Texas Regulations 116.12

(1) claims by carriers for reimbursement made pursuant to section 403.007 of the Act and section 132.10(g) of this title (relating to Payment of Death Benefits to the Subsequent Injury Fund); (2) claims by injured workers for lifetime benefits, as provided by section 408.162 of the Act; (3) claims by carriers for reimbursement, made pursuant to section 410.209 and section 413.055 of the Act and section 116.11 of this title (relating to Request for Reimbursement or Refund from the Subsequent Injury Fund).; and (4) claims by carriers for reimbursement made pursuant to section 408.042(g) of the Act relating to multiple employment and those in accordance with commission rule(s) adopted pursuant to section 413.0141 of the Act relating to initial pharmaceutical coverage.

(b) The SIF uses the fiscal year September 1 through August 31.

(c) Claims described in subsections (a)(1), (a)(2) and (a)(3) of this section may be reviewed and ordered paid by the SIF administrator at any time during the fiscal year.

(d) Following the end of the fiscal year, the administrator of the SIF shall review:

(1) the SIF available balance and projected revenues and liabilities; (2) the current claims against the SIF, in the order of priorities set out in subsection (a) of this section; and (3) all completed requests for reimbursement as described in section 116.11 and section 132.10 of this title, received during the prior fiscal year, except as provided in subsection (g) of this section.

(e) In accordance with section 403.006(d) of the Act, if the commission determines that partial payments of the claims described in subsection (a)(4) of this section is necessary, partial payments shall be calculated in the following manner:

(1) The total amount of completed eligible requests for reimbursement submitted under subsection (a)(4) that are received during the previous fiscal year will be used to establish a baseline amount. (2) The baseline amount will be divided by the total amount of SIF funding available as determined in accordance with the Act. (3) The resulting fraction will be equally applied to all claims submitted under subsection (a)(4) to determine the partial reimbursement amount. (4) If reimbursement requests are paid with partial payments, no further future recovery is available from the subsequent injury fund for the non-reimbursed portion of that particular request.

(f) Following the end of each fiscal year, the SIF administrator shall, no later than October 30, enter appropriate orders for claims described in subsection (a)(3) of this section. The order shall specify the amount the SIF shall pay to the carrier.

(g) The SIF administrator shall submit orders to the state comptroller for payment and send a copy of the order to the requesting carrier.

(h) The SIF administrator will refrain from acting on a carrier's request for reimbursement or refund from the SIF until final resolution of the claim by a final decision of the commission, State Office of Administrative Hearings or the court of last resort except as provided in section 116.11(a)(3) and (4).

The provisions of this section 116.12 adopted to be effective February 11, 1992, 17 TexReg 689; amended to be effective March 13, 2000, 25 TexReg 2090, amended to be effective August 15, amended to be effective August 15, 2002, 27 Tex. Reg. 7128.