WSR 06-06-065

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed February 28, 2006, 11:09 a.m. , effective April 1, 2006 ]


     Effective Date of Rule: April 1, 2006.

     Purpose: Residence modification, chapter 296-14 WAC, Industrial insurance. Pursuant to chapter 411, Laws of 2005 (EHB 2185), L&I was directed to implement rules that will establish guidelines and processes for providing residence modification assistance to workers who have sustained catastrophic injury.

     Statutory Authority for Adoption: RCW 51.04.010, 51.04.020, 51.32.240, and chapter 411, Laws of 2005 (EHB 2185).

      Adopted under notice filed as WSR 05-22-084 on November 1, 2005.

     Changes Other than Editing from Proposed to Adopted Version: WAC 296-14-6200 What is a residence modification?

•     Example added for clarity.


WAC 296-14-6206 Which residences may be eligible to be modified?

•     Amended wording to allow payment for a residence to be brought to state or local code when the work is required to complete a necessary and approved modification.


WAC 296-14-6210 What is the maximum amount of the residence modification benefit?

•     Amended wording to allow payment up to maximum benefit in effect at the time each residence modification is approved.


WAC 296-14-6212 Can the worker receive additional modification benefits for the same residence?

•     Amended wording to allow payment up to maximum benefit in effect at the time each residence modification is approved.


WAC 296-14-6222 What is a residence modification consultant, and how are they involved in the process of residence modification?

•     Amended wording to allow qualified department staff to provide residence modification services without obtaining a provider number.


WAC 296-14-6230 What will the supervisor consider when approving or denying a residence modification request?

•     Deleted subsection (11) because this element is no longer necessary as a result of the changes to WAC 296-14-6210 and 296-14-6212.


WAC 296-14-6238 Who receives payment from the department?

•     Amended wording to allow reimbursement to the worker for any payment already made to the contractor for approved and completed residence modification.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 21, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.

     Date Adopted: February 28, 2006.

Gary Weeks

Director

OTS-8375.2


NEW SECTION
WAC 296-14-6200   What is a residence modification?   A residence modification is a permanent change to an existing residence or a repair of a modification previously approved and paid for by the department or self-insured employer, or a modification made when constructing a new residence.

     Household appliances such as refrigerators, washers, and dryers, are generally not residence modifications and the department or self-insured employer will approve them only under unique circumstances as approved by the supervisor.

     Example: As part of an approved residence modification, the kitchen counters are lowered. To meet the needs of the worker, the department or self-insured employer may approve the purchase of a drop-in range or cooktop.

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NEW SECTION
WAC 296-14-6202   What is the residence modification benefit?   The residence modification benefit is a sum of money used to modify a worker's residence for purposes of safety, mobility and activities of daily living, when those modifications are made necessary by the nature of the worker's condition subsequent to a catastrophic injury. Activities of daily living are tasks required for self-care, communication and mobility and include, but are not limited to, bathing, bed mobility, dressing, eating, grooming, toileting and transfers.

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NEW SECTION
WAC 296-14-6204   Which workers may be eligible to receive benefits for residence modifications?   Residence modification benefits are only available to workers with an allowed catastrophic injury claim. Catastrophic injuries are the most serious of conditions and include, but are not limited to, head trauma, paralysis and amputation.

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NEW SECTION
WAC 296-14-6206   Which residences may be eligible to be modified?   Before the department or self-insured employer will consider an application for modification, the residence must meet the following criteria:

     (1) The residence must be structurally sound and free of obvious structural defects. The department may request a safety inspection. The department or self-insured employer will not pay for a residence to be brought up to state and local code except as required to complete a necessary and approved modification.

     (2) The residence can be adapted to be suitable for the worker's needs for purposes of daily living.

     (3) In the opinion of the worker's health care providers, the worker can live in the residence after modification.

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NEW SECTION
WAC 296-14-6208   When may the worker request residence modification benefits?   The worker may request residence modification at any time when his or her allowed claim is either open or the worker has been determined to be permanently and totally disabled.

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NEW SECTION
WAC 296-14-6210   What is the maximum amount of the residence modification benefit?   The maximum amount of the benefit is the state's average annual wage at the time that each modification request is approved. The department or self-insured employer will not pay for modifications that exceed the maximum amount. The department or self-insured employer may make several payments, so long as the total paid does not exceed the maximum benefit.

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NEW SECTION
WAC 296-14-6212   Can the worker receive additional modification benefits for the same residence?   The department can pay for additional or subsequent residence modifications so long as the cost does not exceed the maximum benefit in effect at the time that each modification request is approved.

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NEW SECTION
WAC 296-14-6214   Can a worker receive residence modification benefits for more than one house?   No. The department or self-insured employer will pay for residence modifications on only one residence for each catastrophically injured worker.

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NEW SECTION
WAC 296-14-6216   How can a worker begin the process of requesting residence modification benefits?   The worker may inquire about residence modification benefits by contacting his or her adjudicator. The department or self-insured employer will then refer the worker to a residence modification consultant for evaluation.

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NEW SECTION
WAC 296-14-6218   How does the department or self-insured employer determine the worker's residence for purposes of residence modification?   The department or self-insured employer will consider modifying a residence when the worker lives in and considers the residence to be his or her permanent residence. It is not required that the worker own or rent the residence.

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NEW SECTION
WAC 296-14-6220   What type of residence may the department or self-insured employer modify?   The department or self-insured employer may modify a standard house, a residential unit in a multiunit dwelling, or a manufactured/mobile residence.

     The department or self-insured employer will only authorize modification of manufactured/mobile residences when the factory assembled structures division of the department reviews and approves the plans in advance.

     The department or self-insured employer will not approve modification of commercial coaches.

     The department or self-insured employer will not approve modification of recreational vehicles or recreational park trailers used as permanent residences, unless the local jurisdiction allows recreational vehicles or recreational park trailers to be used as a dwelling, and the factory assembled structures division of the department reviews and approves the plans in advance.

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NEW SECTION
WAC 296-14-6222   What is a residence modification consultant, and how are they involved in the process of residence modification?   When the worker has notified the department or self-insured employer of his or her intention to request a residence modification, the department or self-insured employer will require an on-site evaluation by a residence modification consultant.

     A residence modification consultant must be either a licensed physical or occupational therapist, or licensed nurse, and must be trained or experienced in both rehabilitation of catastrophic injuries and in modifying residences. The department or self-insured employer will pay for the services of the residence modification consultant pursuant to department provider rules.

     The residence modification consultant will assist the worker, the contractor and the worker's health providers to determine what modifications will be requested and submit a written report to the department or self-insured employer and the worker. If modifications are approved, the residence modification consultant may assist the worker and the contractor if requested by the department or self-insured employer.

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NEW SECTION
WAC 296-14-6223   Will the department pay for professional services needed to design a residence modification?   Yes. However, the department or self-insured employer will not pay for professional services prior to approval of the residence modification.

     If approved, the cost of architectural, engineering, predesign and planning services will be included in the residential modification benefit. The cost for services should be included in the residence modification request.

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NEW SECTION
WAC 296-14-6224   What must the worker submit to the department in a completed request for a residence modification?   For the department to process a residence modification request, the worker must provide the adjudicator with at least the following information:

     (1) Documentation of residence ownership. If the worker does not own the residence, he or she must submit the actual owner's proof of ownership and written legal permission signed by the actual owner to modify the residence as indicated in the proposed plan; and

     (2) A report signed by the residence modification consultant for all necessary modifications; and

     (3) Competing and detailed bids from two licensed, registered and bonded contractors.

Exceptions: If it is not possible to obtain two bids, a written explanation of the circumstances must be provided.
If family or friends will perform free labor, they need not be licensed, registered and bonded, but must still submit a bid for the cost of materials.
     (4) A copy of the acknowledgment of responsibilities letter signed by both the worker and the contractor. A copy of this form can be obtained from the department.

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NEW SECTION
WAC 296-14-6226   What other information must be submitted to the department in a completed application for a residence modification?   (1) The attending health services provider may need to submit medical documentation verifying the worker's condition and the necessity for any residence modification.

     (2) The residence modification consultant must submit an evaluation, based on an in-home inspection, of the worker's needs for safety, mobility and activities of daily living. This evaluation must be in the form of a written report with pictures or drawings.

     (3) Any additional information requested by the department or self-insured employer that might be needed to evaluate a specific request.

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NEW SECTION
WAC 296-14-6228   Who will approve or deny a request for residence modification?   The department will pay the benefit only with the approval of the supervisor of industrial insurance. A self-insured employer may pay the benefit without the supervisor's approval, but may not deny the benefit. The supervisor of industrial insurance alone has the authority to deny a residence modification benefit.

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NEW SECTION
WAC 296-14-6230   What will the supervisor consider when approving or denying a residence modification request?   The supervisor will consider requests for residence modifications on a case-by-case basis. The supervisor may approve all or part of the requested modifications, based on what is reasonable and necessary for the individual worker.

     In order to determine what is reasonable and necessary, the supervisor will review the completed application and will consider at least the following:

     (1) Whether the worker is eligible to receive a residence modification benefit; and

     (2) The needs and preferences of the individual worker, based on information provided by the injured worker; and

     (3) Whether the proposed residence is appropriate for modification; and

     (4) Whether the proposed modifications are appropriate for the style, nature and condition of the residence; and

     (5) The attending health care provider's opinions of the medical condition, physical needs of the worker and whether the worker can reside in the residence after the modifications are complete; and

     (6) The residence modification consultant's evaluation of whether the proposed modification is necessary to meet the worker's current need for safety, mobility and activities of daily living; and

     (7) Whether the contractor's proposed plan will satisfy the necessary modification; and

     (8) Whether the proposed plans submitted by the contractors are consistent with state guidelines for specially adapted residential housing, if any; and

     (9) The contractor's proposed modification plan is consistent with the guidelines established by the United States Department of Veterans Affairs in their publication entitled "Handbook for Design: Specially Adapted Housing," or the recommendations published in "The Accessible Housing Design File" by Barrier Free Environments, Inc.; and

     (10) Whether the proposed modifications are being provided at the least cost while maintaining quality.

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NEW SECTION
WAC 296-14-6232   What happens if the residence modification costs exceed the maximum benefit?   The department or self-insured employer may approve a payment of a portion of a residence modification request, not to exceed the maximum benefit. The department or self-insured employer will identify the portions of the residence modification for which payment will be approved based on the worker's current need for safety, mobility and activities of daily living.

     If the costs of the proposed modifications of an existing residence exceed the benefit, the worker is responsible for payment of the balance of the costs. The worker must choose one of the following options:

     (1) Adjust their request for modifications to remain within the benefit; or

     (2) Obtain additional financing. If the worker chooses to obtain additional financing, he or she must submit to the department written verification of the additional financing from the funding source. The supervisor will deny the residence modification if the worker is unable to cover the additional costs.

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NEW SECTION
WAC 296-14-6234   Can a worker apply the residence modification benefit to the cost of building a new residence?   Yes. However, the benefit may be applied only to the cost difference between a standard residence structure and the modified structure.

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NEW SECTION
WAC 296-14-6236   How is a worker advised that the supervisor has approved or denied the request for residence modification benefits?   The department will notify the worker, contractors, homeowner (if not the worker), residence modification consultant, attending health services provider and employer of the supervisor's decision in writing.

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NEW SECTION
WAC 296-14-6238   Who receives payment from the department?   The department will pay the contractor directly and/or reimburse the worker for any payment already made to the contractor for approved and completed residence modifications. In order to determine that modifications have been satisfactorily completed, the department will require the following documents to be submitted before releasing final payment:

     (1) A signed letter of satisfaction from the worker; and

     (2) A positive report of a final inspection from the appropriate inspection authorities, if required; and

     (3) A report of an inspection from the residence modification consultant if requested by the department; and

     (4) A release of lien form signed by the contractors or subcontractors or both.

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