Revised 06/04/2015
Prepare required paperwork in a timely and professional manner (e.g. IEP, evaluations,
progress notes, MCAS-Alt, Incident reports, Classroom supply orders, Substitute forms).
Report to Program Director pertinent information related to staff, student, family, or district
information, requesting assistance as needed.
Notifies CCC office of any illness or absence. (Notifies “back-up” teacher as needed.)
SPECIAL EDUCATION PARAPROFESSIONAL
In each of the following areas, Paraprofessionals demonstrate the ability to:
¾ Classroom Responsibilities:
Follow the prescribed program and supports as developed by the Lead Teacher and/or
Therapists including any classroom data required.
Inform the teacher of any student or classroom need, difficulty or safety concern that arises.
Request assistance and/or training as needed.
Refer to the teacher any request for individual student information (e.g. parent
questions/concerns, district requests, etc.)
Maintain a positive interaction in stressful situations by consistently following students
program and seeking assistance as needed.
Participate physically to safely support students (e.g. behavior—preventative, blocking,
escorts, restraints; Medical—positioning, lifting, guide/escort).
¾ Schedule:
Comply with program hours (working seven hours daily).
Attend scheduled staff meetings/trainings, including all scheduled in-service days within the
school calendar.
Notifies CCC office (& teacher) of any illness or absence.
Provide a supportive and professional environment for a student which facilitates an optimal
learning environment.
Follow Teacher prescribed duties and responsibilities, seeking clarification, training, and/or
information as needed.
Maintain the schedule, routines, and procedures when teacher is not present.
Maintain personal issues outside of school/classroom time or during a break (e.g. cell
phones, private conversations in front of students, etc.).
Provide (and/or accept) support, encouragement, & ideas to co-workers.
Attend all scheduled in-service trainings.
Immediately inform the classroom teacher, and if necessary, the Program Director of any
event involving a student which in his/her opinion is potentially dangerous, unhealthy,
negligent, or abusive as required by child and adult protection laws of mandatory reporting.
Page 51 of 57
Revised 06/04/2015
PROGRAM NURSE
Scope of responsibilities: The Cape Cod Collaborative Program Nurse is responsible for
assessment, guidance, and provision of medical needs for the students of Cape Cod Collaborative
programs. He/she will interact with the classroom team in providing and promoting a healthful
atmosphere in the educational setting. He/she will also communicate with parents, community health
providers and educators to promote a well-rounded health care plan for the student. In addition, the
nurse is expected to participate in ADL’s, teaching programs and educational programs as dictated by
classroom teacher.
Reports to: The Program Nurse shall report directly to the Nursing Supervisor of the Cape Cod
Collaborative.
Responsibilities are divided into four categories: Nursing Services, Record Keeping, Collaboration
and Professional Responsibilities.
Nursing Services
x Administers prescribed medications following doctors’ orders, as well as DPH and Cape Cod
Collaborative policies.
x Performs Specialized Procedures as directed by the physician.
x Provide daily assessment of students.
x Provide care to ill students on a daily basis.
x Recognizes signs and symptoms of communicable diseases.
x Evaluate student injury and provide intervention and follow–up.
x In the event of a medical emergency, will follow student specific guidelines.
x Utilizes, demonstrates, and directs current infection control practices in the classroom.
x Provide home visits, when necessary, for student admission to programs.
x Develop a child specific care plan with nursing diagnosis, specific goals, interventions and
evaluation. This shall be done at least yearly, and updated as needed.
x Recommends modification of the school program or environment, to maintain optimal health
and safety conditions.
x Provide information and training for other personnel in the educational setting regarding special
medical needs of the student, when appropriate.
x Protects confidentiality of students/information.
x Provide professional and compassionate care as outlined in the American Nurses Association
Code for Nurses.
Record Keeping
x Maintains daily medication and procedure logs.
x Maintains student Health Immunization records and ensures compliance with state
regulations.
x Maintains current and cumulative student health records.
x Maintains medication counts where indicated.
x Document in Nurse’s Notes when appropriate.
x Complete, file, and follow-up on Incident Reports.
Page 52 of 57
Revised 06/04/2015
Collaboration:
x Will act as liaison, where indicated, between the Collaborative Program, parents, hospital staff,
and teacher, should child be hospitalized.
x Will act as a liaison between the Collaborative program and the local rescue squad,
assuring initial contact and a visit at the beginning of each school year.
x Will interact with the host school’s School Nurse to promote good will and inform of any Cape
Cod Collaborative student’s needs.
x Collaborates with other team members to develop a needs assessment and date collection
procedures.
x Shares information with other team members about children with special health care needs
which affect learning and growth.
x The nurse will assist in ADL’s feeding programs and educational programming as directed by
program teacher.
Professional Responsibilities:
x Maintains current Massachusetts Nursing License.
x *Maintains current CPR certification.
x *Maintains professional skills and knowledge through state mandated continuing
x Education programs and current publications.
x *Ability to work cooperatively in a team setting with all related personnel.
Other duties as assigned by classroom teacher and/or Executive Director.
Page 53 of 57
Revised 06/04/2015
BOARD CERTIFIED BEHAVIORAL CONSULTANT (BCBA) CONSULTATION
In each of the following areas, CCC Consultants demonstrate the ability to:
¾ Consulting Skills
Show an understanding of definitions, etiology, & characteristics of students’ disabilities.
Provide technical assistance to support teachers/teams working with students with challenging
behaviors (and/or ASD) to increase opportunities for supportive inclusive environments.
Conduct student observations & relay pertinent information to support district staff in identifying
students’ strengths & needs to develop appropriate individualized supports.
Develop modifications appropriate to individual students taking into consideration cognitive
levels & age-appropriateness.
Incorporate accommodations needed for student success (e.g. visual schedules, tasks lists,
visual cues/prompts, graphic organizers, levels of AT, ACD, etc.)
Provide modeling and hands-on training related to specialty.
React professionally & objectively to unpredictable situations (e.g. environment changes,
behavior/aggression, seizure activity, etc.).
Support district staff to develop a data system that measures student growth & progress,
making adjustments when data reflects that objectives are not being met.
Participate in ongoing professional development related to student populations served.
¾ Relationships
Develop a working relationship with team members, school staff, families, administrative &
district staff.
Maintain ongoing contact with designated district liaisons communicating progress, problems, &
successes.
Provide district staff with reasonable training to support success of student objectives.
Prepare required paperwork in a timely & professional manner (e.g. summaries,
recommendations, observation notes, time sheets, etc.)
Report to Program Director pertinent information related to staff, student, family, or district
information, requesting assistance as needed.
Attend scheduled staff meetings and trainings.
Notify CCC office of any illness or absence.
ANNUAL EVALUATIONS
All employees who hold certification through the Massachusetts Department of Elementary
and Secondary Education (DESE) will be evaluated on an annual basis in a manner aligned
with DESE evaluation guidelines.
All professional non-DESE staff, paraprofessionals and teacher assistants shall be evaluated
annually by the employee’s supervisor.
Page 54 of 57
Revised 06/04/2015
Volunteer/Intern
Volunteers and interns must agree to execute a release of information form authorizing the
Collaborative access to the Criminal Offender Records Information (C.O.R.I.) of the volunteer or intern.
C.O.R.I. results must be reviewed by the Program Director prior to the volunteer or intern working in
contact with students. Volunteers and interns will be supervised by staff at all times and will complete a
Volunteer/Intern Memorandum of Understanding (see below).
VOLUNTEER/INTERN
MEMORANDUM OF UNDERSTANDING
It is the policy of the Cape Cod Collaborative to encourage volunteer efforts in our schools. We also
accept interns in graduate and under graduate programs for those learning to understand the field of
special education. Volunteers and interns must adhere to the personnel policies found in the Employee
Handbook and will work under the direct supervision of the Program Director and Collaborative staff.
It is the policy that all prospective volunteers and interns execute a release of information form where
by the school district shall be authorized access to the Criminal Offender Records Information
(C.O.R.I.) of said applicant as permitted by law.
Volunteer and interns who are approached by parents or other persons with questions about the
Collaborative’s programs and/or services, or with specific questions pertaining to students attending
Collaborative programs, must direct the questions to the program teacher, the appropriate itinerant
therapist or to the Program Director. In particular, information pertaining to specific students must be
treated with the utmost confidentiality. Consistent with the federal Family Educational Rights and
Privacy Act (FERPA), the volunteer/intern will not disclose data in any manner that could identify any
individual student.
Volunteer/Intern Name (Please print) Date
Signature
Page 55 of 57
Revised 06/04/2015
Cape Cod Collaborative
Employee Handbook
Signature Page
x I have completed the Commonwealth of Massachusetts Ethics Training on-line and
have provided a copy of the acknowledgement for my file.
x I agree to allow the Cape Cod Collaborative to perform a CORI/SORI (background)
check at least annually or as requested.
x I understand the physical requirements of the job (refer to Job Descriptions) and state
that I have no physical or mental impairment that would interfere with my ability to
perform my responsibilities.
x I have read and understand the Harassment in the Workplace Policy.
x By signing below, I acknowledge that I have read and understand the handbook policies
and agree, as a condition of employment, to adhere to the Cape Cod Collaborative’s
Rules and Regulations.
Employee Signature Date
Page 56 of 57
Revised 06/04/2015 I
II
APPENDICES III
EMPLOYMENT FORMS, DOCUMENTS AND INFORMATION IV
x SALARY STEPS AND PAY OPTIONS 2014-2015 V
x EMPLOYEE BENEFITS SUMMARY
x SHARED BENEFIT COSTS
x EMPLOYEE BENEFIT PLAN DETAILS
WORKERS COMPENSATION INFORMATION
Page 57 of 57
2015-2016 Salary Steps
Teachers Itinerent
Bachelors Masters Masters+30 Bachelors Masters Masters+30
1 42,595 1 46,842 49,184 53,074
2 44,299 45,265 48,894 2 48,716 51,151 55,197
3 46,071 3 50,665 53,197 57,405
4 47,914 47,076 50,850 4 52,691 55,325 59,701
5 49,831 5 54,799 57,538 62,089
6 51,824 48,959 52,884 6 56,991 59,840 64,573
7 53,897 7 59,270 62,233 67,156
8 56,053 50,917 54,999 Please note: Teachers who are 8 61,641 64,723 69,842
9 58,295 working subject to a certification 9 64,107 67,312 72,635
10 60,627 52,954 57,199 Waiver will be paid at Step 1. 10 66,671 70,004 75,541
11 63,052 11 69,338 72,804 78,563
12 65,574 55,072 59,487 12 72,112 75,716 81,705
13 68,197 13 74,996 78,745 84,973
57,275 61,867 14 77,996 81,895 88,372
59,566 64,342
61,948 66,915
64,426 69,592
67,003 72,375
69,684 75,270
72,471 78,281
Teacher's Assistant Therapy
Assistant
Level I Level II 1 Nurse
2 (OT-PT-SP/L)
1 19,047 32,004 3 32,639
2 19,809 33,284 4 33,944 1 42,597
3 20,601 34,615 5 35,302 2 44,301
4 21,425 36,000 6 36,714 3 46,073
5 22,282 37,440 7 38,183 4 47,915
6 23,173 8 39,710 5 49,832
7 24,100 9 41,299 6 51,825
8 25,064 10 42,951 7 53,898
9 26,067 11 44,669 8 56,054
10 27,110 12 46,455
11 28,194 48,313
12 29,322 Bi-weekly 50,246
Pay Dates
Contract Pay Installment Options: Pay Options
4-Sep-15
A 26 Bi-weekly payments 18-Sep-15 A B&C
B 21 Bi-weekly payments 2-Oct-15 26 21
C 21 Bi-weekly payments w/Lump Sum paid June 14* 16-Oct-15
30-Oct-15 11
Note: 13-Nov-15 22
Option C is paid at the 26 Bi-weekly rate for 21 payments with the balance paid as a lump sum on June 14th. 27-Nov-15 33
11-Dec-15 44
25-Dec-15 55
8-Jan-16 66
22-Jan-16 77
5-Feb-16 88
19-Feb-16 99
4-Mar-16 10 10
18-Mar-16 11 11
1-Apr-16 12 12
15-Apr-16 13 13
29-Apr-16 14 14
13-May-16 15 15
27-May-16 16 16
10-Jun-16 17 17
24-Jun-16 18 18
19 19
8-Jul-16 20 20
22-Jul-16 21 *21
5-Aug-16 22
19-Aug-16 23
24
25
26
2016Steps
Workers Compensation Insurance Employee Benefits Summary
Employees are covered for medical and disability under Workers’ Com-
pensation Insurance at no cost to them. Report a job-related accident im- As of July 1, 2015
mediately to your supervisor and complete a Notice of Injury Form. In or-
der to qualify you must report an accident immediately (within 24 hours) or Please check the Addenda to the
the claim may be denied. Employee Handbook for more details
Tax Sheltered Annuity—Deferred Compensation Plan
Cape Cod Collaborative 403(b) Plan—Available to all part-time and full-
time employees, this allows employees to defer compensation (minimum
of $250 annually) for retirement. Select an investment account from par-
ticipating vendors and authorize the Collaborative to withhold funds
through payroll deduction. It is important to understand that withdrawal of
these funds prior to age 59 1/2 could result in substantial penalty and tax.
Retirement Plans
Massachusetts Teachers Retirement System
Certified Educators/Administrators
The MTRS is meant to take the place of Social Security for Certified Ther-
apists, Teachers, Clinicians, Nurses and Administrators in Massachusetts.
The amount of the deduction depends upon when you enter the system,
but generally is 11% of your compensation. If you are a Certified Teacher,
you must enroll in the MTRS prior to your first paycheck by visiting the
website: http://www.mass.gov/mtrs. (If you are retired under the MTRS
you are exempt from this withholding requirement.)
Massachusetts State Retirement—Full Time Staff
Since most municipalities and the Collaborative do not participate in Social
Security, full time employees, other than Certified Teachers, are required
to contribute to the MSRS. The employee contribution is generally 9% for
compensation under $30,000 and 2% on the amount over. (If you are cur-
rently retired under the MSRS, you are exempt from this withholding re-
quirement but are required to contribute to the OBRA 457(b) Plan until age
70.)
OBRA 457(b) Plan
Since most municipalities and the Collaborative do not participate in Social
Security, part-time employees and employees retired under MSRS are
required to contribute to the OBRA 457(b) Plan. The employee contribu-
tion is 7.5% of compensation. Members of another retirement system may
participate on a voluntary basis up to the IRS maximum (depending on
employee age).
Collaborative Health Plans New Health Insurance Marketplace Coverage Options
Available to employees who work 20+ hours per week. The Affordable Care Act created the Health Insurance Marketplace to
provide assistance as you evaluate insurance options. Please visit
Network Blue (HMO) see CCMHG below HealthCare.gov for more information.
Harvard Pilgrim (EPO) see CCMHG below
Section 125 Cafeteria Plan
HMO and EPO—These plans generally require a referral from the Primary
Care Physician (PCP) prior to seeing a medical specialist. They may Pre-tax employee portion—This is available to all employees. It allows
require that you use physicians within their Network of Doctors, unless you those with health or dental premium payments to pay them with pre-tax
are away from home and in an emergency. (Under this situation, you will dollars. This can represent a significant tax savings for employees.
need to notify the provider within 24 hours.)
FSA—Flexible Spending Account—Employees can deposit
Cape Cod Municipal Health Group
As a health or dental plan enrollee you can participate in Cape Cod up to $2,550 for medical expenses and/or up to $5,000 for dependent care
Municipal Health Group (CCMHG) health and wellness programs. A expenses into their FSA through payroll deduction.
wealth of information, including: health and dental plan website links, well-
ness events, myMedicationAdvisor and the Diabetes Reward Program can Life Insurance
be found on the CCMHG website: www.ccmhg.com.
Offered through the Boston Mutual Life Insurance Company
Retiree Health Plans—Collaborative employees can chose Medicare
supplemental plans available from Blue Cross, Harvard Pilgrim and Tufts. Available to employees who work 20+ hours per week
Dental see CCMHG above Basic Term Life AD&D—$10,000 of Term Life insurance. Cost is shared
55% Collaborative, 45% Employee.
Offered through Delta Dental, this insurance offers coverage to $1,000
Voluntary Term Life—Additional Term Life insurance is available in
calendar maximum for dental services for each family member. increments of $10,000 up to a maximum of $500,000. The Premiums
depend upon the amount of insurance selected and the age of the
Dependents are covered to age 19, full time students to age 23. Please employee. The cost is paid entirely by the employee through payroll
deduction. Term Life insurance coverage is also available to the spouse
see the Coverage Summary for details regarding deductibles and and dependent children of the employee.
orthodontic coverage. Voluntary Long Term Disability—Available to full-time employees on a
voluntary basis. Premiums depend upon the employee’s monthly salary
Open Enrollment—Existing participants may elect coverage, add, and age. The cost is paid entirely by the employee through payroll
delete or change coverage in May of this year unless there is a qualifying deduction.
event. (Examples of a qualifying event are birth, marriage, Please see the Employee Handbook addenda for further details.
divorce, or loss of employment.) Changes made during open enrollment www.CapeCodCollaborative.org
will take effect July 1, 2015.
Cost—Currently, the cost is shared 55% Collaborative, 45% Employee.
Deductions are made pre-tax through payroll deduction (see Section 125
Cafeteria Plan).
COBRA—Upon termination of employment, you have the opportunity to
continue your coverage for up to 18 months at your own expense. A
COBRA request form will be mailed to you at that time.
Updated 02/05/2015
2015-2016 Employee Portion of Benefits**
Pay Options - 21 Weeks 26 Weeks 21 + Lump Sum 38 Weeks 52 Weeks ADMIN
Single Total EE Coverage Coverage Coverage Lump sum Coverage Weekly Rate 26 Weeks 52 Weeks
Premium Share through through through check through coverage to
Network (HMO) Blue August 31st* August 31st* August 31st* August 31st* coverage to
Harvard Pilgrim (EPO) 670.00 301.50 Deduction June 30th June 30th
Dental 680.00 306.00 175.73 141.94
Boston Mutual (Employee Only) 39.00 178.35 144.06 141.94 709.68 97.11 69.58 139.15 69.58
17.55 144.06 720.28 98.56 70.62 141.23 70.62
Parent & 1.70 0.77 10.23 8.26 4.05
One Child 0.45 0.36 8.26 41.31 5.65 0.18 8.10 4.05
Total EE 0.36 1.80 0.25 0.35 0.18
Network (HMO) Blue Premium Share
Harvard Pilgrim (EPO) Deduction Deduction Deduction Deduction Deduction Deduction Deduction Deduction
Dental 1,343.00 604.35
Boston Mutual (Employee Only) 1,360.00 612.00 352.25 284.51 284.51 1,422.55 194.66 139.47 278.93 139.47
356.71 288.11 288.11 1,440.55 197.13 141.23 282.46 141.23
Family 77.00 34.65
1.70 0.77 20.20 16.31 16.31 81.56 11.16 8.00 15.99 8.00
Network (HMO) Blue 0.45 0.36 0.36 1.80 0.25 0.18 0.35 0.18
Harvard Pilgrim (EPO) Total EE
Dental Premium Share Deduction Deduction Deduction Deduction Deduction Deduction Deduction Deduction
Boston Mutual (Employee Only)
1,793.00 806.85 470.28 379.84 379.84 1,899.20 259.89 186.20 372.39 186.20
1,818.00 818.10 476.84 385.14 385.14 1,925.68 263.51 188.79 377.58 188.79
101.00 45.45 26.49 21.40 21.40 106.98 14.64 10.49 20.98 10.49
1.70 0.77 0.45 0.36 0.36 1.80 0.25 0.18 0.35 0.18
MEDEX (Over 65) Total EE
Premium Share
Harvard Pilgrim Medicare Enhance 289.28 144.64 NA NA NA NA NA NA NA NA
Tufts Medicare Supplement with PDP
Plus 332.00 166.00 NA NA NA NA NA NA NA NA
NA - not available
* Rates reflect a 12% estimated increase for July and August. The new plan year begins July 1st.
** All changes must be made during the open enrollment period; thereafter, changes can be made only for a qualifying event.
Network Blue $250/$500/$750 Deductible Cape Cod Municipal Health Group Coverage Period: on or after 07/01/2015
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family | Plan Type: Managed
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
www.bluecrossma.com or by calling 1-800-782-3675.
Important Questions Answers Why this Matters:
$250 member / $500 two-person / You must pay all the costs up to the deductible amount before this plan begins to pay for covered
What is the overall $750 family. Does not apply to services you use. Check your policy or plan document to see when the deductible starts over
deductible? preventive care, prenatal care, (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for
prescription drugs, most office visits, covered services after you meet the deductible.
Are there other therapy visits and mental health visits.
deductibles for specific You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for
services? No. other costs for services this plan covers.
Is there an out–of–
pocket limit on my Yes. For medical benefits, $2,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for
expenses? member / $4,000 family, and for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in prescription drug benefits, $2,000
the out–of–pocket limit? member / $4,000 family. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Prescription drugs, premiums,
Does this plan use a balance-billed charges, and health If you use an in-network doctor or other health care provider, this plan will pay some or all of the
network of providers? care this plan doesn't cover. costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network
provider for some services. Plans use the term in-network, preferred, or participating for
Do I need a referral to Yes. See providers in their network. See the chart starting on page 2 for how this plan pays different kinds
see a specialist? www.bluecrossma.com/findadoctor of providers.
Are there services this or call 1-800-821-1388 for a list of This plan will pay some or all of the costs to see a specialist for covered services but only if you
plan doesn’t cover? network providers. have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
Yes. document for additional information about excluded services.
Yes.
Questions: Call 1-800-782-3675 or visit us at www.bluecrossma.com. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association 1 of 9
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.bluecrossma.com/sbcglossary or call 1-800-782-3675 to request a copy.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount (or provider’s charge if it is less than the allowed
amount) for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000 (and it is less than the provider’s charge), your
coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you
may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may
have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. (If you are eligible to
elect a Health Reimbursement Account (HRA), Flexible Spending Account (FSA) or you have elected a Health Savings Account (HSA), you may have access
to additional funds to help cover certain out-of-pocket expenses such as copayments, coinsurance, deductibles and costs related to services not
otherwise covered.)
Common Services You May Need Your cost if you use Limitations & Exceptions
Medical Event
Primary care visit to treat an injury or illness In-Network Out-of-Network ––– none –––
If you visit a health care Specialist visit Not covered ––– none –––
provider’s office or clinic Other practitioner office visit $20 / visit Not covered
$35 / visit ––– none –––
Not covered / Not covered
chiropractor visit GYN exam limited to one exam per
calendar year
Preventive care/screening/immunization No charge Not covered
Diagnostic test (x-ray, blood work) Deductible applies first
No charge Not covered Deductible applies first; copayment
applies per category per test / day;
If you have a test Imaging (CT/PET scans, MRIs) $100 Not covered
pre-authorization required for
certain services
2 of 9
Common Services You May Need Your cost if you use Limitations & Exceptions
Medical Event Generic drugs In-Network Out-of-Network
Up to 30-day retail (90-day mail
$10 / retail supply Not covered service) supply; cost share may be
or $20 / mail waived for certain covered drugs and
service supply supplies; pre-authorization required
If you need drugs to treat $25 / retail supply Not covered for certain drugs
your illness or condition Preferred brand drugs or $50 / mail
service supply Up to 30-day retail (90-day mail
service) supply; cost share may be
More information about Non-preferred brand drugs $50 / retail supply Not covered waived for certain covered drugs and
prescription drug or $110 / mail Not covered supplies; pre-authorization required
coverage is available at service supply Not covered
www.bluecrossma.com. for certain drugs
Applicable cost
Specialty drugs share (generic, Up to 30-day retail (90-day mail
preferred, non- service) supply; cost share may be
Facility fee (e.g., ambulatory surgery center) waived for certain covered drugs and
Physician/surgeon fees preferred) supplies; pre-authorization required
$150 / admission for certain drugs
If you have outpatient When obtained from a designated
surgery specialty pharmacy; pre-authorization
No charge Not covered required for certain drugs
If you need immediate Emergency room services $100 / visit $100 / visit Deductible applies first;
medical attention pre-authorization required for
Emergency medical transportation No charge No charge
Urgent care $35 / visit $35 / visit certain services
Deductible applies first;
pre-authorization required for
certain services
Deductible applies first; copayment
waived if admitted or for
observation stay
Deductible applies first
Out-of-network coverage limited to
out of service area
3 of 9
Common Services You May Need Your cost if you use Limitations & Exceptions
Medical Event In-Network Out-of-Network
Deductible applies first;
Facility fee (e.g., hospital room) $500 / admission Not covered pre-authorization required
If you have a hospital stay Deductible applies first;
No charge Not covered pre-authorization required
Physician/surgeon fee Pre-authorization required for
Mental/Behavioral health outpatient services $20 / visit Not covered certain services
Deductible applies first;
If you have mental health, Mental/Behavioral health inpatient services $500 / admission Not covered pre-authorization required
behavioral health, or Pre-authorization required for
substance abuse needs Substance use disorder outpatient services $20 / visit Not covered
certain services
Substance use disorder inpatient services $500 / admission Not covered Deductible applies first;
pre-authorization required
If you are pregnant Prenatal and postnatal care No charge Not covered Deductible applies first for in-network
Delivery and all inpatient services Not covered postnatal care and out-of-network
$500 / admission prenatal and postnatal care
and no charge for
Deductible applies
delivery
4 of 9
Common Services You May Need Your cost if you use Limitations & Exceptions
Medical Event Home health care In-Network Out-of-Network
Deductible applies first;
Rehabilitation services No charge Not covered pre-authorization required
$20 / visit Not covered Limited to 60 visits per calendar year
(other than for autism, home health
If you need help Habilitation services $20 / visit Not covered
recovering or have other care, and speech therapy); pre-
special health needs authorization required for certain
Skilled nursing care No charge Not covered services
Durable medical equipment 20% coinsurance Not covered Rehabilitation therapy coverage limits
apply; cost share and coverage limits
Hospice service No charge Not covered waived for early intervention services
No charge Not covered for eligible children; pre-authorization
If your child needs dental Eye exam Not covered Not covered
or eye care Glasses No charge Not covered required for certain services
Dental check-up Deductible applies first; limited to 100
days per calendar year; pre-
authorization required
Deductible applies first; cost share
waived for one breast pump per birth
Deductible applies first;
pre-authorization required for
certain services
Limited to one exam every 12 months
––– none –––
Limited to children under age 12
(every 6 months) and under age 18
with a cleft palate / cleft lip condition
5 of 9
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Acupuncture Cosmetic surgery Non-emergency care when traveling outside the U.S.
Children's glasses Dental care (adult) Private-duty nursing
Chiropractic care Long-term care
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Bariatric surgery Infertility treatment Routine foot care (only for patients with systemic
circulatory disease)
Hearing aids ($2,000 per ear every 36 months for Routine eye care - adult (one exam every 12
members age 21 or younger) months) Weight loss programs ($150 per calendar year per
policy)
6 of 9
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any
such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan.
Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact your plan sponsor. Note: A plan sponsor is usually the member’s employer or organization that provides
group health coverage to the member. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at
1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your
rights, this notice, or assistance, you can contact the Member Service number listed on your ID card or contact your plan sponsor. Note: A plan sponsor is usually the
member’s employer or organization that provides group health coverage to the member.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide
minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health
coverage does meet the minimum value standard for the benefits it provides.
Disclaimer:
This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview
only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and
the policy, the terms and conditions of the policy will govern.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
7 of 9
About these Coverage Having a baby Managing type 2 diabetes
Examples:
(normal delivery) (routine maintenance of
These examples show how this plan might cover a well-controlled condition)
medical care in given situations. Use these examples Amount owed to providers: $7,540
to see, in general, how much financial protection a Plan pays $6,620 Amount owed to providers: $5,400
sample patient might get if they are covered under Patient pays $920 Plan pays $3,100
different plans. Patient pays $2,300
Sample care costs:
This is Hospital charges (mother) $2,700 Sample care costs: $2,900
not a cost Routine obstetric care $2,100 Prescriptions $1,300
estimator. Hospital charges (baby) Medical Equipment and Supplies
Anesthesia $900 Office Visits and Procedures $700
Don’t use these examples to estimate Laboratory tests $900 Education $300
your actual costs under this plan. Prescriptions $500 Laboratory tests $100
The actual care you receive will be Radiology $200 Vaccines, other preventive $100
different from these examples, and Vaccines, other preventive $200 Total $5,400
the cost of that care will also be Total $40
different. $7,540 Patient pays: $140
Patient pays: Deductibles $2,080
See the next page for important Deductibles $250 Copays
information about these examples. Copays $520 Coinsurance $0
Coinsurance Limits or exclusions $80
Limits or exclusions $0 Total $2,300
Total $150
$920
8 of 9
Questions and answers about the Coverage Examples:
What are some of the assumptions What does a Coverage Example show? Can I use Coverage Examples to
behind the Coverage Examples? compare plans?
For each treatment situation, the Coverage
Costs don’t include premiums. Example helps you see how deductibles, 9Yes. When you look at the Summary of
Sample care costs are based on national copayments, and coinsurance can add up. It also Benefits and Coverage for other plans, you’ll find
averages supplied by the U.S. Department of helps you see what expenses might be left up to the same Coverage Examples. When you
Health and Human Services, and aren’t you to pay because the service or treatment isn’t compare plans, check the “Patient Pays” box in
specific to a particular geographic area or covered or payment is limited. each example. The smaller that number, the
health plan. more coverage the plan provides.
The patient’s condition was not an excluded or Does the Coverage Example predict my
preexisting condition. own care needs? Are there other costs I should consider
All services and treatments started and ended when comparing plans?
in the same coverage period. 8 No. Treatments shown are just examples. The
There are no other medical expenses for any care you would receive for this condition could 9Yes. An important cost is the premium you
member covered under this plan. be different based on your doctor’s advice, your pay. Generally, the lower your premium, the
Out-of-pocket expenses are based only on age, how serious your condition is, and many more you’ll pay in out-of-pocket costs, such as
treating the condition in the example. other factors. copayments, deductibles, and coinsurance.
The patient received all care from in-network You should also consider contributions to
providers. If the patient had received care Does the Coverage Example predict my accounts such as health savings accounts
from out-of-network providers, costs would future expenses? (HSAs), flexible spending arrangements (FSAs)
have been higher. or health reimbursement accounts (HRAs) that
8No. Coverage Examples are not cost help you pay out-of-pocket expenses.
estimators. You can’t use the examples to
estimate costs for an actual condition. They are
for comparative purposes only. Your own costs
will be different depending on the care you
receive, the prices your providers charge, and
the reimbursement your health plan allows.
Questions: Call 1-800-782-3675 or visit us at www.bluecrossma.com. ® Registered Marks of the Blue Cross and Blue Shield Association.© 2015 Blue Cross and Blue Shield of Massachusetts, Inc., and 9 of 9
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
at www.bluecrossma.com/sbcglossary or call 1-800-782-3675 to request a copy.
147522BS (3/15) 1.85C JI
MCC Compliance
This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that
went into effect as of January 1, 2014, as part of the Massachusetts Health Care Reform Law.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross
and Blue Shield Association. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
#139512BS 55-0647 (6/14) 150M
The Harvard Pilgrim Tiered Copayment HMO Coverage Period: 07/01/2015 — 06/30/2016
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CCMHG Plan Benefit Comparison
These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s)
& riders will govern.
Effective 07-01-2015 BLUE CROSS BLUE SHIELD HARVARD PILGRIM HEALTH CARE
BENEFIT NETWORK BLUE HMO HPHC HMO
Deductible - applies to: In-patient Admission; Out- $250 per member $250 per member
$750 per family
patient Surgery; ER, High Tech Imaging (MRI, CT, & PET) $750 per family
and Diagnostic Tests & Procedures. Does not apply to
routine office visits or pharmacy. Per plan year (July 1 to
June 30) - See plan document for full details
Out-of-Pocket (OOP) Maximum - Once your out-of-pocket Medical: $3,000 per member Medical: $3,000 per member
expenses for applicable services reaches this amount, you $2,000 per member $2,000 per member
pay $0 for remainder of plan year. NOTE: a separate out-of- $4,000 per family Prescription: $4,000 per family Prescription:
pocket maximum for prescription copays added effective July $6,000 per family $6,000 per family
1, 2015 as required by ACA (in-network only).
Lifetime Benefit Maximum None None
YOU PAY
INPATIENT YOU PAY
$500 copay per admission $500 copay per admission
General Hospital/Mental Hospital/Substance Abuse
Nothing
Facility (semi-private room and board and special
services) - Deductible Applies
Physician Services Nothing
Skilled Nursing Facility Deductible Applies Nothing to 100 days per calendar year benefit maximum Limit to 100 days per Plan Year - $500 copayper admission
Rehabilitation Hospital Deductible Applies Nothing to 60 days per calendar year benefit maximum Limit to 60 days per Plan Year - $500 copay per admission
1
CCMHG Plan Benefit Comparison
These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s)
& riders will govern.
Effective 07-01-2015 BLUE CROSS BLUE SHIELD HARVARD PILGRIM HEALTH CARE
BENEFIT NETWORK BLUE HMO HPHC HMO
OUTPATIENT HOSPITAL YOU PAY YOU PAY
Emergency Room Visits for Emergency or Accident Care - $100 copay (waived if admitted or for observation stay) $100 copay, (waived if admitted)
Deductible Applies
Emergency Room Visits for Medical Care - Deductible $100 copay (waived if admitted or for observation stay) $100 copay, (waived if admitted)
Applies
Surgery - Deductible Applies $150 copay $150 copay
Radiation and Chemotherapy Deductible Applies Nothing Nothing
Diagnostic X-ray and Lab - Deductible Applies Nothing Nothing
$0 copay $0 copay
Routine Colonoscopy (without surgery) $100 copay $100 copay
High Cost Radiology (MRI, CT & PET) -
Deductible Applies $0 copay $0 copay
Hemodialysis - Deductible Applies
Physical Therapy $20 copay to 60 visits per calendar year Copay Level 1 : $20 copay per visit, 30 visits per Plan Year
PHYSICIAN'S OFFICE YOU PAY YOU PAY
Surgery - Copay Level 1 provider : $20 copay per visit Copay Level 2
NO DEDUCTIBLE $20/35 co-pay provider : $35 per visit
2
CCMHG Plan Benefit Comparison
These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s)
& riders will govern.
Effective 07-01-2015 BLUE CROSS BLUE SHIELD HARVARD PILGRIM HEALTH CARE
BENEFIT NETWORK BLUE HMO HPHC HMO
PHYSICIAN'S OFFICE YOU PAY YOU PAY
Adult Preventative Exam $0 copay $0 copay
(includes preventative lab tests) $20 copay
PCP Medical Care/ Mental Health Care/ Substance Copay Level 1 :$20 copay
Abuse Care
Well Child Care $0 copay $0 copay (including routine physical exams, immunizations,
(includes preventative lab tests) school, camp, sports)
Routine GYN Exam ( one per calendar year , includes $0 copay $0 copay
preventative lab tests)
$0 copay $0 copay
Routine Mammogram $0 copay (once every 12 months) Limited 1 visit per Plan Year - No Charge
Routine Vision Exam
$35 copay YOU PAY Copay Level 2 : $35 copay
Specialist Office Visit Nothing YOU PAY
OTHER OUTPATIENT
Visiting Nurse Nothing
Home Health Care Deductible Applies
After deductible, member pays 20%, plan pays 80% with no After deductible, member pays 20% until member has paid
Durable Medical Equipment - Deductible Applies
limit. Wigs are covered in full when needed as a result of any $1,000 out of pocket, then plan pays in full. Wigs are
form of cancer, leukemia, alopecia areata, alopecia totalis, or covered in full when needed as a result of any form of
permanent hair loss due to injury. cancer, leukemia, alopecia areata, alopecia totalis, or
permanent hair loss due to injury.
Ambulance- Deductible Applies Nothing Nothing
3
CCMHG Plan Benefit Comparison
These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s)
& riders will govern.
Effective 07-01-2015 BLUE CROSS BLUE SHIELD HARVARD PILGRIM HEALTH CARE
BENEFIT NETWORK BLUE HMO HPHC HMO
Routine Pediatric Nothing Covered in full: Preventive care for children under age 12 2
Dental (through age 11) visits per member per plan year including exam, cleaning, x-
rays, & flouride treatment.
Chiropractor Visits All charges All charges
Prescription Drugs
Retail: (30 day supply) Retail: (30 day supply)
Fitness Benefit
Tier 1: $10.00 copay Tier 1: $10.00 copay
Tier 2: $25.00 copay Tier 2: $25.00 copay
Tier 3: $50.00 copay Tier 3: $50.00 copay
Mail Order: (90 day supply) Mail Order: (90 day supply)
Tier 1: $20.00 copay Tier 1: $20.00 copay
Tier 2: $50.00 copay Tier 2: $50.00 copay
Tier 3: $110.00 copay Tier 3: $110.00 copay
Up to $150 reimbursement per calendar year. Must be an
active member of HPHC for at least 4 months and a member
of any qualified health & fitness club for 4 consecutive
months.
Up to $150 reimbursement toward membership or exercise
classes at a health club. See plan details.
Enroll in a qualified Weight Watchers or hospital based weight
loss program and receive up to $150 per calendar year
toward your program fees.
*After Deductible
4
Coverage Summary for
Cape Cod Municipal Group
Deductible: $50 per individual / $100 per family. Deductible waived for Diagnostic and Preventive categories. Co-insurance
Calendar Year Maximum: $1,000 per person.
Category / Procedure Qualifications In Out of
Network Network*
Diagnostic 100% 100%
Comprehensive Evaluation
Periodic Oral Exam Once every 60 months. 100% 100%
Full Mouth X- rays Twice per calendar year.
Bitewing X-rays Once every 60 months. 80% 80%
Single Tooth X-rays Twice per calendar year.
As needed. 80% 80%
Preventive
Teeth Cleaning Twice per calendar year. 80% 80%
Fluoride Treatments Twice per calendar year for members under age 19.
Space Maintainers Required due to the premature loss of teeth. For members under age 14 and not for the 100% 100%
replacement of primary or permanent anterior teeth. 80% 80%
Sealants Unrestored permanent molars, every 4 years per tooth for members through age 15. Sealants are
also covered for members aged 16 up to age 19 for those who had a recent cavity and are at risk 80% 80%
Chlorhexidine Mouthrinse for decay.
This is a covered benefit only when administered and dispensed in the dentist's office following 80% 80%
Fluoride Toothpaste scaling and root planing.
This is a covered benefit only when administered and dispensed in the dentist's office following 50% 50%
Restorative periodontal surgery.
Silver Fillings 50% 50%
White Fillings (Front Teeth) Once every 24 months per surface per tooth.
White Fillings (Back Teeth) Once every 24 months per surface per tooth.
Covered only for single surfaces. Once every 24 months per surface, per tooth, multi-surfaces will
Temporary Fillings be processed as a silver filling and the patient is responsible up to the submitted charge.
Stainless Steel Crowns Once per tooth.
Oral Surgery Once every 24 months per tooth.
Simple Extractions
Surgical Extractions Once per tooth.
Periodontics Once per tooth.
Periodontal Surgery
Scaling and Root Planing One surgical procedure per quadrant in 36 months.
Periodontal Cleaning Once in 24 months, per quadrant.
Once every 3 months following active periodontal treatment. Not to be combined with preventive
Endodontics cleanings.
Root Canal Treatment
Vital Pulpotomy Once per tooth.
Limited to deciduous teeth.
Prosthetic Maintenance
Bridge or Denture Repair Once within 12 months, same repair.
Rebase or Reline of Dentures Once within 36 months.
Recement of Crowns &
Onlays Once per tooth.
Emergency Dental Care Three occurrences in 12 months.
Minor treatment for Pain General Anesthesia and IV sedation are allowed with covered surgical impacted wisdom teeth
Relief only.
General Anesthesia
Once within 60 months.
Prosthodontics When part of a bridge. Once within 60 months.
Dentures An Endosteal Implant: Only when it is to replace one missing tooth and when adjacent teeth are
Fixed Bridges and Crowns healthy and do not require crowns. Once per 60 months per Implant. (Pre-estimates
Implants (only in lieu of a recommended).
3-unit bridge)
When teeth cannot be restored with regular fillings. Once within 60 months per tooth.
Major Restorative
Crowns
Orthodontics: Covered at 50% of Maximum Plan Allowance charges to any age. $1,000 separate LIFETIME maximum.
Dependent Eligibility: Eligible dependents up to age 19 and full time-students to age 23.
Additional Benefit Information
Deductible waived for periodontal cleanings.
This plan is eligible for Rollover Max. See the benefit guide for details.
Deductible met in fourth quarter are carried over
*Non-participating dentists may balance bill. Subscribers are responsible for the difference between the non-participating maximum
plan allowance and the full fee charged by the dentist.
Massachusetts Workers’ Compensation
Guide For Injured Workers
Esta guía está disponible en español en nuestro
sitio electrónico: www.mass.gov/dia
Este Guia está disponível em português no
nosso site: www.mass.gov/dia
Es manual sta skritu na Kriolu di Kabu Verdi prontu
pa bu uzu na website (pagina na interneti):
www.mass.gov/dia
本指南的中文版位於我們的網址:
www.mass.gov/dia
Có Hướng Dẫn này bằng tiếng Việt Nam tại mạng lưới của chúng tôi:
www.mass.gov/dia
W ap jwenn gid sa a ekri nan lang kreyòl sou sit entènèt nou an:
www.mass.gov/dia
eKalkarN_ENnaMenH
GacmanCaPasaExrμ enAeleI vbsayrbse; yIg ³
www.mass.gov/dia
:ﻳﺘﻮﻓﺮ ﻫﺬﺍ ﺍﻟﺪﻟﻴﻞ ﺑﺎﻟﻠﻐﺔ ﺍﻟﻌﺮﺑﻴﺔ ﻋﻠﻰ ﻣﻮﻗﻌﻨﺎ ﺍﻟﺘﺎﻟﻲ ﻋﻠﻰ ﺍﻟﻮﻳﺐ
www.mass.gov/dia
What Is Workers’ Compensation?
The Massachusetts Workers’ Compensation system is in place to make sure that workers are protected by insurance if they are
injured on the job or contract a work-related illness.
Under this system, all employers are required to provide Workers’ Compensation (WC) insurance coverage to all their
employees by Massachusetts General Laws Ch. 152, Sec. 25A. This insurance pays for any reasonable and necessary medical
treatment related to a job-related injury or illness, pays compensation for lost wages after the first five calendar days of full or
partial disability, and in some cases provides retraining for employees who qualify.
The Department of Industrial Accidents (DIA) is the agency responsible for administering the Workers' Compensation law in
Massachusetts.
What We Do
The DIA is primarily a court system responsible for resolving disputed Workers’ Compensation claims. Our Public Information staff
can answer your questions about Workers' Compensation benefits and let you know the correct procedures to follow to receive
these benefits. If your injury or illness claim is denied by the insurer or if you do not receive all the benefits you think you are
entitled to, the DIA’s Public Information staff is available to help guide you through the process.
It is important that you keep any documents your employer or its insurer sends you, as well as copies of any forms they have you
fill out for them. If you call our Public Information Office, have these forms available along with a pen or pencil and notepaper. It
might be helpful to write out your questions in advance so you don't forget to ask any questions you might have.
This pamphlet is a general overview of the process to follow if you have a work-related injury or illness. This guide provides
information about your responsibilities and those of your employer and your employer’s insurance company. The guide
will explain the Workers’ Compensation dispute process, and available benefits, including Lump Sum Settlements and Vocational
Rehabilitation Services. Many frequently asked questions can be found on our website at www.mass.gov/dia.
Please be advised that the information contained in this brochure is general in nature and is not intended as a substitute for legal
advice. Changes in the law or the specific facts of your case may result in legal interpretations, which are different than
presented here.
Do You Need An Attorney?
Half of all injured worker claims are not disputed by an insurer or employer. If your claim is disputed, it is strongly advised that
you seek legal counsel to protect your rights and interests, due to the complexity of the workers’ compensation law. The law
requires that the insurer pay the attorney’s fee if you win your case. In certain cases the insurer may reduce your payments to help
pay your attorney. If you lose, the attorney can charge you only for very specific expenses. You do not necessarily need an
attorney to file a claim, and you may represent yourself for any proceedings before the DIA. This is not recommended in most
cases.
Employees of the DIA are not allowed to make attorney referrals. The Massachusetts Bar Association can refer you to
attorneys who handle workers’ compensation cases. To reach the Massachusetts Bar Association attorney referral service, call (617)
654-0400 in the Boston area or toll free at (866) 627-7577, or visit www.massbar.org, and click on the “Need a Lawyer?” tab.
What Happens If You Have A Work-Related Injury Or Illness?
If you have a work-related injury or illness which results in lost work time of at least five full or partial days, your employer must file
the Employer’s First Report of Injury or Fatality (Form 101). One copy is filed with the DIA, a second with the employer’s Workers’
Compensation insurance company, and a third provided to you. The Form 101 must be filed within seven days (not including
Sundays and legal holidays) from the fifth day of lost time due to injury or illness. Once the insurance company receives the form
from your employer, they have 14 days to investigate the claim and determine whether to pay the claim or not.
IMPORTANT: If your employer does not send the Form 101 to the insurer within 30 days of your injury, report the injury in
writing to the insurance company yourself, or complete the DIA’s Employee’s Claim (Form 110) and send the insurer a copy of the
completed form. You can access, fill out, and print the form in the Forms and Publications section at www.mass.gov/dia.
Your employer is required to have a poster displayed in the workplace with the name and address of its Workers’
Compensation insurer and policy information. If your employer does not have this poster displayed and will not tell you the
name of its insurance company, the DIA’s Office of Insurance (617-626-5480 or 617-626-5481) will try to help you. If you suspect
your employer is not carrying insurance, call our Office of Investigations at 617-727-4900, ext. 7406.
2
What Happens When The Insurer Decides To Pay The Claim?
If the insurer agrees to pay the claim, they will send you an Insurer’s Notification of Payment (Form 103).
When Will The Benefits or Checks Start?
You should start getting a check within three to four weeks after your injury or illness. You will receive compensation for lost wages
for any days you are disabled after the first five full or partial calendar days. You are not compensated for the first five days of
incapacity unless you are disabled for 21 calendar days or more.
The first 180 days after your initial injury are considered a “Pay-Without-Prejudice” period. This means the insurer may pay benefits
to you for up to 180 days without making a final decision on your case. Paying you during this period DOES NOT mean they
have accepted liability. During this initial period, the insurer may stop or reduce your payments by giving you seven days written
notice via an Insurer's Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice
Period (Form 106). The insurer must give the reasons for taking this action. If the insurer continues paying you past this period,
they will, in most cases, need permission from you or a judge to stop or reduce your benefits. If you receive a Form 106 and you
receive notification of termination of benefits, be sure to consult an attorney to discuss your rights and responsibilities.
The insurer may ask you to extend the initial 180-day “Pay-Without-Prejudice” period for up to a year, with your written consent,
on an Agreement To Extend 180 Day Payment-Without-Prejudice Period (Form 105). The DIA must approve the form. You should
make sure you are aware of all your rights before giving your consent or signing any other document.
What Happens When The Insurer Denies Your Claim?
If the insurer decides to deny your claim, they must send you by certified mail an Insurer’s Notification of Denial (Form 104),
including the reasons for denial and must inform you of your right to appeal. If you have questions about a denial or lack of
payment on these forms, contact the insurer’s claim representative. Their phone number will be listed on the form. If you have
hired an attorney, have the attorney call the claim representative about your denial. The claim representative cannot speak with
you about your claim once you retain an attorney.
What You Should Do When the Insurer Denies Your Claim, or You Do Not Receive All
Benefits You Are Entitled To
If an insurer denies your claim, you have the right to file a claim with the DIA. If you wish to file a claim with the DIA, legal
representation is strongly advised at this point in the process. Fully and accurately complete and submit an Employee’s
Claim (Form 110) to the DIA, which you can access from the “Forms and Publications” area at our website, www.mass.gov/dia
and at any DIA office. Do not send this form to the DIA unless you have received an Insurer’s Notification of Denial (Form 104), or
it’s been 30 or more calendar days from your injury or illness date, and you have not heard from the insurer.
When filing the Form 110, be sure to attach copies of any medical evidence that supports your claim, including medical bills
and medical reports (do not attach x-rays, MRI’s, etc.) that document how your injury or illness is related to your work.
Submit the claim package to the DIA at the address printed on the top of the Form 110.
You must also send a copy of the completed Form 110 to the insurer. We recommend that you keep a copy of this form for
your own files.
Once the DIA receives your completed Form 110, you will be scheduled for a Conciliation within two weeks or so. This will
start the dispute process. You will be notified in writing of the date, time and location of this meeting.
Please Note: When you come to any DIA office for any proceeding, be sure to bring with you any communications the insurer or
the DIA has sent to you, along with any other relevant paperwork, especially the Notice of Proceeding telling you to come
to the DIA.
The Dispute Process
1. Conciliation
The first stage of the Dispute Resolution process is initiated when the DIA receives either of the following forms:
1. Employee's Claim (Form 110), which is filed by an injured employee or their legal counsel against the Workers’
Compensation insurance carrier.
2. Insurer’s Complaint for Modification, Discontinuance or Recoupment of Compensation (Form 108), which is filed when an
insurance company requests permission to stop or change your benefits.
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Upon receiving either of these forms, an informal meeting will be automatically scheduled between you (or your legal
representative), the insurer’s attorney, and a conciliator from the DIA. This meeting, called a “Conciliation,” normally takes place
within 12 business days of filing a Form 110 or Form 108. At the Conciliation, an effort is made to reach a voluntary agreement
between you and the insurer. If a voluntary agreement cannot be reached, the status of your claim would remain the same as
before, and your case could be referred to one of our judges for a Conference.
2. Conference
The Conference is an informal legal proceeding before an Administrative Judge, and usually will take place between 8 - 12 weeks
from the date of the Conciliation. The judge learns about the case from presentations by both parties and the submission of
documents, such as medical reports, wage statements and affidavits from witnesses. Witnesses are not called. You or your attorney
indicates to the judge what the witnesses would have said.
At the Conference you need to show:
(A) you were disabled;
(B) the injury or illness was work related; and
(C) That any disputed medical bills were for necessary treatment.
After the Conference the judge issues an order, either telling the insurer to pay your benefits or ruling that they are not required to
pay your benefits.
The Conference Order can be appealed by either party on an Appeal of a Conference Proceeding (Form 121). You have 14 days to
appeal from the date of the order. There is a fee to appeal the Conference Order if your appeal is based on a medical
issue. This fee pays for you to be evaluated by an impartial medical physician. This fee may be waived if you can prove you cannot
afford to pay the fee by filing an Affidavit of Indigence and Request for Waiver of Sec. 11A (2) Fees (Form 136). If either party
appeals the Conference Order, a formal hearing before the same judge will be scheduled.
3. Hearing
The Hearing is a formal legal proceeding. It is usually held before the same judge who presided at the Conference.
Massachusetts Rules of Evidence will apply and sworn testimony is taken. Witnesses are called and cross-examined by the opposing
party. A stenographer records the proceedings.
The judge will render a Hearing decision in which you will either be awarded benefits or not. The decision can be appealed to the
Reviewing Board by either party on an Appeal to Reviewing Board (Form 112). This appeal can only be made if the party contends
that the judge made an error of law in issuing their decision or during the Hearing. The appeal must be received within 30 days
from the date of the Hearing decision. There is an appeal fee equal to 30 percent of the State Average Weekly Wage1 in place at
the time of the appeal. The fee may be waived by filing an Affidavit in Support of Request for Waiver of Filing Fee Under Sec.11C
(Form 112A).
4. The Industrial Accidents Reviewing Board
If one or both of the parties wishes to appeal the Hearing decision, that appeal is heard and decided by the Reviewing Board. This
board is comprised of six Administrative Law Judges, three of whom will examine the hearing transcripts. They may ask for
additional written legal briefs or oral arguments from the parties. The Reviewing Board can reverse or uphold the decision of the
Administrative Judge, or can determine that more work needs to be done, and remand (send back) the case to the Administrative
Judge for further finding. Either party may appeal Reviewing Board decisions to the Court of Appeals within 30 days of the
Reviewing Board decision.
5. Further Appeals
If one or both of the parties wishes to appeal the decision of the Reviewing Board, the appeal is heard by the Massachusetts Court
of Appeals.
1 As of October 1, 2012, the State Average Weekly Wage (SAWW) is $1,173.06, and the appeal fee is $351.91. The
SAWW is updated annually on October 1. You can find updated information at www.mass.gov/dia and click on the
Minimum/Maximum Compensation Rate icon.
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What Are The Workers’ Compensation Benefits?
Temporary Total Incapacity Benefits (Sec. 34)
Who Qualifies?
You qualify if your injury or illness leaves you unable to work – considering age, training, and experience – for 5 or more full or
partial days (the days don’t have to be consecutive).
What Are The Benefits?
Your benefits will be 60% of your gross (pre-tax, pre-benefits) average weekly wage.2 To determine your compensation, take the
sum of your total gross earnings, including overtime, bonuses, etc., for the 52 weeks prior to your date of injury and divide the sum
by 52 to compute your average weekly wage. (Note: If you were employed by your current employer for only a portion of the 52
weeks prior to injury or illness, divide the total gross earnings by the number of weeks of employment in the prior year, to
determine your average weekly wage.) Multiply your average weekly wage by 60% (.60) to find your approximate weekly
compensation under Sec. 34. The maximum that you can receive is the State's Average Weekly Wage (SAWW) 3 at the time of your
injury.
For How Long?
You can receive these benefits for up to 156 weeks (3 years). Compensation begins on the sixth day of incapacity; you will not be
compensated for the first five days of incapacity unless you are disabled for 21 days or more. These days do not have to be
consecutive.
Partial Incapacity Benefits (Sec. 35)
Who Qualifies?
You qualify if you can still work but lose part of your earning capacity because of your injury or illness. This may include an injury
forcing you to change jobs at a lower pay rate, or an injury that requires you to work fewer hours.
What Are The Benefits?
The maximum compensation under Sec. 35 is up to 75% (.75) of what your weekly total temporary benefits would be. For
example, if you receive $440 a week as a total temporary benefit, the most you could receive if you collected partial benefits would
be $330 a week. ($440 x .75 = $330).
For How Long?
You can receive benefits for up to 260 weeks (5 years).
Permanent and Total Incapacity Benefits (Sec. 34A)
Who Qualifies?
You qualify if you are totally and permanently unable to do any kind of work as a result of a work-related injury or illness. You do
not have to exhaust your temporary benefits before applying for permanent benefits.
What Are The Benefits?
You will get two-thirds of your average weekly wage (or a minimum of 20% of the SAWW) based on the 52 weeks prior to your
injury, up to a maximum of the SAWW. You may also be entitled to annual Cost-Of-Living Adjustments (COLA).
For How Long?
You can receive benefits for as long as you are disabled.
2 A complete definition of Average Weekly Wage can be found in Massachusetts General Laws Ch. 152, Sec.1.
3 As of October 1, 2012, the State Average Weekly Wage (SAWW) is $1,173.06. You can find updated information at
www.mass.gov/dia and click on the Minimum/Maximum Compensation Rate icon.
5
Medical Benefits (Sec. 13 & Sec. 30)
Who Qualifies?
You qualify if you suffer a work-related injury or illness that requires medical attention.
What Are The Benefits?
You are entitled to adequate and reasonable medical care as a result of the injury or illness. You are also entitled to prescription
reimbursement and mileage reimbursement for travel to and from medical visits for your work-related injury or illness. For your first
visit to the doctor or hospital, your employer has the right to designate a healthcare provider within the employer’s preferred
provider arrangement. After that initial treatment, you have the right to choose your own healthcare providers. The insurer has the
right to send you periodically to see its doctor for an evaluation of your incapacity.
Once your claim has been reported to the insurance company, the insurer must issue you an insurance card with a claim number
and contact information on it. Give the claim number to your doctor so the doctor can bill the insurer directly and get pre-approval
for treatment of your injury or illness. If you do not get this card promptly after your injury or illness, contact the insurer and get
the number as most medical providers will not treat you without the claim number.
For How Long?
You can receive benefits for as long as medical and hospital services are required due to your injury or illness.
Permanent Loss of Function and Disfigurement Benefits (Sec. 36)
Who Qualifies?
You qualify if a work-related injury or illness results in a permanent loss of certain specific bodily functions, or if you suffer scarring
or disfigurement on your face, neck or hands.
What Are The Benefits?
You receive a one-time payment for your disfigurement and/or scarring. This benefit is paid in addition to other payments; for
example, medical bills, lost wages, etc. The amount paid depends on the location and severity of the disfigurement or function lost.
If you were injured or suffered an illness prior to December 24, 1991, you have slightly different benefits. Contact our Public
Information Office if you have any questions about these benefits. If you do not have an attorney, you may want to contact our
Conciliation Unit once the insurer has made an offer for your scarring and disfigurement and speak to a Conciliator. The Conciliator
can give you an idea of whether the offer falls within established guidelines.
For How Long?
You receive a one-time payment for your loss of body function, disfigurement and/or scarring.
Survivors’/Dependents’ Benefits (Sec. 31)
Who Qualifies?
You qualify if you are the spouse or child of an employee who has died as a result of a work-related injury or illness. Children are
eligible only if they are under age 18, are full-time students or are unable to work because of physical or mental disabilities.
What Are The Benefits?
Surviving spouses can receive weekly benefits equal to two-thirds of the deceased worker’s average weekly wage, up to the
maximum of the State’s Average Weekly Wage (SAWW) in place at the time of their injury or illness.
Surviving spouses become eligible for yearly cost of living adjustments two years after the date of the injury or illness.
If the spouse remarries, $60 a week is paid to each eligible child. The total weekly amount paid to dependent children cannot
exceed the amount the spouse had been receiving.
For How Long?
Surviving spouses can receive these benefits for as long as they remain dependent (as determined by a judge) and do not remarry.
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Burial Expenses (Sec. 33)
In all cases where death has occurred as a result of an injury or illness, the insurer will pay up to $4000 for reasonable burial
expenses.
When Benefits May Be Stopped or Reduced
Your benefits may be stopped or reduced for several reasons. Examples of those reasons are:
Benefits are ordered to be stopped by an Administrative Judge, Reviewing Board, higher court, or arbitrator.
You have returned to work. The insurer must resume benefits if you leave work again due to the same injury within 28 days,
provided that the insurer has accepted or been assigned liability for your injury.
The insurer has been given a medical report by your treating doctor or an impartial medical examiner stating that you are
capable of returning to work, and your employer has reported in writing that a suitable position is available for you that your
doctor has approved.
You are requested to attend an evaluation by a DIA Vocational Rehabilitation Review Officer and you refuse to attend, or you
refuse to cooperate with the provision of vocational rehabilitation services.
You are asked to go to the insurer’s doctor for evaluation, and you fail to attend.
You are imprisoned after conviction for either a misdemeanor or felony.
Lump Sum Settlements
A lump sum settlement is a legal contract between you, the insurer, and in some cases your employer. A lump sum settlement
is one-time payment usually made in place of your weekly compensation checks. Be sure when accepting a settlement
that you are clear on your rights, and what you may be giving up, as you must carefully consider whether settling your case is in
your own best interest. Again, this is a critical time to seek legal advice. A lump sum is not given automatically; both you and the
insurance company must agree to it, and in most cases, it must be approved by an Administrative Judge at the DIA.
In receiving a lump sum settlement, you may still be eligible for Vocational Rehabilitation Services paid by the insurer. Discuss these
rights with a judge or your attorney prior to signing any agreement.
Visit our website at www.mass.gov/dia under “Forms and Publications” to download a Lump Sum Brochure.
Vocational Rehabilitation Services
The goal of vocational rehabilitation (VR) is to return you to work earning as close as possible to what you were earning prior to
your injury or illness, if not more. VR services cover all non-medical services that you may require to return to a suitable job.
Depending on your situation, services may include: evaluation of your capabilities, vocational testing and training, counseling or
guidance, workplace modifications, formal retraining, and job placement assistance.
If you receive a notice to meet with one of our VR Review Officers, you must attend this meeting. If you fail to come to this
meeting, your benefits can be discontinued. This meeting is to determine if you are suitable for services designed to help put
you back to work. If you refuse to take part in a rehabilitation program after being found suitable, your weekly benefits can be
reduced by the insurance company with the DIA’s permission. For more information, please visit our website at
www.mass.gov/dia or call our Public Information Office at 617-727-4900, ext. 7470 for a VR Brochure.
How to Verify Workers’ Compensation Coverage
The DIA provides a free web-based “Proof of Coverage” (POC) tool that can help verify whether an employer has a current
Workers’ Compensation policy. Although the POC tool is not designed to detect fraud, it may assist in determining whether fraud
exists. To access the POC tool, go to www.mass.gov/dia and click on the link to “Verify Workers’ Compensation Coverage.”
If after checking the POC tool you believe that an employer is not providing coverage, contact our Office of Investigations at 617-
727-4900 ext. 7313 or toll free at 1-877-MASSAFE (627-7233). Or fill out a referral form online.
Frequently Asked Questions By Injured Workers
For “Frequently Asked Questions,” visit our website at www.mass.gov/dia.
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Public Information
The procedures for filing a Workers' Compensation claim may be confusing. This brochure may answer basic questions. If you need
more information, call any of our regional offices or contact our Boston office; from within Massachusetts: 1-800-323-3249, ext.
7470. From outside Massachusetts, call 617-727-4900, ext. 7470 and ask for Public Information. You can also visit
www.mass.gov/dia.
TDD (teletype for the hard of hearing only): 1-800-224-6196
DIA Regional Offices
Boston Springfield
1 Congress Street, Suite 100 436 Dwight Street
Boston, MA 02114-2017 Springfield, MA 01103
(617) 727-4900, (800) 323-3249 (413) 784-1133
Fall River Worcester
1 Father DeValles Boulevard, 3rd Floor 340 Main Street
Fall River, MA 02723 Worcester, MA 01608
(508) 676-3406 (508) 753-2072
Lawrence
354 Merrimack Street
Bldg. 1, Suite # 230
Lawrence, MA 01843
(978) 683-6420
Commonwealth of Massachusetts
Executive Office of Labor and Workforce Development
Department of Industrial Accidents
YOUR GUIDE TO WORKERS’ COMPENSATION
is published by the
Massachusetts Department of Industrial Accidents,
1 Congress St., Suite 100,
Boston, MA 02114-2017
July, 2013
Printed on recycled paper
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Revised 06/04/2015 Page 2 of 57 NOTE: This handbook is intended to provide information about current policies that pertain to all employees of the Cape Cod Collaborative.
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