(820 ILCS 320/17)
Sec. 17. Reporting forms.
(a) A person who qualified for benefits under subsections (a) and (b) of Section 10 of this Act (hereinafter referred to as "PSEBA recipient") shall be required to file a form with his or her employer as prescribed in this Section. The Commission on Government Forecasting and Accountability (COGFA) shall use the form created in this Act and prescribe the content of the report in cooperation with one statewide labor organization representing police, one statewide law enforcement organization, one statewide labor organization representing firefighters employed by at least 100 municipalities in this State that is affiliated with the Illinois State Federation of Labor, one statewide labor organization representing correctional officers and parole agents that is affiliated with the Illinois State Federation of Labor, one statewide organization representing municipalities, and one regional organization representing municipalities. COGFA may accept comment from any source, but shall not be required to solicit public comment. Within 60 days after the effective date of this amendatory Act of the 98th General Assembly, COGFA shall remit a copy of the form contained in this subsection to all employers subject to this Act and shall make a copy available on its website.
"PSEBA RECIPIENT REPORTING FORM:
Under Section 17 of the Public Safety Employee
Benefits Act (820 ILCS 320/17), the Commission on Government Forecasting and Accountability (COGFA) is charged with creating and submitting a report to the Governor and the General Assembly setting forth information regarding recipients and benefits payable under the Public Safety Employee Benefits Act (Act). The Act requires employers providing PSEBA benefits to distribute this form to any former peace officer, firefighter, or correctional officer currently in receipt of PSEBA benefits.
The responses to the questions below will be used by
COGFA to compile information regarding the PSEBA benefit for its report. The Act prohibits the release of any personal information concerning the PSEBA recipient and exempts the reported information from the requirements of the Freedom of Information Act (FOIA).
The Act requires the PSEBA recipient to complete this
form and submit it to the employer providing PSEBA benefits within 60 days of receipt. If the PSEBA recipient fails to submit this form within 60 days of receipt, the employer is required to notify the PSEBA recipient of non-compliance and provide an additional 30 days to submit the required form. Failure to submit the form in a timely manner will result in the PSEBA recipient incurring responsibility for reimbursing the employer for premiums paid during the period the form is due and not filed.
(1) PSEBA recipient's name:
(2) PSEBA recipient's date of birth:
(3) Name of the employer providing PSEBA
benefits:
(4) Date the PSEBA benefit first became payable:
(5) What was the medical diagnosis of the injury
that qualified you for the PSEBA benefit?
(6) Are you currently employed with compensation?
(7) If so, what is the name(s) of your current
employer(s)?
(8) Are you or your spouse enrolled in a health
insurance plan provided by your current employer or another source?
(9) Have you or your spouse been offered or
provided access to health insurance from your current employer(s)?
If you answered yes to question 8 or 9, please
provide the name of the employer, the name of the insurance provider(s), and a general description of the type(s) of insurance offered (HMO, PPO, HSA, etc.):
(10) Are you or your spouse enrolled in a health
insurance plan provided by a current employer of your spouse?
(11) Have you or your spouse been offered or
provided access to health insurance provided by a current employer of your spouse?
If you answered yes to question 10 or 11, please
provide the name of the employer, the name of the insurance provider, and a general description of the type of insurance offered (HMO, PPO, HSA, etc.) by an employer of your spouse:"
COFGA shall notify an employer of its obligation to notify any PSEBA recipient receiving benefits under this Act of that recipient's obligation to file a report under this Section. A PSEBA recipient receiving benefits under this Act must complete and return this form to the employer within 60 days of receipt of such form. Any PSEBA recipient who has been given notice as provided under this Section and who fails to timely file a report under this Section within 60 days after receipt of this form shall be notified by the employer that he or she has 30 days to submit the report or risk incurring the cost of his or her benefits provided under this Act. An employer may seek reimbursement for premium payments for a PSEBA recipient who fails to file this report with the employer 30 days after receiving this notice. The PSEBA recipient is responsible for reimbursing the employer for premiums paid during the period the report is due and not filed. Employers shall return this form to COGFA within 30 days after receiving the form from the PSEBA recipient.
Any information collected by the employer under this Section shall be exempt from the requirements of the Freedom of Information Act except for data collected in the aggregate that does not reveal any personal information concerning the PSEBA recipient.
By July 1 of every odd-numbered year, beginning in 2015, employers subject to this Act must send the form contained in this subsection to all PSEBA recipients eligible for benefits under this Act. The PSEBA recipient must complete and return this form by September 1 of that year. Any PSEBA recipient who has been given notice as provided under this Section and who fails to timely file a completed form under this Section within 60 days after receipt of this form shall be notified by the employer that he or she has 30 days to submit the form or risk incurring the costs of his or her benefits provided under this Act. The PSEBA recipient is responsible for reimbursing the employer for premiums paid during the period the report is due and not filed. The employer shall resume premium payments upon receipt of the completed form. Employers shall return this form to COGFA within 30 days after receiving the form from the PSEBA recipient.
(b) An employer subject to this Act shall complete and file the form contained in this subsection.
"EMPLOYER SUBJECT TO PSEBA REPORTING FORM:
Under Section 17 of the Public Safety Employee
Benefits Act (820 ILCS 320/17), the Commission on Government Forecasting and Accountability (COGFA) is charged with creating and submitting a report to the Governor and General Assembly setting forth information regarding recipients and benefits payable under the Public Safety Employee Benefits Act (Act).
The responses to the questions below will be used by
COGFA to compile information regarding the PSEBA benefit for its report.
The Act requires all employers subject to the PSEBA
Act to submit the following information within 120 days after receipt of this form.
(1) Name of the employer:
(2) The number of PSEBA benefit applications
filed under the Act during the reporting period provided in the aggregate and listed individually by name of applicant and date of application:
(3) The number of PSEBA benefits and names of
PSEBA recipients receiving benefits awarded under the Act during the reporting period provided in the aggregate and listed individually by name of applicant and date of application:
(4) The cost of the health insurance premiums
paid due to PSEBA benefits awarded under the Act during the reporting period provided in the aggregate and listed individually by name of PSEBA recipient:
(5) The number of PSEBA benefit applications
filed under the Act since the inception of the Act provided in the aggregate and listed individually by name of applicant and date of application:
(6) The number of PSEBA benefits awarded under
the Act since the inception of the Act provided in the aggregate and listed individually by name of applicant and date of application:
(7) The cost of health insurance premiums paid
due to PSEBA benefits awarded under the Act since the inception of the Act provided in the aggregate and listed individually by name of PSEBA recipient:
(8) The current annual cost of health insurance
premiums paid for PSEBA benefits awarded under the Act provided in the aggregate and listed individually by name of PSEBA recipient:
(9) The annual cost of health insurance premiums
paid for PSEBA benefits awarded under the Act listed by year since the inception of the Act provided in annual aggregate amounts and listed individually by name of PSEBA recipient:
(10) A description of health insurance benefit
levels currently provided by the employer to the PSEBA recipient:
(11) The total cost of the monthly health
insurance premium currently provided to the PSEBA recipient:
(12) The other costs of the health insurance
benefit currently provided to the PSEBA recipient including, but not limited to:
(i) the co-pay requirements of the health
insurance policy provided to the PSEBA recipient;
(ii) the out-of-pocket deductibles of the
health insurance policy provided to the PSEBA recipient;
(iii) any pharmaceutical benefits and co-pays
provided in the insurance policy; and
(iv) any policy limits of the health
insurance policy provided to the PSEBA recipient."
An employer covered under this Act shall file copies of the PSEBA Recipient Reporting Form and the Employer Subject to the PSEBA Act Reporting Form with COGFA within 120 days after receipt of the Employer Subject to the PSEBA Act Reporting Form.
The first form filed with COGFA under this Section shall contain all information required by this Section. All forms filed by the employer thereafter shall set forth the required information for the 24-month period ending on June 30 preceding the deadline date for filing the report.
Whenever possible, communication between COGFA and employers as required by this Act shall be through electronic means.
(c) For the purpose of creating the report required under subsection (d), upon receipt of each PSEBA Benefit Recipient Form, or as soon as reasonably practicable, COGFA shall make a determination of whether the PSEBA benefit recipient or the PSEBA benefit recipient's spouse meets one of the following criteria:
(1) the PSEBA benefit recipient or the PSEBA benefit
recipient's spouse is receiving health insurance from a current employer, a current employer of his or her spouse, or another source;
(2) the PSEBA benefit recipient or the PSEBA benefit
recipient's spouse has been offered or provided access to health insurance from a current employer or employers.
If one or both of the criteria are met, COGFA shall make the following determinations of the associated costs and benefit levels of health insurance provided or offered to the PSEBA benefit recipient or the PSEBA benefit recipient's spouse:
(A) a description of health insurance benefit levels
offered to or received by the PSEBA benefit recipient or the PSEBA benefit recipient's spouse from a current employer or a current employer of the PSEBA benefit recipient's spouse;
(B) the monthly premium cost of health insurance
benefits offered to or received by the PSEBA benefit recipient or the PSEBA benefit recipient's spouse from a current employer or a current employer of the PSEBA benefit recipient's spouse including, but not limited to:
(i) the total monthly cost of the health
insurance premium;
(ii) the monthly amount of the health insurance
premium to be paid by the employer;
(iii) the monthly amount of the health insurance
premium to be paid by the PSEBA benefit recipient or the PSEBA benefit recipient's spouse;
(iv) the co-pay requirements of the health
insurance policy;
(v) the out-of-pocket deductibles of the health
insurance policy;
(vi) any pharmaceutical benefits and co-pays
provided in the insurance policy;
(vii) any policy limits of the health insurance
policy.
COGFA shall summarize the related costs and benefit levels of health insurance provided or available to the PSEBA benefit recipient or the PSEBA benefit recipient's spouse and contrast the results to the cost and benefit levels of health insurance currently provided by the employer subject to this Act. This information shall be included in the report required in subsection (d).
(d) By June 1, 2014, and by January 1 of every even-numbered year thereafter beginning in 2016, COGFA shall submit a report to the Governor and the General Assembly setting forth the information received under subsections (a) and (b). The report shall aggregate data in such a way as to not reveal the identity of any single beneficiary. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, Minority Leader, and Clerk of the House of Representatives, the President, Minority Leader, and Secretary of the Senate, the Legislative Research Unit as required under Section 3.1 of the General Assembly Organization Act, and the State Government Report Distribution Center for the General Assembly as required under paragraph (t) of Section 7 of the State Library Act. COGFA shall make this report available electronically on a publicly accessible website.
(Source: P.A. 98-561, eff. 8-27-13.)
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Last modified: February 18, 2015