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1 | | firefighters employed by at least 100 municipalities in this |
2 | | State that is affiliated with the Illinois State Federation of |
3 | | Labor, one statewide labor organization representing |
4 | | correctional officers and parole agents that is affiliated with |
5 | | the Illinois State Federation of Labor, one statewide |
6 | | organization representing municipalities, and one regional |
7 | | organization representing municipalities. COGFA may accept |
8 | | comment from any source, but shall not be required to solicit |
9 | | public comment. Within 60 days after the effective date of this |
10 | | amendatory Act of the 98th General Assembly, COGFA shall remit |
11 | | a copy of the form contained in this subsection to all |
12 | | employers subject to this Act and shall make a copy available |
13 | | on its website. |
14 | | "PSEBA RECIPIENT REPORTING FORM: |
15 | | Under Section 17 of the Public Safety Employee Benefits |
16 | | Act (820 ILCS 320/17), the Commission on Government |
17 | | Forecasting and Accountability (COGFA) is charged with |
18 | | creating and submitting a report to the Governor and the |
19 | | General Assembly setting forth information regarding |
20 | | recipients and benefits payable under the Public Safety |
21 | | Employee Benefits Act (Act). The Act requires employers |
22 | | providing PSEBA benefits to distribute this form to any |
23 | | former peace officer, firefighter, or correctional officer |
24 | | currently in receipt of PSEBA benefits. |
25 | | The responses to the questions below will be used by |
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1 | | COGFA to compile information regarding the PSEBA benefit |
2 | | for its report. The Act prohibits the release of any |
3 | | personal information concerning the PSEBA recipient and |
4 | | exempts the reported information from the requirements of |
5 | | the Freedom of Information Act (FOIA). |
6 | | The Act requires the PSEBA recipient to complete this |
7 | | form and submit it to the employer providing PSEBA benefits |
8 | | within 60 days of receipt. If the PSEBA recipient fails to |
9 | | submit this form within 60 days of receipt, the employer is |
10 | | required to notify the PSEBA recipient of non-compliance |
11 | | and provide an additional 30 days to submit the required |
12 | | form. Failure to submit the form in a timely manner will |
13 | | result in the PSEBA recipient incurring responsibility for |
14 | | reimbursing the employer for premiums paid during the |
15 | | period the form is due and not filed. |
16 | | (1) PSEBA recipient's name: |
17 | | (2) PSEBA recipient's date of birth: |
18 | | (3) Name of the employer providing PSEBA benefits: |
19 | | (4) Date the PSEBA benefit first became payable: |
20 | | (5) What was the medical diagnosis of the injury |
21 | | that qualified you for the PSEBA benefit? |
22 | | (6) Are you currently employed with compensation? |
23 | | (7) If so, what is the name(s) of your current |
24 | | employer(s)? |
25 | | (8) Are you or your spouse enrolled in a health |
26 | | insurance plan provided by your current employer or |
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1 | | another source? |
2 | | (9) Have you or your spouse been offered or |
3 | | provided access to health insurance from your current |
4 | | employer(s)? |
5 | | If you answered yes to question 8 or 9, please provide |
6 | | the name of the employer, the name of the insurance |
7 | | provider(s), and a general description of the type(s) of |
8 | | insurance offered (HMO, PPO, HSA, etc.): |
9 | | (10) Are you or your spouse enrolled in a health |
10 | | insurance plan provided by a current employer of your |
11 | | spouse? |
12 | | (11) Have you or your spouse been offered or |
13 | | provided access to health insurance provided by a |
14 | | current employer of your spouse? |
15 | | If you answered yes to question 10 or 11, please |
16 | | provide the name of the employer, the name of the insurance |
17 | | provider, and a general description of the type of |
18 | | insurance offered (HMO, PPO, HSA, etc.) by an employer of |
19 | | your spouse:" |
20 | | COFGA shall notify an employer of its obligation to notify |
21 | | any PSEBA recipient receiving benefits under this Act of that |
22 | | recipient's obligation to file a report under this Section. A |
23 | | PSEBA recipient receiving benefits under this Act must complete |
24 | | and return this form to the employer within 60 days of receipt |
25 | | of such form. Any PSEBA recipient who has been given notice as |
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1 | | provided under this Section and who fails to timely file a |
2 | | report under this Section within 60 days after receipt of this |
3 | | form shall be notified by the employer that he or she has 30 |
4 | | days to submit the report or risk incurring the cost of his or |
5 | | her benefits provided under this Act. An employer may seek |
6 | | reimbursement for premium payments for a PSEBA recipient who |
7 | | fails to file this report with the employer 30 days after |
8 | | receiving this notice. The PSEBA recipient is responsible for |
9 | | reimbursing the employer for premiums paid during the period |
10 | | the report is due and not filed. Employers shall return this |
11 | | form to COGFA within 30 days after receiving the form from the |
12 | | PSEBA recipient. |
13 | | Any information collected by the employer under this |
14 | | Section shall be exempt from the requirements of the Freedom of |
15 | | Information Act except for data collected in the aggregate that |
16 | | does not reveal any personal information concerning the PSEBA |
17 | | recipient. |
18 | | By July 1 of every third odd-numbered year, beginning in |
19 | | 2017 2015 , employers subject to this Act must send the form |
20 | | contained in this subsection to all PSEBA recipients eligible |
21 | | for benefits under this Act. The PSEBA recipient must complete |
22 | | and return this form by September 1 of that year. Any PSEBA |
23 | | recipient who has been given notice as provided under this |
24 | | Section and who fails to timely file a completed form under |
25 | | this Section within 60 days after receipt of this form shall be |
26 | | notified by the employer that he or she has 30 days to submit |
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1 | | the form or risk incurring the costs of his or her benefits |
2 | | provided under this Act. The PSEBA recipient is responsible for |
3 | | reimbursing the employer for premiums paid during the period |
4 | | the report is due and not filed. The employer shall resume |
5 | | premium payments upon receipt of the completed form. Employers |
6 | | shall return this form to COGFA within 30 days after receiving |
7 | | the form from the PSEBA recipient. |
8 | | (b) An employer subject to this Act shall complete and file |
9 | | the form contained in this subsection. |
10 | | "EMPLOYER SUBJECT TO PSEBA REPORTING FORM: |
11 | | Under Section 17 of the Public Safety Employee Benefits |
12 | | Act (820 ILCS 320/17), the Commission on Government |
13 | | Forecasting and Accountability (COGFA) is charged with |
14 | | creating and submitting a report to the Governor and |
15 | | General Assembly setting forth information regarding |
16 | | recipients and benefits payable under the Public Safety |
17 | | Employee Benefits Act (Act). |
18 | | The responses to the questions below will be used by |
19 | | COGFA to compile information regarding the PSEBA benefit |
20 | | for its report. |
21 | | The Act requires all employers subject to the PSEBA Act |
22 | | to submit the following information within 120 days after |
23 | | receipt of this form. |
24 | | (1) Name of the employer: |
25 | | (2) The number of PSEBA benefit applications filed |
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1 | | under the Act during the reporting period provided in |
2 | | the aggregate and listed individually by name of |
3 | | applicant and date of application: |
4 | | (3) The number of PSEBA benefits and names of PSEBA |
5 | | recipients receiving benefits awarded under the Act |
6 | | during the reporting period provided in the aggregate |
7 | | and listed individually by name of applicant and date |
8 | | of application: |
9 | | (4) The cost of the health insurance premiums paid |
10 | | due to PSEBA benefits awarded under the Act during the |
11 | | reporting period provided in the aggregate and listed |
12 | | individually by name of PSEBA recipient: |
13 | | (5) The number of PSEBA benefit applications filed |
14 | | under the Act since the inception of the Act provided |
15 | | in the aggregate and listed individually by name of |
16 | | applicant and date of application: |
17 | | (6) The number of PSEBA benefits awarded under the |
18 | | Act since the inception of the Act provided in the |
19 | | aggregate and listed individually by name of applicant |
20 | | and date of application: |
21 | | (7) The cost of health insurance premiums paid due |
22 | | to PSEBA benefits awarded under the Act since the |
23 | | inception of the Act provided in the aggregate and |
24 | | listed individually by name of PSEBA recipient: |
25 | | (8) The current annual cost of health insurance |
26 | | premiums paid for PSEBA benefits awarded under the Act |
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1 | | provided in the aggregate and listed individually by |
2 | | name of PSEBA recipient: |
3 | | (9) The annual cost of health insurance premiums |
4 | | paid for PSEBA benefits awarded under the Act listed by |
5 | | year since the inception of the Act provided in annual |
6 | | aggregate amounts and listed individually by name of |
7 | | PSEBA recipient: |
8 | | (10) A description of health insurance benefit |
9 | | levels currently provided by the employer to the PSEBA |
10 | | recipient: |
11 | | (11) The total cost of the monthly health insurance |
12 | | premium currently provided to the PSEBA recipient: |
13 | | (12) The other costs of the health insurance |
14 | | benefit currently provided to the PSEBA recipient |
15 | | including, but not limited to: |
16 | | (i) the co-pay requirements of the health |
17 | | insurance policy provided to the PSEBA recipient; |
18 | | (ii) the out-of-pocket deductibles of the |
19 | | health insurance policy provided to the PSEBA |
20 | | recipient; |
21 | | (iii) any pharmaceutical benefits and co-pays |
22 | | provided in the insurance policy; and |
23 | | (iv) any policy limits of the health insurance |
24 | | policy provided to the PSEBA recipient." |
25 | | An employer covered under this Act shall file copies of the |
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1 | | PSEBA Recipient Reporting Form and the Employer Subject to the |
2 | | PSEBA Act Reporting Form with COGFA within 120 days after |
3 | | receipt of the Employer Subject to the PSEBA Act Reporting |
4 | | Form. |
5 | | The first form filed with COGFA under this Section shall |
6 | | contain all information required by this Section. All forms |
7 | | filed by the employer thereafter shall set forth the required |
8 | | information for the 36-month 24-month period ending on June 30 |
9 | | preceding the deadline date for filing the report. |
10 | | Whenever possible, communication between COGFA and |
11 | | employers as required by this Act shall be through electronic |
12 | | means. |
13 | | (c) For the purpose of creating the report required under |
14 | | subsection (d), upon receipt of each PSEBA Benefit Recipient |
15 | | Form, or as soon as reasonably practicable, COGFA shall make a |
16 | | determination of whether the PSEBA benefit recipient or the |
17 | | PSEBA benefit recipient's spouse meets one of the following |
18 | | criteria: |
19 | | (1) the PSEBA benefit recipient or the PSEBA benefit |
20 | | recipient's spouse is receiving health insurance from a |
21 | | current employer, a current employer of his or her spouse, |
22 | | or another source; |
23 | | (2) the PSEBA benefit recipient or the PSEBA benefit |
24 | | recipient's spouse has been offered or provided access to |
25 | | health insurance from a current employer or employers. |
26 | | If one or both of the criteria are met, COGFA shall make |
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1 | | the following determinations of the associated costs and |
2 | | benefit levels of health insurance provided or offered to the |
3 | | PSEBA benefit recipient or the PSEBA benefit recipient's |
4 | | spouse: |
5 | | (A) a description of health insurance benefit levels |
6 | | offered to or received by the PSEBA benefit recipient or |
7 | | the PSEBA benefit recipient's spouse from a current |
8 | | employer or a current employer of the PSEBA benefit |
9 | | recipient's spouse; |
10 | | (B) the monthly premium cost of health insurance |
11 | | benefits offered to or received by the PSEBA benefit |
12 | | recipient or the PSEBA benefit recipient's spouse from a |
13 | | current employer or a current employer of the PSEBA benefit |
14 | | recipient's spouse including, but not limited to: |
15 | | (i) the total monthly cost of the health insurance |
16 | | premium; |
17 | | (ii) the monthly amount of the health insurance |
18 | | premium to be paid by the employer; |
19 | | (iii) the monthly amount of the health insurance |
20 | | premium to be paid by the PSEBA benefit recipient or |
21 | | the PSEBA benefit recipient's spouse; |
22 | | (iv) the co-pay requirements of the health |
23 | | insurance policy; |
24 | | (v) the out-of-pocket deductibles of the health |
25 | | insurance policy; |
26 | | (vi) any pharmaceutical benefits and co-pays |
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1 | | provided in the insurance policy; |
2 | | (vii) any policy limits of the health insurance |
3 | | policy. |
4 | | COGFA shall summarize the related costs and benefit levels |
5 | | of health insurance provided or available to the PSEBA benefit |
6 | | recipient or the PSEBA benefit recipient's spouse and contrast |
7 | | the results to the cost and benefit levels of health insurance |
8 | | currently provided by the employer subject to this Act. This |
9 | | information shall be included in the report required in |
10 | | subsection (d). |
11 | | (d) By June 1, 2014, and by January 1 of every third |
12 | | even-numbered year thereafter beginning in 2018 2016 , COGFA |
13 | | shall submit a report to the Governor and the General Assembly |
14 | | setting forth the information received under subsections (a) |
15 | | and (b). The report shall aggregate data in such a way as to |
16 | | not reveal the identity of any single beneficiary. The |
17 | | requirement for reporting to the General Assembly shall be |
18 | | satisfied by filing copies of the report with the Speaker, |
19 | | Minority Leader, and Clerk of the House of Representatives, the |
20 | | President, Minority Leader, and Secretary of the Senate, the |
21 | | Legislative Research Unit as required under Section 3.1 of the |
22 | | General Assembly Organization Act, and the State Government |
23 | | Report Distribution Center for the General Assembly as required |
24 | | under paragraph (t) of Section 7 of the State Library Act. |
25 | | COGFA shall make this report available electronically on a |
26 | | publicly accessible website.
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