PFML and Private Insurance Plan Issues Template
Context: With the passing of the Massachusetts Paid Family Medical Leave Act (PFMLA), people who give birth can be eligible for up to 26 weeks of paid, protected leave (up to 14 weeks of medical leave, and 12 weeks of bonding leave). Although there are a few exceptions, most employees in MA are eligible for this leave (see: https://www.mass.gov/info-details/your-eligibility-for-paid-family-and-medical-leave-pfml).
The Department of Family Medical Leave (DFML) requires a medical provider to sign off on the amount of medical leave they recommend using this form, and does not require any additional documentation to justify the length of leave recommended. As part of PFMLA, employers may opt out of paying into the State’s fund by offering a private plan that offers equal or better benefits as PFML. However, many private insurance companies are routinely denying claims of more than 6-8 weeks of medical leave (without further medical justification), even when medical providers indicate additional time on the state approved PFML form. (Many providers are now routinely signing off on more than 6-8 weeks and indicating up to 14 weeks of leave).
Below is a template of an email I sent to my company’s private insurance provider that ultimately led to them approving the full 14 weeks of medical leave (previously they had repeatedly told me I could not take more than 6 weeks for an “uncomplicated” vaginial birth, unless my doctor filled out a separate form with all sorts of diagnostic codes). The sections highlighted in green should be customized to your specific employer/private plan.
Additional helpful links:
Hello,
This email is in reference to claim #X.
My understanding is that (insert name of private plan provider company) is administering the Massachusetts Paid Family and Medical Leave (MA PFML) through a private plan of insurance with my employer, (insert name of employer), which allows them to be exempt from collecting, remitting, and paying contributions under the state's Paid Family and Medical Leave (PFML) law. Per the MA Family and Medical Leave Law, private plans must offer paid leave benefits greater than or equal to the benefits provided by the paid leave law to be granted this exemption.
I am being informed by representatives at (name of private plan company) that they cannot approve my medical leave for childbirth for more than 6 weeks without additional documentation even though my health care provider has indicated X - number of weeks your medical provider has signed off on (in my case this was 14) weeks on the certification of serious health condition form required by the state of MA. I have spoken with a representative at the Department of Family Medical Leave (DFML) who has confirmed that they do not require additional documentation to support the length of leave other than what is indicated on this form. Therefore, (name of private plan company) is imposing different criteria about what qualifies as medical leave than the MA DFML - which is not allowable under the MA PFML law.
Here is the full text of the PFML law: https://malegislature.gov/Laws/SessionLaws/Acts/2018/Chapter121
Within that, the relevant text which requires a private plan to approve a leave that would be approved by the state:
Section 8(h): (h) This chapter shall be liberally construed as remedial law to further its purpose of providing job-protected family and medical leave and family and medical leave benefits. All presumptions shall be made in favor of the availability of leave and the payment of family and medical leave benefits under this chapter.
Language about private plans: Section 11:
Section 11. (a)(1) Employers may apply to the department of family and medical leave for approval to meet their obligations under this chapter through a private plan. In order to be approved as meeting an employer’s obligations under this chapter, a private plan must confer all of the same rights, protections and benefits provided to employees under this chapter, including but not limited to: (i) providing family leave to a covered individual for the reasons set forth in paragraph (1) of subsection (a) and subsection (b) of section 2 for the maximum number of weeks required in paragraph (1) of subsection (c) of section 2, in a benefit year; (ii) providing medical leave to a covered individual for the reasons defined in paragraph (2) of subsection (a) of section 2 for the maximum number of weeks required in paragraph (1) of subsection (c) of section 2, in a benefit year; (iii) allowing covered individuals to take, in the aggregate, the maximum number of weeks of family and medical leave in a benefit year as required by paragraph (1) of subsection (c) of section 2; (iv) allowing family leave to be taken for all purposes specified in paragraph (1) of subsection (a) and subsection (b) of section 2; (v) allowing family leave under paragraph (1) of subsection (a) of section 2 to be taken to care for any family member; (vi) allowing medical leave to be taken by a covered individual with any serious health condition; (vii) providing a wage replacement rate during all family and medical leave of at least the amount required by paragraph (1) of subsection (b) of section 3; (viii) providing a maximum weekly benefit during all family and medical leave of at least the amount specified in paragraph (2) of subsection (b) of section 3; (ix) allowing family or medical leave to be taken intermittently or on a reduced schedule as authorized by paragraph (A) of paragraph (2) of subsection (c) of section 2; (x) imposing no additional conditions or restriction on the use of family or medical leave beyond those explicitly authorized by this chapter or regulations issued pursuant to this chapter; (xi) allowing any employee covered under the private plan who is eligible to take family or medical leave under this chapter to take family or medical leave under the private plan; and (xii) providing that the cost to employees covered by a private plan shall not be greater than the cost charged to employees under the state program.
Length of medical leave: Section 5(a)(2):
(2) Certification for a covered individual taking medical leave shall be sufficient if it states the date on which the serious health condition commenced, the probable duration of the condition and the appropriate medical facts within the knowledge of the health care provider as required by the department.
Serious health condition definition:
“Serious health condition”, an illness, injury, impairment or physical or mental condition that involves (i) inpatient care in a hospital, hospice or residential medical facility; or (ii) continuing treatment by a health care provider.