.gov Revision Type (check all that apply): x Amendment New Repeal Rule(s) Revised (ALL chapters and rules contained in filing must be listed here. f needed, copy and paste additional tables to accommodate multiple chapters. Please enter only ONE Rule Number/Rule Title per row) Chapter Number Chapter Title Mediation and Hearing Procedures Rule Number Rule Title - L Forms j! -j SS-7038 (October 2017) RDA 1693

11 (Place substance of rules and other info here. Statutory authority must be given for each rule change. For information on formatting rules go to Amendments Chapter Mediation and Hearing Procedures Rule is amended by adding the following: (1) Pursuant to TC.A , the following statistical data form is to be used for settlements approved by the court of workers' compensation claims involving injuries occurring on or after July 1, 2014: Tennessee Bureau of Workers' Compensation 220 French Landing Drive, 1-B Nashville, TN ST A TS T CAL DATA FORM FOR NJURES ON/ AFTER JULY 1, 2014-Form SD-2 EMPLOYEE NFORMATON Docket# State File# *Date of njury Employee Last Name First Name M SSN Date of Birth Year of Hire Education Level D less Than High School D High School D More than High School CLAM/NJURY NFORMATON - - Employer s Employer Self-nsured? D Y es 0 No ls Employer a member of the Bureau's Tennessee Drug Free Workplace Program? (select one) D Yes D No nsurer TPA njury occurred in TN D Yes 0 No County of njury First date out of work Date of return to work Total # of days lost Date of MM ATP mpairment Rating% Average Weekly Wage Compensation Rate Was claim denied? D Yes O No f yes, basis of denial? O Statute of limitations D Notice D Not Work-Related Vocational Assessment performed? 0 Yes D No D ntoxication!+ Drug Test O Other (Specify) Nature of Primary njury/body Part Occupational llness D Yes D No Chiropractic Treatment? O Yes D No Physical Therapy? D Yes D No Case Manager? D Yes D No Was there an Employee ME?O Yes D No f yes, mpairment Rating% Was there an Employer ME? o Yes D No f yes, mpairment Rating% SETTLEMENT/ HEARNG NFORMATON Type of Conclusion: D Compensation Hearing D Settlement Approval SS-7038 (October 2017) 2 RDA 1693

12 Was Bureau Mediation conducted? D Yes D No f yes, was dispute resolved in mediation? D Yes D No f concluded by a Compensation Hearing: Style of Case Date of Hearing Name of Approving/Hearing Judge Date of Settlement Approval mpairment Rating% used to settle the claim Has nitial Compensation Period expired? O Yes 0 No fno, insert date this Period will expire PPD increased benefits awarded? 0 Yes 0 No Vocational mpairment for ncreased Benefits f yes, check all that apply: D Did not return to work D 40+ years old D County Unemployment Rate D Education level Was there a trial for increased benefits 0 Yes 0 No Was there a judgment for increased benefits? 0 Yes 0 No Was there a judgment for the Employer? D Yes O No f yes, what was the basis: O statute oflimitations 0 Notice D Not work related D No permanency D ntoxication o wmrul Misconduct Other Did Employee return to work for any Employer? 0 Yes D No f yes, was return to work pay D Less O same D Higher Was claim settled pursuant to T.C.A (e)? D Yes 0 No SECOND NJURY.FUND NFORMATON Was there a judgment entered against the Subsequent njury and Vocational Recovery Fund? 0 Yes 0 No f there was a judgment against the Subsequent njury and Vocational Recovery Fund, how was the settlement apportioned? Employer% # of Weeks Subsequent njury and Vocational Recovery Fund% # of Weeks MONETARY AMOUNTS PAD Temporary Total Disability Temporary Partial Disability Permanent Partial Disability Permanent Total Disability (including those to be paid) ncreased PPD Benefits Death Benefits (i ncluding those to be paid) Burial Benefits Medical Benefits # of weeks, or $ # of days # of weeks, or $ # of days PPD % # of weeks, or $ # of days PTO% # of weeks, or $ # of days $ $ $ $ SS-7038 (October 2017) 3 RDA 1693

13 Future Medical Expenses Closure ---j-date closed After prior settlement? $ J 0Yes 0No f ~---- Lump Sum per (e) $ Amount of Settlement Paid in Lump Sum: $ (SSA requirement) ( do not include this amount in total) Total Paid for all above columns $ Date Settlement Lump Sum Paid: Employee's Attorney Fee$ % of Settlement Was fee approved by Court? D Yes D No Employer's Attorney Fee Range D Under $1,500 O$1,501-$3,000 D $3,001-$10,000 D Over $10,000 Certification and Signatures: By providing my BPR Number and my signature, hereby certify that have read the contents of the form and the information provided is true and correct to the best of my knowledge. Printed name of Employee Signature Date Printed name of Employee's Attorney BPR# Signature Date - Printed name of Adjuster Signature Date Printed name of Employer's Attorney BPR# Signature Date Authority: T.C.A , , SS-7038 (October 2017) 4 RDA 1693

14 * f a roll-call vote was necessary, the vote by the Agency on these rules was as follows: Board Member Aye No Abstain Absent Signature (if required) certify that this is an accurate and complete copy of proposed rules, lawfully promulgated and adopted by the (board/commission/other authority) on (date as mmldd/yyyy), and is in compliance with the provisions of T.C.A The Secretary of State is hereby instructed that, in the absence of a petition for proposed rules being filed under the conditions set out herein and in the locations described, he is to treat the proposed rules as being placed on file in his office as rules at the expiration of sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. Date: Signature: Name of Officer: _A_b_bi_e_H_u_d_g~e_n_s Title of Officer: Administrator, Bureau of Workers' Compensation Subscribed and sworn to before me on: Notary Public Signature: My commission expires on: All proposed rules provided for herein have been examined by the Attorney General and Reporter of the State of Tennessee and are approved as to legality pursuant to the provisions of the Administrative Procedures Act, Tennessee Code Annotated, Title 4, Chapter 5. Department of State Use Only Herbert H. Slatery ll Attorney General and Reporter Date Filed with the Department of State on: Effective on: Tre Hargett Secretary of State SS-7038 (October 2017) 5 RDA 1693

15 Regulatory Flexibility Addendum Pursuant to T.C.A through , prior to initiating the rule making process as described in T.C.A (a)(3) and T.C.A (a), all agencies shall conduct a review of whether a proposed rule or rule affects small businesses. 1. The type or types of small business and an identification and estimate of the number of small businesses subject to the proposed rule that would bear the cost of, or directly benefit from the proposed rule: The rule will affect small employers that fall under the Tennessee Workers' Compensation Laws, which would be employers with at least five employees, or for those in the construction industry at least one employee. There should be no additional costs associated with these rule changes. 2. The projected reporting, recordkeeping and other administrative costs required for compliance with the proposed rule, including the type of professional skills necessary for preparation of the report or record: There is no additional record keeping requirement or administrative cost associated with these rule changes. 3. A statement of the probable effect on impacted small businesses and consumers: These rules should not have any impact on consumers or small businesses. 4. A description of any less burdensome, less intrusive or less costly alternative methods of achieving the purpose and objectives of the proposed rule that may exist, and to what extent the alternative means might be less burdensome to small business: There are no less burdensome methods to achieve the purposes and objectives of these rules. 5. Comparison of the proposed rule with any federal or state counterparts: None. 6. Analysis of the effect of the possible exemption of small businesses from all or any part of the requirements contained in the proposed rule: None. SS-7038 (October 2017) 6 RDA 1693

16 mpact on Local Governments Pursuant to T.C.A and "any rule proposed to be promulgated shall state in a simple declarative sentence, without additional comments on the merits of the policy of the rules or regulation, whether the rule or regulation may have a projected impact on local governments." (See Public Chapter Number 1070 ( of the 2010 Session of the General Assembly) This proposed rule will have little, if any, impact on these entities. SS-7038 (October 2017) 7 RDA 1693

17 Additional nformation Required by Joint Government Operations Committee All agencies, upon filing a rule, must also submit the following pursuant to T.C.A (i)(1 ). (A) A brief summary of the rule and a description of all relevant changes in previous regulations effectuated by such rule; This form (SD-2), as promulgated, is a simplified version of the pre-reform SD-1 form that has been in both prereform and post-reform settlements. The SD-2 form will be used in workers' compensation settlements that are a roved b the Court of WC Claims in est-reform cases in uries occurrin on/after 7/1/14. (B) A citation to and brief description of any federal law or regulation or any state law or regulation mandating promulgation of such rule or establishing guidelines relevant thereto; T.C.A (a) requires the development or alternation of the bureau's statistical data form to be promulgated by rule, pursuant to the Uniform Administrative Procedures Act, compiled in Tennessee Code Annotated, title 4, chapter 5. (C) dentification of persons, organizations, corporations or governmental entities most directly affected by this rule, and whether those persons, organizations, corporations or governmental entities urge adoption or rejection of this rule; Employees and employers may be affected by the promulgation of this form, which is a simplified version of an existin form. No entit has ur ed ado tion or re ection of these rules. (D) dentification of any opinions of the attorney general and reporter or any judicial ruling that directly relates to the rule; None (E) An estimate of the probable increase or decrease in state and local government revenues and expenditures, if any, resulting from the promulgation of this rule, and assumptions and reasoning upon which the estimate is based. An agency shall not state that the fiscal impact is minimal if the fiscal impact is more than two percent (2%) of the agency's annual budget or five hundred thousand dollars ($500,000), whichever is less; The effect of the rule change will be negligible. (F) dentification of the appropriate agency representative or representatives, possessing substantial knowledge and understanding of the rule; Troy Haley, Director of Administrative Legal Services and Legislative Liaison (G) dentification of the appropriate agency representative or representatives who will explain the rule at a scheduled meeting of the committees; Troy Haley, Director of Administrative Legal Services and Legislative Liaison (H) Office address, telephone number, and address of the agency representative or representatives who will explain the rule at a scheduled meeting of the committees; and Tennessee Bureau of Workers' Compensation 220 French Landing Drive, Floor 1-B, Nashville TN (615) troy. haley@tn. qov () Any additional information relevant to the rule proposed for continuation that the committee requests. SS-7038 (October 2017) 8 RDA 1693

18 None SS-7038 (October 2017) 9 RDA 1693