2013-01-21 - Ordinance 2013-005 - AMENDING CHAPTER 2.08 AND ADDING CHAPTER 2.72ORDINANCE NO. 2013- 05
AN ORDINANCE AMENDING
CHAPTER 2.08 AND ADDING CHAPTER 2.72 TO THE
VILLAGE OF BUFFALO GROVE MUNICIPAL CODE
WHEREAS, the Village of Buffalo Grove is a Home Rule Unit by virtue of the
Provisions of the Constitution of the State of Illinois of 1970;
WHEREAS, Chapter 2.08 of the Village of Buffalo Grove Municipal Code invests
certain defined duties, rights and responsibilities unto the position of Village Manager; and
WHEREAS, the Village desires to add a new provision in the Village of Buffalo Grove
Municipal Code to govern the application and determination of benefits under the Public Safety
Employee Benefits Act (820 ILCS 320/1 et. seq.).
NOW, THEREFORE, BE IT ORDAINED BY THE PRESIDENT AND BOARD OF
TRUSTEES OF THE VILLAGE OF BUFFALO GROVE, COOK AND LAKE COUNTIES,
ILLINOIS that:
Section 1: That Chapter 2.08.040 (Duties of the Village Manager) be amended to include the
following:
The Village Manager shall establish and administer policies and procedures pursuant to Chapter
2.72 of the Village of Buffalo Grove Municipal Code for purposes of determining whether an
employee subject to the Public Safety Employee Benefits Act (820 ILCS 320/1 et. seq.) is
eligible to receive benefits pursuant to the Act.
Section 2: That Title 2 (Administration and Personnel) be amended to add a new Chapter 2.72
which provides as follows:
2.72.010: Purpose
The purpose of this chapter is to provide a fair and efficient method of determining the eligibility
of an employee for the benefits enumerated under the Public Safety Employee Benefits Act (820
ILCS 320/1 et seq.) ( PSEBA). All benefits provided employees pursuant to PSEBA will be
consistent with PSEBA.
2.72.020: Authority
The ordinance codified in this Chapter is adopted by the Corporate Authorities of the Village of
Buffalo Grove pursuant to the Home Rule authority granted by Article VII, Section 6 of the
Illinois Constitution of 1970.
2.72.030: Policy and Procedure for Administering Applications for PSEBA Benefits
Except as otherwise provided below, the following policies and procedures established pursuant
to this subchapter 2.72.030 shall be administered and interpreted by the Village Manager as
follows:
A. Application for PSEBA Benefits.
A PSEBA benefit application form prepared by the Village shall be the standard form required
for PSEBA benefit applicants (hereinafter the "applicant ") to utilize to request benefits under
PSEBA. The form shall be completed and executed by the requesting applicant and delivered to
the Village Manager. The applicant shall provide, along with the application, any medical
records regarding the injury, any decisions by a governing public safety pension board and
supporting documentation related to such pension board decisions and any additional pertinent
documentation that the applicant wants to have considered or that is requested by the Village.
B. Application Review Process.
1. When the Village Manager receives a complete and executed PSEBA
benefit application, the Village Manager shall review the application and engage in such
additional fact - finding and /or investigation as may be deemed necessary or appropriate to
evaluate the application, including, but not limited to the review of public safety pension
board hearing transcripts and decisions, worker's compensation documentation and
independent medical examinations.
2. If additional fact - finding and /or investigation is determined to be
necessary, the applicant shall fully cooperate. If the applicant refuses or otherwise fails
to fully cooperate, then a reminder notice shall be sent to the applicant explaining the
duty of full cooperation in the fact - finding and/or investigation process. If the applicant
fails to cooperate as requested within 21 calendar days after receipt of such notice, then
the application for PSEBA benefits shall be deemed withdrawn.
3. The Village Manager shall make a written recommendation, including
reasons for the recommendation, to the Corporate Authorities of the Village within forty -
five (45) calendar days after the later of the following:
a. the submission of the relevant documentation; or
b. the completion of such additional fact - finding or investigation as
deemed necessary or appropriate by the Village Manager (as stated in paragraph
1, above).
The Village Manager's written recommendation shall state whether:
a. the applicant is eligible for benefits under PSEBA; or
b. a hearing should be convened in order to determine whether or not
the applicant is eligible for benefits under PSEBA and shall inform the applicant,
in writing, of the decision and the reasons for the decision.
4. If the Village Manager recommends that the applicant is eligible for
benefits under PSEBA, the recommendation shall be presented to the Village Board at the
next regularly scheduled Village Board meeting (subject to the notice provisions of the
Open Meetings Act). The Village Board or its authorized designee shall make a
determination that:
a. the applicant is eligible for benefits under PSEBA; or
b. a hearing as set forth in subchapter 2.72.040(C) should be
convened in order to determine whether or not the applicant is eligible for benefits
under PSEBA.
2.72.040: Policy and Procedure for Administering Hearings for PSEBA Benefits
If the Village Board, following the Village Manager's recommendation, determines that a
hearing should be convened, the Village Board or its authorized designee shall convene a hearing
which shall be overseen by a hearing officer whose power and authority and limitations are as
follows:
A. Power of the Hearing Officer. The hearing officer shall have the necessary powers
granted to him relative to conduct an administrative hearing including the power to:
1, preside over all Village hearings involving PSEBA;
2. administer oaths;
3. hear testimony and accept evidence that is relevant to the issue of eligibility under
PSEBA;
4. issue subpoenas to secure attendance of witnesses and the production of relevant
papers or documents upon the request of the parties or their representatives; and
5. issue a written determination based on the evidence presented at the hearing.
B. Hearing Officer. The President with the consent of the Village Board is hereby
authorized to appoint a person to hold the position of a hearing officer for each
PSEBA hearing that shall come before the Village.
C. The Administrative Hearing. A hearing may be held to adjudicate and determine
whether the subject public safety employee is eligible for benefits under PSEBA. If
the employee is found eligible, the employee benefits shall be consistent with
PSEBA.
1. Time and date. Hearings shall be held on the date, time and place as established
by the Village with appropriate notice served upon the public safety employee.
2. Record. All hearings shall be attended by a certified court reporter and a transcript
of all proceedings shall be made by said certified court reporter.
3. Procedures. The Village and the petitioning public safety employee shall be
entitled to representation by counsel at said hearing and may present witnesses,
may present testimony and documents, may cross - examine opposing witnesses,
and may request the issuance of subpoenas to compel the appearance of relevant
witnesses or the production of relevant documents.
4. Final Determination. The determination by the hearing officer of whether the
petitioning public safety employee is eligible for the benefits under PSEBA shall
constitute a final determination for the purpose of judicial review under the
common law writ of certiorari.
Section 3: The Village Clerk is hereby authorized to publish this ordinance in pamphlet form.
Section 4: This Ordinance shall be in full force and effect from and after its passage and
approval. This Ordinance shall be codified.
AYES: 6 Berman Trilling Sussman Terson Stein, Ottenheimer
NAYES: 0 -
ABSENT: 0 -None
PASSED: January 21 2013. APPROVED: January 21 , 2013.
Village President
ATTEST:
Village Clerk
VILLAGE OF
utlFFai.n GROVE
Fifty Raupp Blvd.
Buffalo Grove, IL 60089 -2196
Phone 847 - 459 -2500
Fax 847 - 459 -7906
Date
Name
Address
City, State, Zip Code
Dear
> ;ter
a;.
I am in receipt of your request dated to receive benefits pursuant to
the Public Safety Employees Benefits Act (820 ILCS 320/) (PSEBA).
For your information, I have attached a copy of the applicable statute and the Village's PSEBA
benefit application.
In the event that the Village conducts an administrative hearing to determine if you are eligible
for PSEBA benefits based on the terms of PSEBA and the relevant Illinois case law interpreting
PSEBA, you will be notified and will be welcome to be represented by legal counsel at the
hearing to present evidence supporting your request.
At this time, please complete and return the enclosed PSEBA benefit application along with any
supporting documentation to the Village within 30 days of the date of this letter. If you have any
questions, please feel free to contact me.
Sincerely,
Dane C. Bragg
Village Manager
Attachments
VILLAGE OF BUFFALO GROVE
APPLICATION FOR BENEFITS PURSUANT TO
THE PUBLIC SAFETY EMPLOYEE BENEFITS ACT ( "PSEBA ")
The undersigned states as follows:
A. Applicant Information
1. Name of Applicant:
2. If Applicant is a family member of the Public Service Officer, please describe
relationship to injured or deceased Public Safety Officer:
3. Employment Status (select one of a or b):
a. I am employed by
b. I am not employed
4. Marital Status (select one of a, b, or c):
a. Single
b. Married to (Name):
Social Security Number,
C. Divorced or widowed
5. Dependent Children (select one of a or b):
a. I have dependent children under age 26 totaling:
b. I do not have any dependent children.
6. Date of Hire with the Village of related Public Service Officer:
7. Has the injured or deceased Public Safety Officer or any family member on his /her behalf
previously made a request for PSEBA benefits? If so, identify when the request was
made, how it was made, to whom it was made, whether any PSEBA benefits were paid
and for how long and provide any documentation:
B. Health Coverage Information
Note: Please be advised that if you are granted continued health coverage under PSEBA, you
will receive coverage under the Village's basic group health insurance plan which is the least
expensive health plan offered by the Village as determined solely by the Village. This means that
you may be obligated to switch group health plans if you are awarded PSEBA benefits and elect
1
to receive such PSEBA benefits. If you wish to maintain different coverage other than the
Village's basic group health insurance plan, you may be charged for the difference between such
different coverage and the Village's basic group health insurance plan. PSEBA coverage does
not include supplemental coverage such as dental or life insurance. Additionally, if your PSEBA
coverage is secondary to any other group health plan, your PSEBA coverage will be considered
supplemental and may be reduced or eliminated as determined by the Village.
Please indicate whether (select one,of I or 2):
1. No other health insurance coverage is available to me
2. Other health insurance coverage is available from (check all that apply):
a. My current employer's plan
b. My spouse's employer's plan
C. COBRA from a former employer
d. Medicare, Medicaid or other coverage provided through a state or
federal health benefit exchange
C. Individual policy (Policy Issuer:
The above indicated coverage began on (insert date). This
coverage runs until (insert last month of coverage). Please
indicate the name of the health plan or insurance company providing other
health coverage:
3. Are you currently enrolled in any other coverage? Yes No
4. 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 health plan or policy that is available to you
(including coverage not currently in effect):
Contact person_
Address
Phone
Web or E -Mail
2
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
C. Information Related to the Disability
1. Has a Line -Of -Duty Disability Pension been applied for or granted by the Police /Fire
Pension Fund Board?
If so, provide the date of application or pension, copies of any materials submitted in
support of such a pension and the Pension Board award:
2. Describe when, where and how the disabling injury or injuries and/or death occurred for
which you are now seeking PSEBA benefits and provide any supporting
information/documents (attach additional sheets if necessary):
3. List any and all witnesses to the qualifying injury and/or death and provide any witness
statements (attach additional sheets if necessary):
4. Provide any other facts that would qualify the injured or deceased Public Safety Officer
for PSEBA benefits (attach additional sheets if necessary):
3
D. Medical Information and Supporting Documentation to be Provided to the Village
The applicant shall provide, along with this application, any medical records regarding
the injury, any decisions by a governing public safety pension board and supporting
documentation related to such pension board decisions and any additional pertinent
documentation that the applicant wants to have considered or that is requested by the Village.
To determine continuing eligibility for PSEBA benefits, the Village Manager may need
to review relevant medical records of the applicant and/or the injured Public Safety Officer. In
order to process an application for PSEBA coverage, it is necessary that you complete and return
to the Village the attached waiver form to authorize the Village to obtain and review copies of
these medical records.
E. Agreement to Update Information
This statement is made for the sole purpose of receiving benefits provided by the Village
of Buffalo Grove under the Public Safety Employee Benefits Act. The information contained in
this application is true to the best of my knowledge and belief. If any of the information
provided in this application changes, I agree to provide documentation to the Village of Buffalo
Grove within 30 days of such change, including in particular any change in the marital status of
the spouse of a Public Safety Officer or my dependent reaching age 26, a change in disability
status and the availability of any other health coverage to any person listed above.
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).
I, the undersigned applicant, understand that if I am awarded PSEBA benefits and later
become eligible to enroll in another group health plan, including Medicare, that my PSEBA
benefits may be reduced or eliminated.
Signature of Applicant:
Date:
................. ............................... a a N 0 0 N a a 0 0 M 0 1 1 1 0 0 0 0 S a a 0 0 0 0 0 0 a a.
For office use only:
Date PSEBA Application Received:
Received by:
2
VILLAGE OF BUFFALO GROVE
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I. Information About the Use or Disclosure of Protected Health Information (PHI)
Employee:
Address:
Date of Birth:
hori
I (name of Employee, PSEBA Applicant or Patient), , hereby autze
the use or disclosure of my written, electronic and oral protected health information (PHI), as described in this authorization.
(`Authorized Releasor(s) ") to provide my health information.
Please specify the individual /organization authorized to receive your health information:
❑ Human Resources Division, Village of Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089 -2196
Name:
Address:
Daytime Tel. ( )
H. Description of Specific Information You Wish The Authorized Releasor To Disclose: (check all boxes that apply)
❑ PHI related to an illness or injury associated with a duty - disability pension award eligibility issued on
❑ PHI related to an illness or injury identified in an application filed with the Village of Buffalo Grove for continued health
coverage pursuant to the Illinois Public Safety Employee Benefits Act.
❑ Other:
State the purpose of this request below:
❑ To allow the recipient to make a determination of eligibility for benefits under the Illinois Public Safety Employee
Benefits Act.
❑ Other:
(If do not wish to state a purpose, please state "At request of the individual.'
This authorization will expire on: (If no date or occurrence specified, authorization will expire
❑ Give date or occurrence (Example: "When my PSEBA application case is resolved. "):
year from date signed.)
III. Important Information About Your Rights - I have read and understand the followine statements about my rights:
• I understand that I have the right to revoke this authorization at any time by notifying the Human Resources Division, Village of
Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089 -2196. I understand that the revocation is only effective after it is
received and logged by the Human Resources Division. I understand that any use or disclosure made prior to the revocation
under this authorization will not be affected by a revocation.
• 1 understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it again.
• 1 understand that I am entitled to receive a copy of this authorization.
• I understand that I may refuse to sign this authorization and that my refusal to signed this authorization will not affect my ability to enroll in a
health plan, obtain health care treatment or payment, or eligibility for benefits unless authorized by law.
IV Si nature of Participant or Beneficiary:
Date:
g -
V. Personal Representative (If the person signing this form is the Personal Representative of the Employee /Patient, sign here.)
Personal Representative Date:
• I swear under penalty of perjury that I am the Personal Representative of the employee /patient named above.
Please state status (for example, parent, guardian, Power Of Attorney)
Print name of personal representative: Day time Tel:
Address:
If a personal representative executes this form, please attach copy of document, if'applicable, which creates the status as personal
representative, such as Legal Guardianship, General Power ofAttorne.v, Power of Attorney for Health Care Matters.
Please return this form to: Human Resources Division, Village of Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089-
2196
EMPLOYMENT
(820 ILCS 3201) Public Safety Employee Benefits Act.
(820 ILCS 320/1)
Sec. 1. Short title. This Act may be cited as the Public Safety Employee Benefits Act.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 32013)
Sec. 3. Definition. For the purposes of this Act, the term "firefighter" includes, without
limitation, a licensed emergency medical technician (EMT) who is a sworn member of a public
fire department.
(Source: P.A. 93 -569, eff. 8- 20 -03.)
(820 ILCS 320/5)
Sec. 5. Declaration of State interest. The General Assembly determines and declares that the
provisions of this Act fulfill an important State interest.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/10)
Sec. 10. Required health coverage benefits.
(a) An employer who employs a full -time law enforcement, correctional or correctional
probation officer, or firefighter, who, on or after the effective date of this Act suffers a
catastrophic injury or is killed in the line of duty shall pay the entire premium of the employer's
health insurance plan for the injured employee, the injured employee's spouse, and for each
dependent child of the injured employee until the child reaches the age of majority or until the
end of the calendar year in which the child reaches the age of 25 if the child continues to be
dependent for support or the child is a full -time or part-time student and is dependent for support.
The term "health insurance plan" does not include supplemental benefits that are not part of the
basic group health insurance plan. If the injured employee subsequently dies, the employer shall
continue to pay the entire health insurance premium for the surviving spouse until remarried and
for the dependent children under the conditions established in this Section. However:
(1) Health insurance benefits payable from any other source shall reduce benefits payable
under this Section.
(2) 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 under this
Section. A violation of this item is a Class A misdemeanor.
(3) Upon conviction for a violation described in item (2), a law enforcement, correctional or
correctional probation officer, or other beneficiary who receives or seeks to receive health
insurance benefits under this Section shall forfeit the right to receive health insurance benefits
and shall reimburse the employer for all benefits paid due to the fraud or other prohibited
activity. For purposes of this item, "conviction" means a determination of guilt that is the result
of a plea or trial, regardless of whether adjudication is withheld.
(b) In order for the law enforcement, correctional or correctional probation officer, firefighter,
spouse, or dependent children to be eligible for insurance coverage under this Act, the injury or
death must have occurred as the result of the officer's response to fresh pursuit, the officer or
firefighter's response to what is reasonably believed to be an emergency, an unlawful act
perpetrated by another, or during the investigation of a criminal act. Nothing in this Section shall
be construed to limit health insurance coverage or pension benefits for which the officer,
firefighter, spouse, or dependent children may otherwise be eligible.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/15)
Sec. 15. Required educational benefits. If a firefighter, law enforcement, or correctional or
correctional probation officer is accidentally or unlawfully and intentionally killed as specified in
subsection (b) of Section 10 on or after July 1, 1980, the State shall waive certain educational
expenses which children of the deceased incur while obtaining a vocational - technical certificate
or an undergraduate education at a State supported institution. The amount waived by the State
shall be an amount equal to the cost of tuition and matriculation and registration fees for a total
of 120 credit hours. The child may attend a State vocational - technical school, a public
community college, or a State university. The child may attend any or all of the institutions
specified in this Section, on either a full -time or part-time basis. The benefits provided under this
Section shall continue to the child until the child's 25th birthday.
(1) Upon failure of any child benefited by the provisions of this Section to comply with the
ordinary and minimum requirements of the institution attended, both as to discipline and
scholarship, the benefits shall be withdrawn as to the child and no further moneys may be
expended for the child's benefits so long as the failure or delinquency continues.
(2) Only a student in good standing in his or her respective institution may receive the
benefits under this Section.
(3) A child receiving benefits under this Section must be enrolled according to the
customary rules and requirements of the institution attended.
(Source: P.A. 92 -651, eff. 7- 11 -02.)
(820 ILCS 320/20)
Sec. 20. Home rule. An employer, including a home rule unit, that employs a full -time law
enforcement, correctional or correctional probation officer, or firefighter may not provide
benefits to persons covered under this Act in a manner inconsistent with the requirements of this
Act. This Act is a limitation under subsection (i) of Section 6 of Article VII of the Illinois
Constitution on the concurrent exercise of powers and functions exercised by the State.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/95)
Sec. 95. (Amendatory provisions; text omitted).
(Source: P.A. 90 -535, eff. 11- 14 -97; text omitted.)
(820 ILCS 320/99)
Sec. 99. Effective date. This Act takes effect upon becoming law.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
BY FAX AND MAIL
Name
Address
City, State, Zip Code
hR
Dear
Date
Please be advised that the Village of Buffalo Grove has set a hearing regarding
request for Public Safety Employee Benefits Act health insurance benefits on
at in the Village Hall Council Chambers.
This will be the PSEBA applicant's sole opportunity to present evidence and argument in support
of his request.
Sincerely,
Dane C. Bragg
Village Manager
PUBLIC SAFETY EMPLOYEE BENEFIT ACT
HEARING
DATE
VILLAGE OF BUFFALO GROVE
50 RAUPP BOULEVARD
BUFFALO GROVE, ILLINOIS 60089
a.m. — Village Hall Council Chambers
HEARING OFFICER: DANE C. BRAGG, Village Manager
1. Call to Order
2. Hearing for : Application of
3. Adjournment
Date
Name
Address
City, State, Zip Code
Dear
Attached is the Finding and Decision regarding your request for health insurance benefits under
the Public Safety Employee Benefits Act. It has been determined that you (are OR are not)
entitled to health insurance benefits retroactive to the date that your duty disability pension was
granted by the (Firefighter OR Police Officer) Pension Board on
Beginning with the month of , (the Village or you) will be responsible for
your health insurance premium payments.
If you need to discuss insurance changes or have any questions regarding health insurance
benefits, please contact , Director of Human Resources, at your
convenience. Further, please do not hesitate to contact me, if you have any questions regarding
this matter.
Sincerely,
Dane C. Bragg
Village Manager
Attachments
BEFORE THE PUBLIC SAFETY EMPLOYEE
BENEFITS ACT HEARING OFFICER
FOR THE VILLAGE OF BUFFALO GROVE, ILLINOIS
IN THE MATTER OF THE PETITION OF
OF THE VILLAGE OF BUFFALO GROVE, ILLINOIS
1.
FINDING AND DECISION
applied for health benefits under the Public Safety
Employee Benefits Act, 820 ILCS 320/10,
2. On
, a hearing was held pursuant to Buffalo Grove
Municipal Code Chapter 2.72.030 and 2.72.040.
3. Documentary evidence and sworn testimony was received and taken under advisement.
4. , the hearing officer, as a result of said hearing on
5. Finds and determined that:
a. The petitioner was, at all times mentioned herein, a full -time member of the
Department of the Village of Buffalo Grove.
b. Throughout the hearing, the Petitioner appeared in person and was represented by
counsel.
c. The Petitioner (qualifies OR does not qualify) under Section (a) of 820 ILCS 320/10 as a
that has suffered a catastrophic injury in the line of duty.
d. That the Petitioner (was OR was not) responding to an emergency on
and was injured while conducting official duties related to said emergency as required by
section (b) of 820 ILCS 320/10/
e. That the Petitioner (is OR is not) entitled to health benefits as defined in 820 ILCS
320/10 from and after retirement from the Village of Buffalo Grove's
Department.
Dated at Buffalo Grove, Illinois this day of , 201_.
4911 -3668 -2514, v. 1
Dane C. Bragg, Village Manager
- •. ,.
STATE OF ILLINOIS) ss.
COUNTY OF COOK )
CERTIFICATE
I, Janet M. Sirabian, certify that I am the duly elected
and acting Village Clerk of the Village of Buffalo
Grove, Cook and Lake Counties, Illinois. I further
certify that on January 21, 2013, the Corporate
Authorities of the Village passed and approved
Ordinance No. 2013 -05, AN ORDINANCE
AMENDING CHAPTER 2.08 AND ADDING
CHAPTER 2.72 TO THE VILLAGE OF BUFFALO
GROVE MUNICIPAL CODE a copy of such
Ordinance was posted in and at the Village Hall,
commencing on January 22, 2013 and continuing for
at least ten days thereafter. Copies of such Ordinance
were also available for public inspection upon request
in the Office of Village Clerk.
Dated at Buffalo Grove, Illinois, this 22ND day of
January, 2013.
Village Clerk
r'
By
ORDINANCE NO. 2013- 05
AN ORDINANCE AMENDING
CHAPTER 2.08 AND ADDING CHAPTER 2.72 TO THE
VILLAGE OF BUFFALO GROVE MUNICIPAL CODE
WHEREAS, the Village of Buffalo Grove is a Home Rule Unit by virtue of the
Provisions of the Constitution of the State of Illinois of 1970;
WHEREAS, Chapter 2.08 of the Village of Buffalo Grove Municipal Code invests
certain defined duties, rights and responsibilities unto the position of Village Manager; and
WHEREAS, the Village desires to add a new provision in the Village of Buffalo Grove
Municipal Code to govern the application and determination of benefits under the Public Safety
Employee Benefits Act (820 ILCS 320/1 et. seq.).
NOW, THEREFORE, BE IT ORDAINED BY THE PRESIDENT AND BOARD OF
TRUSTEES OF THE VILLAGE OF BUFFALO GROVE, COOK AND LAKE COUNTIES,
ILLINOIS that:
Section 1: That Chapter 2.08.040 (Duties of the Village Manager) be amended to include the
following:
The Village Manager shall establish and administer policies and procedures pursuant to Chapter
2.72 of the Village of Buffalo Grove Municipal Code for purposes of determining whether an
employee subject to the Public Safety Employee Benefits Act (820 ILCS 320/1 et. seq.) is
eligible to receive benefits pursuant to the Act.
Section 2: That Title 2 (Administration and Personnel) be amended to add a new Chapter 2.72
which provides as follows:
2.72.010: Purpose
The purpose of this chapter is to provide a fair and efficient method of determining the eligibility
of an employee for the benefits enumerated under the Public Safety Employee Benefits Act (820
ILCS 320/1 et seq.) (PSEBA). All benefits provided employees pursuant to PSEBA will be
consistent with PSEBA.
2.72.020: Authority
The ordinance codified in this Chapter is adopted by the Corporate Authorities of the Village of
Buffalo Grove pursuant to the Home Rule authority granted by Article VII, Section 6 of the
Illinois Constitution of 1970.
2.72.030: Policy and Procedure for Administering Applications for PSEBA Benefits
Except as otherwise provided below, the following policies and procedures established pursuant
to this subchapter 2.72.030 shall be administered and interpreted by the Village Manager as
follows:
A. Application for PSEBA Benefits.
A PSEBA benefit application form prepared by the Village shall be the standard form required
for PSEBA benefit applicants (hereinafter the "applicant ") to utilize to request benefits under
PSEBA. The form shall be completed and executed by the requesting applicant and delivered to
the Village Manager. The applicant shall provide, along with the application, any medical
records regarding the injury, any decisions by a governing public safety pension board and
supporting documentation related to such pension board decisions and any additional pertinent
documentation that the applicant wants to have considered or that is requested by the Village.
B. Application Review Process
1. When the Village Manager receives a complete and executed PSEBA
benefit application, the Village Manager shall review the application and engage in such
additional fact - finding and /or investigation as may be deemed necessary or appropriate to
evaluate the application, including, but not limited to the review of public safety pension
board hearing transcripts and decisions, worker's compensation documentation and
independent medical examinations.
2. If additional fact - finding and /or investigation is determined to be
necessary, the applicant shall fully cooperate. if the applicant refuses or otherwise fails
to fully cooperate, then a reminder notice shall be sent to the applicant explaining the
duty of full cooperation in the fact - finding and /or investigation process. If the applicant
fails to cooperate as requested within 21 calendar days after receipt of such notice, then
the application for PSEBA benefits shall be deemed withdrawn.
3. The Village Manager shall make a written recommendation, including
reasons for the recommendation, to the Corporate Authorities of the Village within forty -
five (45) calendar days after the later of the following:
a. the submission of the relevant documentation; or
b. the completion of such additional fact- finding or investigation as
deemed necessary or appropriate by the Village Manager (as stated in paragraph
1, above).
The Village Manager's written recommendation shall state whether:
a. the applicant is eligible for benefits under PSEBA; or
b. a hearing should be convened in order to determine whether or not
the applicant is eligible for benefits under PSEBA and shall inform the applicant,
in writing, of the decision and the reasons for the decision.
4. If the Village Manager recommends that the applicant is eligible for
benefits under PSEBA, the recommendation shall be presented to the Village Board at the
next regularly scheduled Village Board meeting (subject to the notice provisions of the
Open Meetings Act). The Village Board or its authorized designee shall make a
determination that:
a. the applicant is eligible for benefits under PSEBA; or
b. a hearing as set forth in subchapter 2.72.040(C) should be
convened in order to determine whether or not the applicant is eligible for benefits
under PSEBA.
2.72.040: Policy and Procedure for Administering Hearings for PSEBA Benefits
If the Village Board, following the Village Manager's recommendation, determines that a
hearing should be convened, the Village Board or its authorized designee shall convene a hearing
which shall be overseen by a hearing officer whose power and authority and limitations are as
follows:
A. Power of the Hearing Officer. The hearing officer shall have the necessary powers
granted to him relative to conduct an administrative hearing including the power to:
1. preside overall Village hearings involving PSEBA;
2. administer oaths;
3. hear testimony and accept evidence that is relevant to the issue of eligibility under
PSEBA;
4. issue subpoenas to secure attendance of witnesses and the production of relevant
papers or documents upon the request of the parties or their representatives; and
5. issue a written determination based on the evidence presented at the hearing.
B. Hearing Officer. The President with the consent of the Village Board is hereby
authorized to appoint a person to hold the position of a hearing officer for each
PSEBA hearing that shall come before the Village.
C. The Administrative Hearing. A hearing may be held to adjudicate and determine
whether the subject public safety employee is eligible for benefits under PSEBA. If
the employee is found eligible, the employee benefits shall be consistent with
PSEBA.
1. Time and date. Hearings shall be held on the date, time and place as established
by the Village with appropriate notice served upon the public safety employee.
2. Record. All hearings shall be attended by a certified court reporter and a transcript
of all proceedings shall be made by said certified court reporter.
3. Procedures. The Village and the petitioning public safety employee shall be
entitled to representation by counsel at said hearing and may present witnesses,
may present testimony and documents, may cross - examine opposing witnesses,
and may request the issuance of subpoenas to compel the appearance of relevant
witnesses or the production of relevant documents.
4. Final Determination. The determination by the hearing officer of whether the
petitioning public safety employee is eligible for the benefits under PSEBA shall
constitute a final determination for the purpose of judicial review under the
common law writ of certiorari.
Section 3: The Village Clerk is hereby authorized to publish this ordinance in pamphlet form,
Section 4: This Ordinance shall be in full force and effect from and after its passage and
approval. This Ordinance shall be codified.
AYES: 6- Berman, Trilling, Sussman Terson Stein Ottenheimer
NAYES: 0 -
ABSENT:
PASSED: January 21 2011 APPROVED: January 21 2013.
Village President
ATTEST:
Village Clerk
VILLAGE OF
BUFFALO GROVE
Fifty Raupp Blvd.
Buffalo Grove, IL 60089 -2196
Phone 847- 459 -2500
Fax 847 - 459 -7906
Date
Name
Address
City, State, Zip Code
Dear
i-
I am in receipt of your request dated to receive benefits pursuant to
the Public Safety Employees Benefits Act (820 ILCS 320/) (PSEBA).
For your information, 1 have attached a copy of the applicable statute and the Village's PSEBA
benefit application.
In the event that the Village conducts an administrative hearing to determine if you are eligible
for PSEBA benefits based on the terms of PSEBA and the relevant Illinois case law interpreting
PSEBA, you will be notified and will be welcome to be represented by legal counsel at the
hearing to present evidence supporting your request.
At this time, please complete and return the enclosed PSEBA benefit application along with any
supporting documentation to the Village within 30 days of the date of this letter. If you have any
questions, please feel free to contact me.
Sincerely,
Dane C. Bragg
Village Manager
Attachments
VILLAGE OF BUFFALO GROVE
APPLICATION FOR BENEFITS PURSUANT TO
THE PUBLIC SAFETY EMPLOYEE BENEFITS ACT ( "PSEBA ")
The undersigned states as follows:
A. Applicant Information
1. Name of Applicant:
2. If Applicant is a family member of the Public Service Officer, please describe
relationship to injured or deceased Public Safety Officer:
3. Employment Status (select one of a or b):
a. I am employed by
b. I am not employed
4. Marital Status (select one of a, b, or c):
a. Single
b. Married to (Name):
Social Security N
C. Divorced or widowed
5. Dependent Children (select one of a or b):
a. I have dependent children under age 26 totaling:
b. I do not have any dependent children.
6. Date of Hire with the Village of related Public Service Officer:
7. Has the injured or deceased Public Safety Officer or any family member on his/her behalf
previously made a request for PSEBA benefits? If so, identify when the request was
made, how it was made, to whom it was made, whether any PSEBA benefits were paid
and for how long and provide any documentation:
B. Health Coverage Information
Nate: Please be advised that if you are granted continued health coverage under PSEBA, you
will receive coverage under the Village's basic group health insurance plan which is the least
expensive health plan offered by the Village as determined solely by the Village. This means that
you ma>> be obligated to switch group health plans if you are awarded PSEBA benefits and elect
to receive such PSEBA benefits. If you wish to maintain different coverage other than the
Village's basic group health insurance plan, you may be charged for the difference between such
different coverage and the Village's basic group health insurance plan. PSEBA coverage does
not include supplemental coverage such as dental or life insurance. Additionally, if your PSEBA
coverage is secondar -v to any other group health plan, your PSEBA coverage will be considered
supplemental and may be reduced or eliminated as determined by the Village.
Please indicate whether (select one of I or 2):
No other health insurance coverage is available to me
2. Other health insurance coverage is available from (check all that apply):
a. My current employer's plan
b. My spouse's employer's plan
C. COBRA from a former employer
d. Medicare. Medicaid or other coverage provided through a state or
federal health benefit exchange
e. Individual policy (Policy Issuer:
The above indicated coverage began on (insert date). This
coverage runs until (insert last month of coverage). Please
indicate the name of the health plan or insurance company providing other
health coverage:
3. Are you currently enrolled in any other coverage? Yes No
4. 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 health plan or policy that is available to you
(including coverage not currently in effect):
Contact person,
Address
Phone
Web or E -Mail
2
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
C. Information Related to the Disability
Has a Line -Of -Duty Disability Pension been applied for or granted by the Police /Fire
Pension Fund Board?
If so, provide the date of application or pension, copies of any materials submitted in
support of such a pension and the Pension Board award:
2. Describe when, where and how the disabling injury or injuries and/or death occurred for
which you are now seeking PSEBA benefits and provide any supporting
inform ation/documents (attach additional sheets if necessary):
3. List any and all witnesses to the qualifying injury and /or death and provide any witness
statements (attach additional sheets if necessary):
4. Provide any other facts that would qualify the injured or deceased Public Safety Officer
for PSEBA benefits (attach additional sheets if necessary):
3
D. Medical Information and Supporting Documentation to be Provided to the Village
The applicant shall provide, along with this application, any medical records regarding
the injury, any decisions by a governing public safety pension board and supporting
documentation related to such pension board decisions and any additional pertinent
documentation that the applicant wants to have considered or that is requested by the Village.
To determine continuing eligibility for PSEBA benefits, the Village Manager may need
to review relevant medical records of the applicant and/or the injured Public Safety Officer. In
order to process an application for PSEBA coverage, it is necessary that you complete and return
to the Village the attached waiver form to authorize the Village to obtain and review copies of
these medical records.
E. Agreement to Update Information
This statement is made for the sole purpose of receiving benefits provided by the Village
of Buffalo Grove under the Public Safety Employee Benefits Act. The information contained in
this application is true to the best of my knowledge and belief. If any of the information
provided in this application changes, I agree to provide documentation to the Village of Buffalo
Grove within 30 days of such change, including in particular any change in the marital status of
the spouse of a Public Safety Officer or my dependent reaching age 26, a change in disability
status and the availability of any other health coverage to any person listed above.
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
1LCS 320/10(a)(3).
I, the undersigned applicant, understand that if I am awarded PSEBA benefits and later
become eligible to enroll in another group health plan, including Medicare, that my PSEBA
benefits may be reduced or eliminated.
Signature of Applicant:
Date:
............................................... ............................... .
For off ce use only:
Date PSEBA Application Received:
Received by:
11
VILLAGE OF BUFFALO GROVE
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I. Information About the Use or Disclosure of Protected Health Information (PHI)
Employee: Address: Date of Birth:
I (name of Employee, PSEBA Applicant or Patient), . hereby authorize
the use or disclosure of my written, electronic and oral protected health information (PHI), as described in this authorization.
I am authorizing the
( "Authorized Releasor(s) ") to provide my health information.
Please specify the individual /organization authorized to receive your health information:
❑ Human Resources Division, Village of Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089 -2196
Name:
Address:
Daytime Tel: ( _)
if. Description of Specific Information You Wish The Authorized Releasor To Disclose: (check all boxes that apply)
❑ PHI related to an illness or injury associated with a duty- disability pension award eligibility issued on
i
❑ PHI related to an illness or injury identified in an application filed with the Village of Buffalo Grove for continued health
coverage pursuant to the Illinois Public Safety Employee Benefits Act.
❑ Other.
Mate the purpose of this request below:
❑ To allow the recipient to make a determination of eligibility for benefits under the Illinois Public Safety Employee
Benefits Act.
❑ Other:
ttl you ao not wish to state a purpose, please state "At request of the individual.
This authorization will expire on: (If no date or occurrence specified, authorization will expire 1 year from date signed.)
❑ Give date or occurrence (Example: "When my PSEBA application case is resolved. "):
Ill. Important Information About Your Rights - I have read and understand the following statements about my riebts:
• I understand that I have the right to revoke this authorization at any time by notifying the Human Resources Division, Village of
Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089 -2196. I understand that the revocation is only effective after it is
received and logged by the Human Resources Division. I understand that any use or disclosure made prior to the revocation
under this authorization will not be affected by a revocation.
• I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it again.
• I understand that I am entitled to receive a copy of this authorization.
• I understand that I may refuse to sign this authorization and that my refusal to signed this authorization will not affect my ability to enroll in a
health plan, obtain health care treatment or payment, or eligibility for benefits unless authorized by law.
IV. Signature of Participant or Beneficiary:
Date:
V. Personal Representative (If the person signing this form is the Personal Representative of the Employee /Patient; sign here.)
Personal Representative Date:
• I swear under penalty of perjury that I am the Personal Representative of the employee /patient named above.
Please state status (for example, parent, guardian, Power Of Attorney)
Print name of personal representative:
Address:
Daytime Tel: (
If a personal representative executes this form, please attach copy of document, if applicable, which creates the status as personal
representative, such as Legal Guardianship, General Power ofAttornev, Power ofAttornev for Health Care Matters.
Please return this form to: Human Resources Division, Village of Buffalo Grove, Fifty Raupp Blvd., Buffalo Grove, IL 60089-
2196
EMPLOYMENT
(820 ILCS 320[) Public Safety Employee Benefits Act.
(820 ILCS 320/1)
Sec. 1. Short title. This Act may be cited as the Public Safety Employee Benefits Act.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/3)
Sec. 3. Definition. For the purposes of this Act, the term "firefighter" includes, without
limitation, a licensed emergency medical technician (EMT) who is a sworn member of a public
fire department.
(Source: P.A. 93 -569, eff. 8- 20 -03.)
(820 ILCS 320/5)
Sec. 5. Declaration of State interest. The General Assembly determines and declares that the
provisions of this Act fulfill an important State interest.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/10)
Sec. 10. Required health coverage benefits.
(a) An employer who employs a full -time law enforcement, correctional or correctional
probation officer, or firefighter, who, on or after the effective date of this Act suffers a
catastrophic injury or is killed in the line of duty shall pay the entire premium of the employer's
health insurance plan for the injured employee, the injured employee's spouse, and for each
dependent child of the injured employee until the child reaches the age of majority or until the
end of the calendar year in which the child reaches the age of 25 if the child continues to be
dependent for support or the child is a full -time or part-time student and is dependent for support.
The term "health insurance plan" does not include supplemental benefits that are not part of the
basic group health insurance plan. If the injured employee subsequently dies, the employer shall
continue to pay the entire health insurance premium for the surviving spouse until remarried and
for the dependent children under the conditions established in this Section. However:
(1) Health insurance benefits payable from any other source shall reduce benefits payable
under this Section.
(2) 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 under this
Section. A violation of this item is a Class A misdemeanor.
(3)' Upon conviction for a violation described in item (2), a law enforcement, correctional or
correctional probation officer, or other beneficiary who receives or seeks to receive health
insurance benefits under this Section shall forfeit the right to receive health insurance benefits
and shall reimburse the employer for all benefits paid due to the fraud or other prohibited
activity. For purposes of this item, "conviction" means a determination of guilt that is the result
of a plea or trial, regardless of whether adjudication is withheld.
(b) In order for the law enforcement, correctional or correctional probation officer, firefighter,
spouse, or dependent children to be eligible for insurance coverage under this Act, the injury or
death must have occurred as the result of the officer's response to fresh pursuit, the officer or
firefighter's response to what is reasonably believed to be an emergency, an unlawful act
perpetrated by another, or during the investigation of a criminal act. Nothing in this Section shall
be construed to limit health insurance coverage or pension benefits for which the officer,
firefighter, spouse, or dependent children may otherwise be eligible.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/15)
Sec. 15. Required educational benefits. If a firefighter, law enforcement, or correctional or
correctional probation officer is accidentally or unlawfully and intentionally killed as specified in
subsection (b) of Section 10 on or after July 1, 1980, the State shall waive certain educational
expenses which children of the deceased incur while obtaining a vocational - technical certificate
or an undergraduate education at a State supported institution. The amount waived by the State
shall be an amount equal to the cost of tuition and matriculation and registration fees for a total
of 120 credit hours. The child may attend a State vocational - technical school, a public
community college, or a State university. The child may attend any or all of the institutions
specified in this Section, on either a full -time or part-time basis. The benefits provided under this
Section shall continue to the child until the child's 25th birthday.
(1) Upon failure of any child benefited by the provisions of this Section to comply with the
ordinary and minimum requirements of the institution attended, both as to discipline and
scholarship, the benefits shall be withdrawn as to the child and no further moneys may be
expended for the child's benefits so long as the failure or delinquency continues.
(2) Only a student in good standing in his or her respective institution may receive the
benefits under this Section.
(3) A child receiving benefits under this Section must be enrolled according to the
customary riles and requirements of the institution attended.
(Source: P.A. 92 -651, eff. 7- 11 -02.)
(820 ILCS 320/20)
Sec. 20. Home rule. An employer, including a home rule unit, that employs a full -time law
enforcement, correctional or correctional probation officer, or firefighter may not provide
benefits to persons covered under this Act in a manner inconsistent with the requirements of this
Act. This Act is a limitation under subsection (i) of Section 6 of Article VII of the Illinois
Constitution on the concurrent exercise of powers and functions exercised by the State.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
(820 ILCS 320/95)
Sec. 95. (Amendatory provisions; text omitted).
(Source: P.A. 90 -535, eff. 11- 14 -97; text omitted.)
(920 ILCS 320199)
Sec. 99. Effective date. This Act takes effect upon becoming law.
(Source: P.A. 90 -535, eff. 11- 14 -97.)
BY FAX AND MAIL
Name
Address
City, State, Zip Code
Re:
Dear
Date
Please be advised that the Village of Buffalo Grove has set a hearing regarding
request for Public Safety Employee Benefits Act health insurance benefits on
at in the Village Hall Council Chambers.
This will be the PSEBA applicant's sole opportunity to present evidence and argument in support
of his request.
Sincerely,
Dane C. Bragg
Village Manager
PUBLIC SAFETY EMPLOYEE BENEFIT ACT
HEARING
DATE
VILLAGE OF BUFFALO GROVE
50 RAUPP BOULEVARD
BUFFALO GROVE, ILLINOIS 60089
a.m. — Village Hall Council Chambers
HEARING OFFICER: DANE C. BRAGG, Village Manager
1. Call to Order
2. Hearing for : Application of
3. Adjournment
Date
Name
Address
City, State, Zip Code
Dear
Attached is the Finding and Decision regarding your request for health insurance benefits under
the Public Safety Employee Benefits Act. It has been determined that you (are OR are not)
entitled to health insurance benefits retroactive to the date that your duty disability pension was
granted by the (Firefighter OR Police Officer) Pension Board on
Beginning with the month of (the Village or you) will be responsible for
your health insurance premium payments.
If you need to discuss insurance changes or have any questions regarding health insurance
benefits, please contact Director of Human Resources, at your
convenience. Further, please do not hesitate to contact me, if you have any questions regarding
this matter.
Sincerely,
Dane C. Bragg
Village Manager
Attachments
BEFORE THE PUBLIC SAFETY EMPLOYEE
BENEFITS ACT HEARING OFFICER
FOR THE VILLAGE OF BUFFALO GROVE, ILLINOIS
IN THE MATTER OF THE PETITION OF
OF THE VILLAGE OF BUFFALO GROVE, ILLINOIS
FINDING AND DECISION
applied for health benefits under the Public Safety
Employee Benefits Act, 820 ILCS 320/10.
2. On
, a hearing was held pursuant to Buffalo Grove
Municipal Code Chapter 2.72.030 and 2.72.040.
3. Documentary evidence and sworn testimony was received and taken under advisement.
4. , the hearing officer, as a result of said hearing on
5. Finds and determined that:
a. The petitioner was, at all times mentioned herein, a full -time member of the
Department of the Village of Buffalo Grove.
b. Throughout the hearing, the Petitioner appeared in person and was represented by
counsel.
c. The Petitioner (qualifies OR does not qualify) under Section (a) of 820 ILCS 320/10 as a
that has suffered a catastrophic injury in the line of duty.
d. That the Petitioner (was OR was not) responding to an emergency on
and was injured while conducting official duties related to said emergency as required by
section (b) of 820 ILCS 320/10/
e. That the Petitioner (is OR is not) entitled to health benefits as defined in 820 ILCS
320 /10 from and after retirement from the Village of Buffalo Grove's
Department.
Dated at Buffalo Grove, Illinois this day of , 201
4811- 3668- 2514.v. 1
Dane C. Bragg, Village Manager