Why am I receiving follow-ups for continued pay?
You are being asked for this information because employees cannot receive more than 100% of their normal weekly salary during their medical disability or family leave benefit period. If you have indicated on claims forms that you have continued to receive pay while on leave, such as top-up pay from your employer, state and private carriers may inquire about exactly what type of pay you are receiving, the dates in which you received pay and the amount of pay. This is expected as there are often limited options to select on initial applications to specify the type of pay so these follow-ups are to determine whether the benefits you’re eligible for need to be offset from the pay you received from your employer.
How does leave pay work?
Throughout your leave, your employer will top up your pay based upon estimations of benefits you’ll receive from applicable state and insurance programs. For example, if we expect 60% of your normal pay to come from state and insurance programs, your employer would provide the remaining 40% to ensure that you receive full pay.*
However, it typically takes up to 2-6 weeks for Cocoon to finalize your claims and for the state and insurance programs to process, approve, and begin distributing benefits. As a result, while claims are being processed, you will only be receiving partial pay from your employer.
Once your claims are approved, you will receive payment for all covered dates leading up to your approval by each applicable claim entity. Payments may be made in one flat sum for the full duration of coverage or once approved, you may begin to receive weekly or biweekly payments for future covered dates. Once you have begun receiving your benefit payments, you can utilize the Benefit Verification Tool in your dashboard to confirm that the benefit rate received aligns with the estimations made.
*Percentage figures may vary based upon program benefit maximums and your current salary. For more information throughout your leave around the amounts coming in from each source, please see the "Your Payments" section in your Cocoon dashboard.
How do I explain my type of pay?
When receiving follow-up questions from state and private carriers regarding the type of pay you’re receiving while on leave you can use the guidance below by claim type.
Disability Claim
For online submission:
“I am paid a regular salary minus expected SDI during leave (top-up pay). I have a wage loss. Combined, my leave pay and SDI equal my regular pay. SDI should be approved.”
For submission via paper or when needing to speak to case managers over the phone:
“Please be advised that my employer [NAME] has a salary supplement program. My employer estimates the expected disability benefits that I am eligible to receive from the state and/or private disability insurance carrier during my leave (my total disability benefit). My employer then calculates the difference between my regular wages and my total disability benefit and my employer pays me this amount as top-up pay. When combined with my state and/or private disability benefits, my employer’s payments during my leave do NOT exceed 100% of the regular wages I would have been paid had I been working during my leave period. Without this Employer pay program, I would experience a significant loss of pay at a time of need and stress, which undermines the goals sought to be achieved through state and/or private disability programs. Please approve my SDI claim for benefits.”
Paid Family Leave Claim
For online submission:
“I am paid a regular salary minus expected PFL during leave (top-up pay). I have a wage loss. Combined, my leave pay and PFL equal my regular pay. PFL should be approved.”
For submission via paper or when needing to speak to case managers over the phone:
“Please be advised that my employer [NAME] has a salary supplement program. My employer estimates the paid family leave benefits that I am eligible to receive from the state during my leave (my paid family leave benefit). My employer then calculates the difference between my regular wages and my paid family leave benefit and my employer pays me this amount as top-up pay. When combined with my state paid family leave benefit, my employer’s payments during my leave do NOT exceed 100% of the regular wages I would have been paid had I been working during my leave period. Without this Employer pay program, I would experience a significant loss of pay at a time of need and stress, which undermines the goals sought to be achieved through the state paid family leave program. Please approve my PFL claim for benefits.”
*This is just general guidance, for more information on the amounts paid by each source, please see the "Your Payments" section in your Cocoon dashboard.
What if my claim is denied due to continued pay?
You may receive a denial for continued pay when calls or other requests for correspondence from state and/or private carriers go unanswered. To try and appeal or request reconsideration to reverse these denials you can use the guidance below by submission type.
For paper submission:
“I request Reconsideration and Appeal my Benefit Determination.
My employer has a salary supplement program that provides me pay during my paid leave. The pay program is administered by Cocoon, my employer’s leave administrator. Despite receiving employer pay, I have experienced a wage loss and am eligible for paid leave benefits. This statement clarifies my employer pay program to establish my eligibility for benefits.
Cocoon calculates the expected benefits that I am eligible to receive from the state during my leave. Cocoon then calculates the difference between my regular wages and my state benefit and my Employer pays me this amount as top up pay. When combined with my state benefits, my Employer’s payments during my leave do NOT exceed 100% of the regular wages I would have been paid had I been working during my leave period. Without this Employer pay program, I would experience a significant loss of pay at a time of need and stress, which undermines the goals sought to be achieved through California’s Paid Leave programs.
Please reverse the Determination and approve my benefit application.”
For online submission:
For Reconsideration:
“Please reconsider the Determination. I receive top-up pay during leave. I have a wage loss. My total pay and state benefit do not exceed my weekly wage under UIC section 2656. My claim should be approved.”
For Appeal:
“I appeal the Determination. I receive top-up pay during leave. My total pay and state benefit do not exceed my weekly wage under UIC section 2656. My claim should be approved.”
Have Questions? We're here to help!
Email us at [email protected]