Please read this prior to completing the package to ensure a timely determination on your case.
If any information is missing or incomplete, this may cause a delay or denial of Catastrophic Leave.
The employee will receive a letter signifying approval or denial. If denied, the letter will identify the specific reason why the leave was not approved.
The manager will receive notification from Human Resources signifying whether the leave was approved.
Please see Administrative Policies and Procedures Manual - Policy 3430: Catastrophic Leave Program for more information.
Catastrophic Leave is addressed by University Administrative Policies - Policy 3430: Catastrophic Leave Program. The policy defines a catastrophic condition as "a serious, life-threatening illness or injury that results in a period of incapacity, whether continuous or intermittent."
Key identifiers of a catastrophic illness or injury include:
The policy further explains that, "The University retains the right to determine whether the illness is 'serious' based on the information it receives from the medical provider." UNM’s Third Party Administrator (TPA) evaluates the medical documentation from the clinical provider based on medical standards for illnesses and injuries to determine whether or not a condition meets the definition of catastrophic. Therefore, it is extremely important that the medical documentation accurately portray the condition so the TPA can properly evaluate whether or not it is catastrophic.
UNM has contracted with CoreVisory as the Third Party Administrator (TPA) to review the employee’s medical information. CoreVisory has access to over 325 credentialed medical reviewers who are board certified physicians in all major specialties. Additionally, CoreVisory utilizes a secure web portal which will allow HR Consultants to upload medical information, provide updates or other key information pertaining to the employee’s case. More importantly, CoreVisory will assign a new physician to review existing and new medical information if an appeal is filed.
Section 3.1 of the policy lists examples that constitute exclusions that will not be covered by the Catastrophic Leave Program. However, exclusions may be covered if complications arise from the initial medical condition.
Medical professionals from the Third Party Administrator review the application in accordance with medical disability guidelines in order to assess the qualifications of the condition with the guidelines for the Catastrophic Leave Program. Consideration is given to the intensity of medical treatment required, the acute nature of the condition, the functioning ability of the individual, and any recent progression in the applicant's condition. A complete review ensures consistency in the application process.
Short-Term Disability covers most medical conditions, not just catastrophic illnesses. A big difference between Catastrophic Leave and Short-Term Disability is that Short-Term Disability will cover maternity leave, sickness, disease, other medical conditions, and injuries, which do not meet the definition of catastrophic.
Please see the Short Term Disability page for more information.
Each case is thoroughly evaluated by the Third Party Administrator (TPA) based on the medical information provided by the health care provider and how that medical condition applies to the policy. A catastrophic leave request may be denied because the condition does not meet the criteria as listed in the policy or if the documentation lacks sufficient information to support an approval of catastrophic leave.
If an employee’s
case is denied, then he/she will have the ability to file an appeal. There are two
appeal processes in place depending on the reason for denial. If an application
is denied by a manager due to misuse or abuse of leave, the employee can appeal
to the next level manager. If an application is denied by the TPA due to
medical reasons, the applicant can have their health care provider resubmit their
application with additional medical details. With an appeal, the TPA will
assign a new health care provider to review the medical documentation. The
application will then be reevaluated based on the new information provided.
Any denial for reasons of misuse of leave or medical review can be appealed to the Vice President of Human Resources. The decision of the VP of HR may be appealed to the Board of Regents as per Regents’ Policy, Section 1.5.
The severity of the illness or injury may change over time which is why a recertification process is necessary. If the individual's health has improved, he/she may no longer be in a catastrophic situation. Conversely, someone may have a progressive illness that originally is not catastrophic but later reaches the catastrophic level.
The Catastrophic Leave Program is administered under an opt-out approach. This means that eligible employees are automatically enrolled unless they choose to opt-out. The opt-out period is offered before the beginning of the fiscal year and is administered via a link that is sent to all eligible employees. Careful consideration should be given to opting-out. Once an employee has chosen to opt-out, he/she will not be eligible to receive benefits from the program for the entire fiscal year. In addition, he/she may have to contribute at a higher rate if they would like to participate at a future time. Employees will have to opt-out each year if they do not want to participate.
The Third Party Administrator’s medical professionals review the application, along with medical disability guidelines, to assess the qualifications of the condition with the guidelines stated in the Catastrophic Leave Policy. Consideration is given to the intensity of medical treatment required, the acute nature of the condition, the functioning ability of the individual, and any recent progression in the applicant's condition. A complete review ensures consistency in the application process.
The employee submits the application to their manager, who will work with their Human Resources Consultant to evaluate the request based on basic eligibility requirements, including contribution to the program, length of service, length of request, and any history of misuse or abuse of leave. Human Resources and the manager do not determine whether the medical requirements of the Catastrophic Leave Program are met. Human Resources will forward the information to the Third Party Administrator (TPA), who will evaluate the medical information submitted by the medical care provider. The TPA may contact the physician directly for additional information. The TPA will forward the final determination back to HR, who will work with the manager in notifying the employee.
The annual and sick leave programs are governed by University Administrative Policies (UAP) #3400, Annual Leave , and UAP #3410, Sick Leave. These policies provide specific information on each program and establish the parameters for appropriate use. In addition, you may contact your HR Consultant to respond to specific questions.
Unfortunately, leave above the amount of 252 hours is not recorded (or expensed), so there is no financial savings to apply this leave to the catastrophic leave program.
University Administrative Policies #3400: Annual Leave states, "Annual leave is accrued at the end of the pay period and cannot be taken until the pay period following the date in which it was accrued." The same would apply for donations. They cannot be taken until the following pay period. It is suggested that employees monitor their annual leave balances by referencing Lobo Web to determine their ability to donate to the program.
Employees may apply for catastrophic leave for a continuous absence or an intermittent absence. Continuous absence is when the employee is out of the work place for a specified period of time. Intermittent leave is when an employee will need follow-up care or treatments and is able to work. Intermittent leave can be used for chemotherapy, dialysis, etc. and can only be used in increments of four (4) or eight (8) hour blocks.
The maximum leave hours for intermittent leave is 520 hours,
prorated based on the employee’s FTE. Employees cannot combine continuous
catastrophic leave and intermittent catastrophic leave to extend beyond the
maximum of 1040 hours.
An employee is approved for continuous catastrophic leave and uses 700 hours of leave. The employee will need to continue treatments and is subsequently approved for intermittent catastrophic leave. Since the combination of continuous and intermittent leave cannot exceed 1040 hours, the employee can only be approved for 340 hours not the 520 hours maximum.