Housekeeping allowance

This step is completed by the case assistant.

At the next scheduled HKA review date, assign the claim to the decision maker to determine the worker's eligibility for ongoing HKA benefits. 

Note: The scheduled review date for monitoring HKA benefits should be the most current date documented in either the initial HKA approval file note or the latest extension approval file note.

The following steps are completed by the decision maker (either the case manager or the adjudicator).

Review the physical demands analysis and/or the Home Independence Assessment - Home Activity Review (HAR) form on the file.

Call the worker to gather information for the HKA review.

Note: If the worker could not be reached after two attempts, send the appropriate letter requesting contact or a reply to the letter so the review can be completed.

Have a collaborative discussion to confirm any changes to ensure the level of support they are receiving meets their current needs. Ask:

• Have there been any significant changes or issues with performing housekeeping tasks (i.e., change in functional limitations, etc). If so, what are they?
• What is their current living situation (i.e., living in a condo, own home, residential care facility etc)? If they have moved, are they still responsible for housekeeping tasks, if applicable?

If there are no significant changes to the worker's functional limitations or living circumstances and they continue to meet the eligibility criteria for HKA as outlined in Policy 04-10, Part II, Application 3 and the Key information section, discuss the decision to extend the HKA benefits and the next scheduled review date. Continue to step 5 to communicate the decision in writing.

Note: If a worker moves to a comparable living situation (e.g., from one house to another house or one apartment to another apartment), this would not be considered a significant change.

If there are significant changes (i.e., functional limitations or living situation has changes or new aids or equipment are being considered, etc.), gather information related to the change and:

• Complete a new Housekeeping physical demands analysis.
• When there is a significant change in their functional limitations (i.e., improvement or deterioration) or their living situation (i.e., worker was moved from a two-story home to an apartment):
  • Explain to the worker a referral an OT assessment will be made to better understand how their functional limitations are affecting their ability to manage housekeeping tasks and to identify any aids or equipment that may help increase their independence.
  • Make a referral for an OT assessment.

Review the OT assessment report and any recommendations provided. 

If there are questions or clarification is needed, follow up with the OT promptly to ensure accuracy while the assessment details are still current.

Evaluate medical aid or equipment recommendations

If medical aid(s) or equipment were recommended:

• Confirm the purpose of the aid(s)/equipment, benefit to the worker and whether it would eliminate the need for HKA. If it
  • does not remove the need for hiring help (HKA benefits), the recommended equipment/aids should not be approved. A worker is eligible for either the equipment or HKA benefits, not both.
  • does remove the need for hiring help (HKA benefits), approve the recommended equipment/aid and end HKA benefits. Review the average cost for the recommended equipment with the Home Assistance Team (HAT).

Consult with the OT and/or the special needs coordinator if there are questions or concerns about the recommended aids/equipment.

Discuss recommendations with the worker

Call the worker and review the OT recommendations including any aids, equipment, strategies and supports to help them complete housekeeping tasks.

When recommended aid/equipment is required, explain what aid(s)/equipment has been approved and that arrangements for purchase and delivery will be made through a WCB special needs coordinator. In some circumstances, the worker may be required to purchases the aid/equipment and submit the receipt for reimbursement. 

In cases where the worker faces financial barriers to obtaining the necessary aids or equipment, an advance may be considered to facilitate access. For larger equipment purchases, ask the worker to send in a couple quotes. Additionally, recommend the worker purchase extended warranty as it will be covered as part of the purchase price.

When the provision or aid(s)/equipment:

• resolves the permanent limitations and no other assistance is needed, discuss the decision end HKA benefits. Continue to step 5 to communicate the decision in writing.
• does not resolve the permanent limitations and additional assistance is needed, continue to the next step to determine the worker's eligibility for ongoing HKA.
   

When aid(s)/equipment are not required or the recommendation is not approved, continue to the next step to determine the worker's eligibility for HKA.

Review the information and confirm the worker's inability to perform the task is due to a functional limitation from their compensable injury. 

Note: The worker's limitations for housekeeping are considered separate from their work restrictions. For example, a worker may be unable to return to work due to job-specific restrictions but still be able to manage household upkeep.

Determine if the worker continues to meet the eligibility criteria for HKA as outlined in Policy 04-10, Part II, Application 3.

When there are no changes and HKA benefits will be extended, continue to the next step.

When there are changes and HKA benefits will be:

• not extended, continue to next step.
• extended, send a recommendation to the supervisor requesting approval for the extension. The supervisor reviews the recommendation and approves or does not approve the extension.

The supervisor reviews the recommendation to extend HKA benefits and approves or does not approve the extension.

Review the supervisor's recommendation to approve or not approve the HKA extension, if applicable. Action any recommendations as appropriate.

Call the worker to discuss the decision and rationale to approve or not approve the HKA extension. 

HKA extension not approved

If the decision is to not approve the HKA extension, clearly explain why the worker does not qualify for an extension of their HKA benefits, if not discussed in an earlier step (e.g., medical aids or equipment resolved the functional limitation for housekeeping, the worker moved and no longer requires the support, etc.).

If applicable, discuss whether the worker may qualify for another benefit like HMA or PCA and explain the next steps for the review. Refer to Policy 04-10, Part I for other available allowances for serious injuries or Policy 04-07, Part I Services for Workers with Severe Injuries. 

Communicate the decision in writing and end this procedure.

HKA extension approved

If the decision is to approve the HKA extension, discuss the next review date and the approved amount according to Policy 04-10, Part II, Addendum B. Encourage the worker to continue to arrange housekeeping support with a service provider in the area where they reside.

Communicate the decision in writing, notify the Medical Aid Team of the approval, and determine the monitoring schedule for the HKA benefits. Refer the HKA review schedule information outlined in step 8 of the Initial Housekeeping allowance decision section.

If no active case management is required, assign the claim to the case assistant for monitoring. 

Repeat steps 1 through 5 of the Monitor housekeeping allowance eligibility section until HKA benefits are discontinued.

Note: If HKA was previously ended for administrative reasons (e.g., benefits were not extended because there was no contact from the worker), confirm the worker's ongoing need for housekeeping assistance (e.g., when contact is made) and reinstate HKA benefits the month the decision is made. After reinstatement, review the worker's eligibility for the retroactive period (the period between the original end date and the reinstatement date).

A worker's eligibility for retroactive HKA is determined by the decision maker (i.e., case manager or adjudicator) responsible for managing the claim. HKA is not intended to be a retroactive benefit. However, retroactive HKA should be considered if prior medical evidence supported that the worker had a permanent disability that impacted their ability to perform housekeeping tasks and a review for HKA eligibility was not completed.

For all retroactive HKA reviews, information relevant to the retroactive period must be considered to determine if the worker met the HKA eligibility criteria at that time.

For the retroactive period under consideration

Determine if the worker met the criteria for a seriously injuredSerious injuries include rotator cuff tears, ruptured discs, severe ankle/wrist fractures, severe knee injuries [e.g., torn anterior cruciate ligament (ACL)]. Soft tissue injuries are not considered serious, unless there is unusual severity (e.g., bilateral epicondylitis, hernia repairs). worker, as outlined out in Policy 04-10, Part I. If the worker:

• was not seriously injured, they do not qualify for HKA. Continue to step 4 to communicate the decision.
• may have be severely injured, they do not qualify for HKA. End this procedure and instead assess their eligibility for other supports under Policy 04-07, Part I Services for Workers with Severe Injuries.

If the worker was seriously injured, determine if the worker had a permanent compensable disability as outlined in Policy 04-04, Part I, Permanent Disability that prevents them from managing medium, awkward and/or or heavy interior housekeeping tasks. 

Note: For workers with temporary disability, consider if the worker may be eligible retroactive short-term home assistance benefits. Refer to the 5-2 Short-term home assistance procedure.

If there is no confirmed permanent compensable disability, the worker is not eligible for retroactive HKA. Continue to step 4 to communicate the decision.

If there is a confirmed permanent compensable disability that:

• did not prevent the worker from managing housekeeping tasks, the worker is not eligible for retroactive HKA. Continue to step 4 to communicate the decision.
• prevented the worker from managing housekeeping tasks, continue to the next step.

Confirm the reason the worker believes retroactive HKA benefits should be paid. Explain that additional information is needed to determine their eligibility for retroactive HKA benefits.

Discuss that to approve retroactive HKA there needs to be proof that they incurred an additional out-of-pocket expense for hiring outside help (i.e., individual not living with the worker) for housekeeping.  Additionally, the medical evidence (e.g., medical reports, etc.) must support they were in need of assistance with housekeeping tasks during the retroactive period under consideration. 

Ask the worker:

• What housekeeping tasks they hired help for?
• Who provided the services?
• What additional costs they incurred to hire outside help?
• If they were in a hospital or extended care facility during the period in question? Refer to the Allowance benefits during hospitalization section.
• Were aids and equipment previously provided to assist with the worker's restrictions?
• Was there another individual living in the worker's home for the period under review, and if so, were they in receipt of HKA?
• Can the worker provide independent evidence to support that they hired outside help? If receipts/invoices are available, ask the worker to submit copies.  If receipts are not available, ask the worker if they can provide other evidence showing a loss occurred due to the permanent limitations from their serious injury.

Note: Receipts are an excellent indicator of costs the worker incurred but are only one method of confirmation. There may be exceptions in cases where receipts are not available and therefore discretion is needed. Although HKA is not intended as reimbursement for specific costs, if the worker provides other evidence to support costs incurred, consult with the Supervisor whether reimbursement for a specific cost is appropriate.”

Review the worker’s submitted information and confirm if it is sufficient to show they incurred additional out-of-pocket expenses (e.g., receipts, invoices, or other documentation) during the retroactive period under consideration. Note: Services or transactions in kind (e.g., meals, baking, gifts received from a neighbor or friend, etc.) are not considered a financial transaction for payment of services.

If there is not sufficient evidence to support the worker incurred additional out-of-pocket expenses, the worker is not eligible for retroactive HKA. Continue to the next step to communicate the decision.

If there is sufficient evidence to support the worker incurred additional out-of-pocket expenses and the worker met the eligibility criteria as outlined in Policy 04-10, Part II, Application 3 and step 1, identify the date the permanent disability should have been accepted. Choose the effective date based on when the medical reports identified that the worker's compensable disability became permanent. Medical evidence to consider may include Return-to-Work program discharge reports, Independent Medical Examination reports, treating specialist reports, Functional Capacity Evaluation reports, medical consultant opinion regarding permanent work restrictions, etc.) 

Send a recommendation to the supervisor requesting approval to pay HKA benefits retroactively. Include the following:

• A description of the permanent functional limitations and the types of home activities (e.g., washing windows, cleaning the stove, etc.) the worker had difficulties performing.
• Information (receipts, invoices, etc.) submitted by the worker that supports out-of-pocket expenses were incurred.
• The medical reports that support and identify the date when the permanent disability should have been accepted.
• The effective (start) date for retroactive HKA and the period of time it will be paid (end date).
• The total amount payable for the retroactive period.

The supervisor reviews the recommendation and approves or does not approve retroactive HKA. If approved, the supervisor includes the effective date and the approved period for the retroactive HKA.

Note: If the information confirms the worker:

• received HKA on another claim for the same period, they are not eligible for payment on a second claim. Confirm HKA is paid under the claim with greater functional limitations; if not, transition payment to that claim.
• lived with another injured worker who was also receiving HKA benefits for the same period, split the eligible costs equally.  Refer to the Benefit allocation for multiple claims or shared household section.

Review the supervisor's recommendation to approve or not approve retroactive HKA benefits. Action any recommendation, if appropriate.

Call the worker to discuss the decision and rationale to approve or not approve retroactive HKA benefits. 

If retroactive HKA is not approved, clearly explain why the worker is not eligible (e.g., worker is not seriously injured, the information does not support the work incurred out-of-pocket expenses, medical evidence does not support the worker had a permanent disability for the retroactive period under consideration, etc.).

If retroactive HKA is approved, discuss the rationale for the approval, the services approved (e.g., washing walls, windows, etc.) and retroactive period (dates) HKA will be paid. 

Communicate the decision in writing. Notify the Medical Aid team of the approval details so they can process the payment. Note: If the effective date is in the middle of the month, the Medical Aid payment clerk will process the payment based on a prorated calculation.

If ongoing entitlement for HKA benefits has:

• not been determined, continue to the Initial housekeeping allowance decision section.
• has been determined, continue to monitor the worker's eligibility. Refer to the Monitoring housekeeping allowance eligibility section.

When the worker is

• confined to a hospital/institution on a permanent basis, HMA and/or HKA is discontinued and only issued to the end of the month in which the worker is admitted.
• admitted to a hospital on a temporary basis the HMA and/or HKA continues as long as the worker is responsible for maintaining the residence. 
   
• admitted to a hospital on a temporary basis for a compensable surgery, determine entitlement to a Short-Term Home Assistance benefit.  Refer to the 5-2 Short-Term Home Assistance procedure.  HKA benefits may be considered again once the disability is confirmed to be permanent.

HMA/HKA benefits are limited to one claim or for one household. In cases where multiple claims exist for: 

• the same worker, consider payment of the allowance on the claim which has the greatest impact on the worker's ability to perform the housekeeping tasks.
• two workers in the same household, the eligible costs are split equally between the claims.  

Splitting HKA allowance benefits

Worker with multiple claims

Call the worker to explain that allowance benefits are only payable on one claim. Confirm which claim the allowance will be paid under and explain the reason why that claim was selected (i.e. the claim with the greatest impact on the worker's abilities for housekeeping).

Send a letter to the worker outlining the decision and clearly explaining how the duplication of benefits is being eliminated and how this impacts their benefits. 

Two workers share the same household 

Call the case manager assigned to the claim for the other worker who lives in the same home to discuss the issue and determine the best approach that is fair to each worker.

Split the allowance equally between both workers, whenever possible. If circumstances warrant, consider alternatives if they will be more effective in eliminating the duplication of benefits.  For example, one worker receives the full allowance, or one allowance is paid to each worker if multiple allowances are payable (i.e. HMA and HKA are both payable).

Discuss the resolution with each worker (each decision maker calls their worker separately). Ensure the discussions is mindful of the need to respect and protect each worker's privacy. 

Send a letter to the worker (each decision maker sends a letter to the worker on their caseload) outlining the decision and clearly explaining how the duplication of benefits is being eliminated and how this impacts their benefits. 

Note:  Duplication of benefits may also occur when PCA and HKA are paid to more than one worker living in the same home as PCA covers housekeeping costs. For this scenario, the same process is followed: Divide the HKA amount allowance and reduce the payment to each worker by that amount. 

For example, if one worker is being paid Level 2/3 PCA ($1029.00) and the other is being paid HKA ($276.00), you would divide $276.00 by 2 and reduce each allowance by that amount. The Level 2/3 PCA would be reduced to $891.00, and the HKA would be reduced to $138.00. 

Housekeeping equipment (e.g., vacuum cleaners) is not automatically replaced when the warranty expires or the normal replacement period ends. A valid reason is required, such as the equipment is no longer working and it is not cost effective to repair or the equipment is no longer meeting the worker’s needs. 

Consider a referral for an OT reassessment before authorizing a replacement purchase.

Note: An extended warranty is covered by WCB as part of the purchase price. Any loss or repair outside of warranty (i.e. due to intentional damage) is the worker's responsibility.

If a worker, an employer, or their representative requests a review of the decision to approve or not approve housekeeping allowance, the request for review should be referred to the decision maker (e.g., the Home Assistance Team for initial HKA decisions or the case manager for HKA extension decisions), except for the following circumstances:

• The case manager is upholding their decision, the request for review is sent to the Dispute Resolution Decision Review Body (DRDRB).  A review by the Home Assistance Team (HAT) is not required.
• New evidence was submitted that may change the decision, refer the request for review to the Home Assistance Team (HAT) CM should refer to HAT for review.

When the request for review has been reviewed by the DRDRB or the Appeals Commission (AC) and:

• The decision is to implement HKA, the case manager may implement the decision. A review by the Home Assistance Team (HAT) is not required.
• Further investigation is needed, the case manager should refer the claim to the refer to Home Assistance Team (HAT) to complete the investigation and determine the worker's eligibility for HKA.