WCB Procedures

Initial hospitalization, treatment center and care facility benefits

Procedure summary

Published On

May 7, 2024

Purpose

To provide assistance to workers and their immediate families when the worker is hospitalized as a result of a serious work-related accident that results in a severe injuryA severe injury may include: spinal cord injuries, severe burns, moderate to severe brain injuries, major amputations, significant respiratory conditions, total loss of vision, terminal cancers, bi-lateral arm or leg fractures, failed back syndrome, and any other injuries of similar severity. . Assistance relates to hospitalizations of less than and greater than 14 days.

Description

When the worker is admitted to the hospital, long term care facility, nursing home or other institution, the decision maker reviews the claim to determine the type of benefits the worker and/or their family are eligible to receive during their hospitalization.

The decision maker approves wage loss benefits along with other available benefits and supports, as appropriate. Ongoing assistance and support are arranged based on the worker's needs.

Key information

When a worker is admitted to a hospital, long term care facility, nursing home or other treatment facility, the decision maker assesses the reason for the admission and determines if it relates to the work injury.

The social worker from the hospital may contact the decision maker to discuss worker's admission. When this has not occurred, the decision maker calls the social worker to gather information about the worker's condition, expected length of stay, supports in place and any other identified concerns.

The decision maker reviews the worker's eligibility for benefits including wage loss benefits and hospital stay benefits. This includes benefits that may be available to immediate family members, such as spouse, adult partner, dependent children, parents, guardian or next of kin. See the Hospitalization benefits section. A hospital visit may be arranged to meet the worker and their family to discuss the benefits and supports available.

When a worker's length of stay in a hospital, long term care facility, nursing home or other treatment facility is longer than 30 days, the decision maker considers if there are other factors contributing to the length of stay (i.e. complications including compensable and non-compensable factors). If the worker's admission to the facility is required as a sole result of the compensable injury, WCB will pay the facility (i.e. hospital, long-term care facility, nursing home or other facility) directly for the costs incurred as WCB is the first payer. Where it cannot be determined that the worker's stay is 100% due to the compensable injury, a medical consultant's opinion is required. If the worker chooses to remain in the facility when care could be provided at home, the decision maker, with the assistance of the medical consultant, determines the percentage of care required for the compensable injury and applies it to the cost to stay in the facility.

Detailed business procedure

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1. Review the claim to determine entitlement When a worker has been hospitalized due to their workplace injury, review the file to determine if the claim is already accepted or determine if the claim will be accepted. Review the worker's eligibility for wage loss benefits and set the compensation rate, if applicable. If the worker's earnings are unclear, set a provisional compensation rate until proof of earnings are confirmed. Contact the hospital social worker to discuss the worker's condition and anticipated recovery time. Confirm the following information: The estimated length of the hospital stay. Any immediate problems or concerns. The amount of family support. The worker's room number. Create a care plan that supports the worker's recovery based on the available information. In some circumstances, there may be limited medical reports and the plan will be developed based on the discussion with the social worker or details provided by the employer. Consider consulting with an internal consultant for assistance in determining the estimated recovery time. Issue wage loss benefits to the worker as required.	Administrative tasks Document the conversation in a file note (Contact/Other). Follow the appropriate procedure: 1-1 Initial entitlement decision 2-1 Rate setting 3-2 Collaborative care planning 11-2 Internal consultant referrals
2. Determine payment for admission to the hospital or facility Determine if the worker's admission to the hospital is related to their workplace injury. When the admission and treatment are solely related to the work injury, approve payment for the invoices received. Note: WCB is responsible for costs incurred during a worker's hospitalization when they are the result of their workplace injury. As the first payer, WCB will compensate the institution directly for the costs incurred when related to the compensable injury. When a worker's length of stay in a hospital, long term care facility, nursing home or other institution is longer than 30 days, consider if the length of stay is solely related to the workplace injury or if there are other contributing factors (i.e. non-compensable medical conditions, etc.) In some circumstances, the admission may not be solely related to the work injury. In these cases, determine the percentage of care that is required for the work injury and apply this to the cost of the facility care. For example, the worker was admitted to a nursing home and receives a portion of care (20%) for their work injury. The rest of the care provided (80%) is due to non-compensable medical conditions. WCB will pay for 20% of the total cost for the worker's stay. Consider a referral to a medical consultant to obtain a medical opinion: When the reason for hospitalization cannot be confirmed as solely related to the compensable injury. To determine the percentage of care required as a result of the compensable condition if care could be provided at home and the worker chooses to remain in the hospital or treatment facility. That percentage is applied to the cost of the institution.	Administrative tasks Payments issued to the hospital or care facility are issued by Medical Aid with approval from the decision maker. Follow the 11-2 Internal consultant referrals procedure.
3. Discuss available benefits and supports with the worker and family Consider meeting with the worker and their family if the worker's injury is serious or severe and the length of stay will be long-term. For other circumstances, ensure the worker and family are aware of the assistance and supports available. Explain the available benefits and provide an expense sheet. Reassure the worker and the family that any reasonable and necessary medical aids will be provided to the worker to support them through their rehabilitation process. See Policy 04-07 Services for Workers with Severe Injuries for more details. Note: The worker can submit receipts for out-of-pocket expenses via the worker mobile app, or by mail, fax, email of a scanned or photographed original receipt, or a printed copy. Original receipts are not required. Talk to the worker and/or their family to obtain the worker's personal information and discuss any outstanding issues. Confirm the following details: Worker's support network. Members of the worker's household, including dependents (spouse, children, etc.) Type of home and/or vehicle the worker has, if applicable. Worker's family doctor. Other disability insurance benefits, such as private, union, employer plan, etc. Worker's financial situation including banking arrangements while the worker is in hospital, for the spouse or parent, if applicable. Worker's medical conditions and vocational background Clearly explain the details of any other services or benefits available including: Wage loss benefits (i.e. temporary total disability benefits and/or permanent total disability benefits). Other available allowances (i.e. personal care, short-term home assistance, home maintenance, housekeeping, clothing, etc.). Equipment needs. Home or workplace modifications. Supportive counselling. Hospitalization benefits and/or expenses. Reimbursement for medication. When the worker isn't eligible for benefits, share the appeal information and information regarding the review and appeal process. Advise there is a one-year time limit from the date of the decision letter.	Administrative tasks Send the Claimant – Custom (CL000A) letter to the worker with a copy to the employer detailing the available benefits. Send the appropriate letter when the worker is eligible for additional benefits. Send Worker travel and expense record (C688) when required. Follow the appropriate procedure: 4-3 Psychological counselling 4-6 Special services and equipment 4-8 Pharmacy and direct billing Internal Electronic workplace procedures: 5.5 - Home maintenance allowance 5.15 - Personal care allowance 5.16 - Short-term home assistance - Acute Phase of Recovery 5.17 - Housekeeping allowance Send a letter to the worker with a copy to the employer outlining the decision and details of the discussion.
4. Make the payments and manage the claim Review incoming billing and receipts to issue the appropriate payments. Document the rationale when the requested amount and the periods exceed those provided in the Hospitalization benefits section, with the exception of the benefits that are outlined in the Levels of Authority, Policy or Legislation. Continue to monitor the claim for ongoing assistance and update the care plan, as required. See the 3-2 Collaborative care planning procedure.	Administrative tasks Update the appropriate benefit details tab(s) for the following lines: Authorized treatment line Claim expense line Medical assistive devices line Severe injury line Travel expense line Authorized medication line Send a file note to the Med Aid Payments, Team Desk to pay the billings and receipts, when necessary.

Hospitalization benefits

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Worker hospitalization benefits

Ensure expenses are authorized consistently with the Levels of Authority for Claims Benefits. Follow the 5-1 Travel and subsistence benefits procedure for benefits related to travel and accommodations. The decision maker will always work in conjunction with the worker and their family to provide the benefits and services that best suit their needs, however, below is a guideline of what can be provided.

Worker hospitalization benefits
Benefit	Eligibility criteria	14 days or less	More than 14 days	Approvals and payment
Attendant	The WCB does not provide extra care by hiring an attendant to assist the worker during the initial hospitalization. If a worker or a hospital request that WCB hire an attendant to assist the worker while in hospital, ensure the hospital is providing appropriate patient care. If the worker lives in the same town or city as the hospital and has a personal care attendant before their initial hospitalization, the attendant may continue to support the worker during the first 30 days of hospitalization. Note: This applies to an attendant who was hired to assist the worker before the worker was hospitalized. It does not apply to the worker's spouse, adult interdependent partner, parent or next of kin. Refer to the Family benefits during hospitalization section.	𐄂	✓	Obtain approval to extend attendant care beyond: 30 days from the supervisor. 60 days from the manager.
Childcare	Review individual circumstances. Childcare expenses are authorized at a fair and competitive rate and should be billed directly to the WCB, (applies to family members that provide care). The worker or their spouse, adult interdependent partner or guardian must submit the childcare invoice (C1441) form for reimbursement when the caregiver cannot bill the WCB directly. Refer to the 5-5 Child and animal care procedure.	✓	✓	Update the benefit details tab of the claim expense line. TOP/NOP EX18
Clothing	Additional clothing is not normally purchased for hospital stays of under 14 days or subsequent hospitalizations. Only clothing damaged or lost at the time of the accident may be replaced. Refer to Policy 03-01, Part II - Personal Belongings.	𐄂	𐄂	TOP/NOP EX07 for lost or damaged clothing.
Clothing to attend rehabilitation	Upon transfer to a rehabilitation hospital, workers may receive a one-time reimbursement for clothing appropriate for rehabilitation activities. Each claim is judged on its own merit in order to meet the worker's functional needs. Refer to Policy 04-07 - Services for Workers with Severe Injuries.	𐄂	✓	TOP/NOP EX14
Clothing allowance	A yearly clothing allowance is payable to workers who use a prosthesis, appliance or wheelchair, on an ongoing basis, to help replace clothing worn or damaged as a consequence. Refer to Policy 04-07, Part II - Self-care.	✓	✓	Payments made by Medical Aid TOP/NOP EX12
Electric shaver	A worker with a work-related hand or arm injury may be eligible for a one-time purchase of an electric shaver, regardless of gender. A replacement shaver may be considered if all of the following conditions are met: Damage to the shaver is the direct result of the worker's work-related injury. Damage occurs within the first two years. Damage is not covered by warranty.	𐄂	✓	A maximum of $70.00 on a one-time basis. Send a file note to Med Aid, Payments, Team Desk for payment. TOP/NOP - SSF02
Long distance charges	A maximum of 30 minutes of long-distance charges may be authorized for the worker and/or family when the worker has a hospital stay from 7 up to 13 consecutive days. For stays 14 days or longer, a maximum of 70 minutes may be authorized. This benefit is meant to address concerns the worker may have for their immediate family.	✓	✓	Send a file note to Med Aid, Payments, Team Desk for payment. TOP/NOP - SSF02 Update the benefit details tab of the severe injury line.
Pet care	Review individual circumstances. Refer to the 5-5 Child and animal care procedure for eligibility criteria.	✓	✓
Private room	A private room may be provided to accommodate the treatment or the necessary medical equipment or other necessities. If the medical equipment or treatment does not warrant a private room, refer to Policy 04-06, Part II-Health Care for the approval criteria. Note: If the private room is medically required, the hospital cannot charge for it.	✓	✓	Send a file note to Med Aid, Payments, Team Desk for payment for payment. TOP/NOP - HS04
Specialty treatment beds	The hospital is responsible for providing all medical equipment required by a patient while in hospital. The WCB does not assume responsibility for bed rental during the initial hospitalization.	𐄂	𐄂
Television rental	A television rental may be authorized when the worker has a hospital stay of seven consecutive days or more.	✓	✓	Send a file note to Med Aid, Payments, Team Desk for payment. TOP/NOP - SF02. Update the benefit details tab of the severe injury line.
Telephone rental	A telephone rental may be authorized when the worker has a hospital stay of seven consecutive days or more.	✓	✓	Send a file note to Med Aid, Payments, Team Desk for payment. TOP/NOP -SSF02. Update the benefit details tab of the severe injury line.
Toiletries	Toiletries are not normally purchased for hospital stays under 14 days or for subsequent hospitalizations. For stays longer than 14 days, approval may be provided on a one-time only basis up to a maximum of $20.00 for these purchases if: The hospital does not provide basic toiletries (e.g., toothpaste, shampoo, etc.) and Only for workers who do not live in the same town or city as the treatment facility. Ongoing toiletry expenses are the responsibility of the worker. This applies to the initial hospitalization only. The worker must provide their own toiletries for subsequent hospitalizations.	𐄂	✓	Send a file note to Med Aid Payments, Team Desk for payment. TOP/NOP - MS05
Transportation	Transportation may be authorized for the worker and one attendant from the worker's home to the hospital and return.	✓	✓	Update the benefit details tab of the travel expenses line. TOP/NOP - EX02 or EX03

Family benefits during worker hospitalization

Ensure expenses are authorized consistent with the Levels of Authority for Claims Benefits. Follow the 5-1 Travel and subsistence benefits procedure for benefits related to travel and accommodations. Family members eligible for benefits during a hospitalization include spouse, adult interdependent partner, dependent children, parent, guardian or next of kin. The decision maker will always work in conjunction with the worker and their family to provide the benefits and services that best suit their needs, however, below is a guideline of what can be provided.

Family benefits during worker hospitalization
Benefit	Eligibility	14 days or less	More than 14 days	Approval/Payment
Accommodations	Must be spouse, parent, dependent child or next of kin. Dependent children must stay with a parent, guardian, or other family member. Boarding allowance may be authorized while the worker is in hospital if no personal attendant is involved. If the family has to travel then accommodations will typically be provided until the worker is transferred out of acute care to a regular hospital ward. Receipts are required or the daily maximum rate will be paid. Refer to Policy 04-02, Part II - Allowances.	✓	✓	Update the benefit details tab of the travel expenses line TOP/NOP -EX01
Accommodations/meals after 30 days	Review and arrange the most cost-effective accommodation as soon as possible (e.g., apartment rental, etc.). Apartment rental includes the payment of hook-ups, power, utilities, and telephone rental. Carpet cleaning may be paid on a one-time basis at the end of the stay. Meal costs should be very limited as groceries are part of the worker's normal expenses. Notes: Accommodations may need to be wheelchair accessible. Per WCB corporate guidelines, accommodations for AirBnB and VRBO are not recommended or arranged by WCB.	𐄂	✓	TOP/NOP - EX01
Hospital visits	Must be spouse, adult interdependent partner, parent, dependent child or next of kin. Travel allowance, for the most cost-effective mode of travel, may be authorized while the worker is in the hospital.	✓	✓	Update the benefit details tab of the travel expenses line. TOP/NOP - EX02 (mileage) or EX03 (bus far)
Income/wage loss	Approval for a wage replacement of gross earnings for the spouse, adult interdependent partner, one parent, or next of kin for up to a maximum of 30 days. Wage loss must be confirmed in writing by the employer or on the Personal Attendant's Wage Loss form (C936) For wage replacement beyond 30 days, assistance should be requested from other agencies (e.g., Employment Insurance, Social Services and private insurance providers). In specific situations, where the treating specialist has identified it is medically required for the spouse, adult interdependent partner to be in attendance for longer than 30 days (continuous period) and the spouse/adult interdependent partner is not eligible for other benefits, payments may be extended for up to 60 days (continuous period) with approval of the supervisor. Any payments beyond 60 days must be reviewed and approved by the manager.	✓	✓	Send to Payment/Comp Payments, Team Desk for payment. TOP/NOP - EX06
Meals	Must be spouse, interdependent adult partner, parent, dependent child or next of kin. Meal allowance may be authorized as required while the worker is in the hospital (includes meals for each dependent child as well). Receipts are not required. Refer to the 5-1 Travel and subsistence benefits procedure.	✓	✓	Update the benefit details tab of the travel expenses line EX01.
Mileage/airfare	Travel allowance may be authorized while the worker is in hospital. One return airfare may be authorized for the spouse, adult interdependent partner, both parents or next of kin. Review each request individually and consider family responsibilities, distance from home, cost effectiveness. Refer to 5-1 Travel and subsistence benefits procedure.	✓	✓	TOP/NOP EX02 (mileage) TOP/NOP EX05 (air travel)
Parking	Must be spouse, adult interdependent partner, parent or attendant. The costs associated with parking at the hospital or treatment facility may be reimbursed once the receipt(s) are received. Workers can submit the receipt via the Worker Mobile App or by mail, fax, or email of scanned or photographed original receipts.	✓	✓	Update the benefit details tab of the travel expenses line. TOP/NOP - EX26 Parking for a person escorting the worker to the hospital is paid as TOP/NOP EX06.
Taxi	Return fare from the accommodations to the treatment facility may be authorized for the spouse/adult interdependent partner/parent or next of kin. After 30 days, arrange the most reasonable mode of transportation. Refer to the 5-1 Travel and subsistence benefits procedure.	✓	✓	TOP/NOP EX04

Paraplegic and quadriplegic services

Supporting references

Policies

Policy 04-07 Part I, Services for Workers with Severe Injuries

Procedures

Workers’ Compensation Act

Applicable sections

Section 79 - Clothing allowance
Section 82 - Allowance for Home Care
Section 86 - No Charge for Medical Aid
Section 89 - Board to Provide Vocational and Rehabilitation Services

General Regulation

Applicable sections

Related Legislation

Applicable sections

Compatibility Warning

WCB Procedures

Initial hospitalization, treatment center and care facility benefits

Procedure summary

Detailed business procedure

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Hospitalization benefits

Supporting references

Policies

Procedures

Related links

Workers’ Compensation Act

General Regulation

Related Legislation