28W701 Stafford Place, Warrenville, Illinois 60555 P: (630) 393-9427 and F: (630) 393-6948 www.warrenville.il.us Public Safety Employee Benefit Act Procedure Introduction The Public Safety Employee Benefit Act (PSEBA) allows for public safety employees, who have suffered a catastrophic injury in the line of duty, the opportunity to apply for the City s base health insurance coverage paid at 100% for the disabled and his/her qualified dependents for the period of time defined by the Act or applicable case law. The PSEBA also allows for the qualified spouse and/or qualified dependent(s), who were granted a surviving spouse/dependent pension, due to a duty related death of a public safety employee, the same opportunity to apply for the City s basice group health insurance plan paid at 100%, for the period of time defined by the Act for both the surviving spouse or qualified dependent. The City of Warrenville has identified its HMO Plan as its basic group health plan. Until processing and acceptance of the Public Safety Employee Benefit, the applicant may remain on the City s health insurance plan; however, they will be responsible to pay 100% of the insurance premium cost. Health insurance premiums must be paid for each month s coverage during the PSEBA review process. Once the application is reviewed, and if the benefit is awarded, the employee will be reimbursed for any insurance premiums that the employee had to pay, retroactive back to the date of death or the date when the Police Pension Board awarded a line-of-duty disability pension. Note PSEBA requires health coverage benefits under the City s basic group health insurance plan. The City of Warrenville has identified its HMO Plan as its basic group health plan. If the PSEBA benefit is not awarded, the applicant may continue to remain on the City s health insurance plan, as provided by applicable law. However, the applicant will be responsible for paying at least 100% of the health insurance premium cost. PSEBA Hearing Process As defined by the Public Safety Employee Benefit Act, 820 ILCS 329/1, et seq., Public Safety employees have a right under the Act to claim entitlement to the extra benefits required by the Act. Page 1 of 4
Also, Ordinance No 2784 authorizes the City to establish an Administrative Hearing Process and appoint a Hearing Officer to fulfill the City s obligations under the Public Safety Employee Benefit Act. The City Administrator will determine if a hearing is needed upon review of the application information. If the claim for benefits is denied, based on the initial review of the application and information, the employee-applicant will have the opportunity to request an administrative hearing. However, before a determination is made on the need for an administrative hearing, the City Administrator must review the application and information related to the incident. PSEBA Application Procedure 1. Public safety employees or family members of an injured or deceased Public Safety Officer must request the Public Safety Employee Benefit Act Application from the Assistant City Administrator once within 90 days of the employee or family has beenbeing granted a duty-related pension. 2. Any public safety employee or family member claiming benefits under the Act shall complete the application provided by the City, and include the employee s or family members firsthand knowledge explaining how the disability injury/death directly resulted from: a. A police officer s response to fresh pursuit; b. A police officer s response to what is reasonably believed to be an emergency; c. A police officer s response to an unlawful act perpetrated by another; or d. A police officer s participating in the investigation of a criminal act. 3. The Public Safety Employee Benefit Act Application must be sworn and notarized as to the content of the completed application, along with a signed Affidavit for Coverage, a signed PSEBA medical authorization release, and a signed PSEBA general information release. Both the PSEBA medical and PSEBA general releases authorize the collection of information related to the incident including but not limited to, the disability pension proceedings, worker s compensation records, sworn testimony from treating physicians, and medical records. 4. The completed application, which will include a completed PSEBA application, Affidavit for Coverage, PSEBA medical release, and PSEBA general release, shall then be submitted to the City Administrator, who will review the application and associated materials in order to determine whether the employee-applicant is eligible for PSEBA benefits. If the City Administrator decides that additional information is necessary in order to render a decision, he/she may schedule an informal meeting with the employee-applicant and/or the employee-applicant s Page 2 of 4
representative. The City Administrator also may consult with other individuals and/or resources as deemed appropriate. 5. In the event that the City Administrator concludes without an administrative hearing that the employee-applicant is entitled to PSEBA benefits, the City will grant such benefits under the City s basic group health insurance plan to the employee-applicant and/or any eligible beneficiaries and the employee-applicant will be contacted by the Assistant City Administrator. The Assistant City Administrator will provide benefit explanation and processing. 6. In the event that the City Administrator denies the benefit based on the record as it stands, he/she will contact the applicant within 14 days to explain the tentative denial, and provide the applicant with an opportunity to provide additional information or attend an in-person meeting. If, after this opportunity, the City Administrator still denies the benefit based on the record as it now stands, the employee-applicant will receive notice of such denial within 10 days and the employee shall have the right to request an administrative hearing which must be served in writing to the City Administrator not later than 30 days after the date of the City Administrator s written decision of denial. If the employee-applicant, upon receiving notice of denial, chooses not to request an administrative hearing, he/she may contact the Assistant City Administrator to discuss other options in which the applicant may be eligible to participate. 7. Alternatively, the City Administrator may decide that additional fact-gathering is necessary, and may schedule an administrative hearing pursuant to the procedures outlined in number eight below. 8. In the event that the City Administrator concludes that an administrative hearing is necessary in order to determine whether an applicant is eligible for PSEBA benefits or if the employee-applicant requests a hearing, the City s Hearing Officers will convene an administrative hearing. An attorney licensed to practice law in the State of Illinois for at least five years who is appointed by the Mayor with consent of the City Council, per Ordinance No. 2784, will serve as a Hearing Officer and will have be responsible for the tasks associate with the administrative hearing as enumerated in Ordinance No. 2784 9. The employee-applicant will be given notice of the administrative hearing along with a date for the scheduled administrative hearing. The employee-applicant must confirm the receipt of said notice and concur with the date set for the administrative hearing in writing within 30 days after being served notice of the administrative hearing. If the employee-applicant fails, or chooses not to confirm the receipt of said hearing notice within 30 days, or otherwise refuses to participate in the administrative hearing, the Hearing Officer will proceed to make a final ruling on the PSEBA application based on his/her investigation and the evidence that the employee-applicant chose to submit for the Hearing Officer s consideration. Page 3 of 4
10. If the employee-applicant, upon receiving notice of the administrative hearing date, cannot attend said date as indicated in the Hearing Officer s notice, the employee-applicant must contact the Assistant City Administrator within 30 days after being served with notice of administrative hearing, communicating alternative hearing date(s), which are within close proximity of the original date indicated by the Hearing Officer. 11. At the administrative hearing, the employee-applicant shall have the obligation to prove that the employee-applicant is qualified to receive the benefits by a preponderance of the evidence. 12. The decision of the Hearing Officer shall be the final administrative determination of the City and may be appealed to the Circuit Court pursuant to Administrative Review Law (735 ILCS 5/3-101 et seq.). 13. All records pertaining to the administrative process will be held in a separate file in the employee s name within the Administration Department of the City of Warrenville. Request for such file shall be through the Freedom of Information Act (FOIA). Page 4 of 4
Affidavit for Coverage Under Public Safety Employee Benefits Act 820 ILCS 320/1 (PSEBA) STATE OF ILLINOIS ) ) SS COUNTY OF DuPAGE ) The undersigned states under oath as follows: 1. Name of Police Officer: 28W701 Stafford Place, Warrenville, Illinois 60555 P: (630) 393-9427 and F: (630) 393-6948 www.warrenville.il.us 2. Employment Status (select one of a or b): a. I am employed by Address of Employer: b. I am not employed 3. Marital Status (select one of a, b, or c): a. Single b. Married to (Name): Spouse Social Security Number c. Divorced or widowed 4. Health Insurance Coverage Please indicate whether (select one of a or b): a. No other health insurance coverage is available to me b. Other coverage is available from (check all that apply): My current employer s plan My spouse s employer s plan COBRA from a former employer This coverage began on (insert date)
This coverage runs until (insert last month of coverage) Individual policy issued by Policy No. Medicare c. Is any other coverage currently in force? Yes No d. Indicate monthly amount paid or payable by you for such coverage $ Provide the following information about insurance carrier or third party administrator of each other heath plan or policy that is available to you (including coverage not currently in effect): Name of contact person Address Phone Website Email Address 5. If married (indicate): Is spouse employed? Yes No Name and address of spouse s employer: Is health insurance coverage available from spouse s employer? Yes No Don t know 6. If you have qualified dependent children (indicate): Is child(ren) employed? Yes No Name and address of child(ren) s employer: Is health insurance coverage available from child(ren) s employer? Yes No Don t know 2
7. Medical Information To determine continuing eligibility for PSEBA benefits, the City of Warrenville may need to review relevant medical records of the applicant and/or the injured Public Safety Officer. In order to process an application for coverage, it is necessary that you complete and provide to the City the attached waiver form to authorize the City to obtain and review copies of these medical records. 8. Agreement to Update Information If any of the information provided in this application changes, I agree to provide documentation to the City of Warrenville within 30 days of such change, including in particular any change (i.e., to being divorced, widowed or married) in the marital status of the spouse of a Public Safety Officer or my dependent reaching age 2526, and the availability of any other health coverage to any person listed above. I also agree to forward copies of notice of any changes in coverage or the cost of it that I or my spouse receives in sufficient time to permit the City to consider payment or stopping payment of premiums for such coverage in the future. I also agree to annually this Affidavit for Coverage to ensure that my status still meets the requirements for benefits under the Public Safety Employee Benefits Act. This statement is made for the sole purpose of receiving benefits provided by the City of Warrenville under the Public Safety Employee Benefits Act. The information contained in this application is true to the best of my knowledge and belief. I understand that it is unlawful for a person to willfully and knowingly make, or cause to be made, or to assist, conspire with, or urge another to make, or cause to be made, any false, fraudulent, or misleading oral or written statement to obtain health insurance coverage as provided by the Public Safety Employee Benefits Act. 820 ILCS 320/10(a)(2). Such actions constitute a Class A Misdemeanor and can serve as the basis for denial of coverage and an obligation to repay any benefits paid out under the Public Safety Employee Benefits Act. 820 ILCS 320/10(a)(3). Signature of Applicant: Date: Subscribed and sworn to before me this day of, 20. Notary Public 3