Lausd Form Hi 22 PDF Details

The Lausd Form Hi 22 is a two-page form that collects employee information for the Los Angeles Unified School District. This form is used to determine eligibility for employment with the school district, and it must be completed by all applicants. The first page of the form collects basic information about the applicant, while the second page gathers more detailed information about their qualifications and work history. Completed forms should be submitted to the LAUSD Human Resources Department.

Here is the details concerning the form you were seeking to fill in. It can show you how much time you will require to complete lausd form hi 22, what parts you need to fill in and a few additional specific facts.

QuestionAnswer
Form NameLausd Form Hi 22
Form Length2 pages
Fillable?Yes
Fillable fields57
Avg. time to fill out11 min 58 sec
Other nameslausd forms and publications, lausd hi 22 form, lausd hi22 form, hi22

Form Preview Example

Los Angeles Unified School District

HI-22

 

Benefits Administration

 

APPLICATION FOR CONTINUATION OF HEALTH BENEFITS

(Complete this form at least 3 months before you retire)

 

Employee Number

 

Last Name

 

First Name

 

 

 

 

M.I.

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

City

 

State

Zip Code

Phone Number

 

 

 

 

 

 

 

 

 

Social Security Number

Date of Birth

Male

Service Retirement

Retirement Date

 

 

 

 

 

Female

Disability Retirement

 

 

 

 

 

 

 

 

 

Classified

PLEASE DO NOT WRITE IN

Retirement Date

Coverage Effective

Process Date

Initial

Certificated

SHADED BOXES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH PLANS (Please select the plans you wish to be enrolled in at the time of retirement.)

MEDICAL

Anthem Blue Cross Select HMO (Retiree must be under 65) Health Net HMO/Health Net Seniority Plus Plan

Anthem Medicare Preferred (PPO) Medical Plan (Available 1/1/2019) Retiree and/or their dependent must be over 65 and enrolled in Medicare Parts A & B. If dependent is under 65 or over 65 with Medicare B only, they will be be enrolled in Anthem Blue Cross EPO.

Anthem Blue Cross EPO

Kaiser Permanente HMO/Kaiser Senior Advantage

No Medical Coverage

DENTAL

United Concordia Dental PPO

DeltaCare® USA DHMO

 

Western Dental DHMO Centers Only

Western Dental DHMO Plan Plus

No Dental Coverage

 

 

 

 

VISION

 

EyeMed Vision Care

VSP® Vision Care

No Vision Coverage

DEPENDENT INFORMATION (Social Security number is mandatory for all dependents. Attach additional pages if necessary) Note: If you have a dependent between age 19-25 please contact Benefits Administration for eligibility requirements

SSN

Last Name

First Name

MI

Relationship

Date of

Sex

Birth

 

 

 

 

 

 

 

 

 

 

Spouse

 

Male

 

 

 

 

Domestic Partner

 

Female

 

 

 

 

 

 

Male

 

 

 

 

 

 

Female

MEDICARE INFORMATION (Mandatory if you and/or your spouse is age 65 or older). Must attach a copy of Medicare card.

 

 

Participant

 

 

Medicare Claim Number

 

 

Medicare A (Hospital)

 

 

Medicare B (Medical)

 

 

 

 

 

 

 

Effective Date

 

 

Effective Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retiree

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your spouse/domestic partner an LAUSD employee or retiree?

Yes

No Employee #_______________________

Retirement System: When you receive a “Notice of Benefit Approval” (PERS) or the “Award Letter” (STRS) from your retirement system, please forward a copy to Benefits Administration. Your retirement benefits will remain in a pending status until receipt of this letter. Please

indicate your retirement system below:

 

State Teachers Retirement System (STRS)

Public Employees Retirement System (PERS)

THIS FORM WILL NOT BE PROCESSED UNLESS SIGNED AND DATED October 31, 2018

I understand this election will remain in effect as long as I remain eligible, or until I make another election during an annual enrollment period. I hereby authorize any insurance company, organization, employer, hospital, physician, surgeon, or pharmacist to release any information requested to pay any claim under the plan selected. I want to enroll myself and my dependents listed above for participation in the plans elected. I understand that I am responsible for notifying the District of any change in the eligibility of my dependents and am responsible for premiums and claims incurred on behalf of ineligible dependents. I also understand that I must abide by the provisions of the plan in which I enroll and that any controversy between any HMO plan member and such HMO (including its agents, staff physicians, employees and providers) is subject to binding arbitration. I certify under penalty of perjury that the above information is true and is accurate to the best of my knowledge and belief. I have read the Retirement with Health Benefits Eligibility Guidelines and agree to the terms and conditions set forth herein.

Applicant’s

Signature

Date

Rev. 10/18

*HI-22*

If you change your address, you must notify Benefits Administration or you may fail to receive important benefits information. Failure to receive information could result in the loss of your benefits.

Retirement with Health Benefits Eligibility Guidelines

TO RECEIVE COVERAGE AS A RETIRED EMPLOYEE, YOU MUST MEET THE FOLLOWING REQUIREMENTS:

1.Select any available plan you wish to be enrolled in at the time of retirement. If your selection is different than the plan you are currently enrolled in, the effective date will be the first of the following month after your retirement date.

If you are not enrolled in a medical, dental, or vision care plan, you must contact Benefits Administration regarding enrollment procedures before your retirement date.

2.You must resign to retire from District service and be eligible to receive an allowance from your retirement system (CalSTRS or CalPERS) for either age or disability retirement the day after your District resignation.

You are not eligible for retirement health benefits if you separated, resigned without retiring, or were dismissed from District Service.

Your District resignation date and CalSTRS/CalPERS retirement date must be consecutive dates (may include weekend days).

If there is a gap between your District resignation date and your CalSTRS/CalPERS retirement date, you will not be eligible for retirement health benefits.

3.You must receive a monthly retirement payment from your retirement system. If you take deferred retirement (that is, leaving funds on deposit with the retirement system for withdrawal at a later date) or a lump sum distribution, you are not eligible for these retirement benefits.

4.You must meet the following requirements:

a.For employees hired prior to March 11, 1984, five (5) consecutive years of qualifying service immediately prior to retirement shall be required in order to qualify for retiree health benefits for the life of the retiree.

b.For employees hired on or after March 11, 1984, but prior to July 1, 1987, ten (10) consecutive years of qualifying service immediately prior to retirement shall be required in order to qualify for retiree health benefits for the life of the retiree.

c.For employees hired on or after July 1, 1987, but prior to June 1, 1992, fifteen (15) consecutive years of qualifying service immediately prior to retirement shall be required, or ten (10) consecutive years immediately prior to retirement plus an additional ten (10) years which are not consecutive.

d.For employees hired on or after June 1, 1992, years of qualifying service and age must total at least eighty (80) in order to qualify for retiree health benefits. For employees who have a break in service, this must include at least ten (10) consecutive years immediately prior to retirement.

e.For employees hired on or after March 1, 2007 shall be required to have a minimum of fifteen (15) consecutive years of service with the District immediately prior to retirement, in concert with the “Rule of 80” eligibility requirement (section 4.0 (d) above) to receive employee and dependents’ health and welfare benefits (medical dental and vision) upon retirement as provided for in this agreement.

f.For employees hired on or after April 1, 2009, years of qualifying service and age must total at least eighty-five (85) in order to qualify for retiree health benefits. This must include a minimum of twenty-five (25) consecutive years of service with the District immediately prior to retirement.

g.For School Police (sworn personnel), if you were hired on or after April 1, 2009, the employee’s age plus the number of consecutive qualifying years of service, when added together, must equal 80 and you must have twenty (20) consecutive years of qualifying service immediately prior to retirement.

5.Medicare requirement (Effective January 1, 2010):

If you and/or your dependent reach/are age 65 or older you must enroll and remain enrolled in Medicare Part B. If you do not enroll in

Medicare Part B, you will lose your health benefits until proof of enrollment is submitted.

If you and/or your dependent are eligible for Medicare Part A premium-free from the Centers of Medicare and Medicaid Services (CMS), you must enroll and remain enrolled in Medicare A.

If you are not eligible for Medicare Part A premium-free from CMS, you must verify ineligibility by providing LAUSD Benefits Administration with a confirmation letter from CMS. Not complying with Medicare A requirements will negatively impact your health coverage.

If you are a member of Kaiser, you must enroll in Senior Advantage (Kaiser’s Medicare Advantage Plan) in order to maintain your coverage. If you are a member of Health Net HMO, you must enroll in Seniority Plus (Health Nets Medicare Advantage Plan) in order to maintain your coverage. All retirees in Anthem Medicare Preferred (PPO) Medical plan or Health Net Seniority Plus plan must have Medicare parts A and B.

6.Life Insurance: Conversion plans are available for both the Basic (District-paid) and Optional (employee-paid) life insurance plans. Also, a continuation decreasing term insurance plan is available for optional life insurance members. Upon retirement, a conversion application will be mailed to you from MetLife. To obtain conversion plan information, you may contact MetLife Life Insurance Company.

7.Flexible Spending Account (FSA): Employees who retire before the end of the plan year have 90 days following the termination date of their account to submit claims for reimbursement. All expenses must be incurred during employment. For more details, contact ConnectYourCare at 877-292-4040.

If you meet the above requirements, you may be eligible for health benefits for yourself and your eligible dependents. Complete and return this form along with copies of the required documents to:

Los Angeles Unified School District - Benefits Administration

P.O. Box 513307

Los Angeles, CA 90051-1307

Telephone: 213-241-4262 Fax: 213-241-4247

eMail: benefits@lausd.net Website: benefits.lausd.net

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