Lausd Pdf Filler Forms 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?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslausd hi 22 form printable, lausd hi22, hi 22 form, lausd hi 22

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Los Angeles Unified School District

Benefits Administration

HI-22

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

Health Net HMO/Health Net Seniority Plus Plan UnitedHealthCare® Group Medicare Advantage HMO*

Anthem Blue Cross EPO

Kaiser Permanente HMO/ Kaiser Senior Advantage

No Medical Coverage

*Retiree and their dependent must be over 65 and enrolled in Medicare Parts A & B.

DENTAL

MetLife Preferred Dentist Program (PPO) Western Dental DHMO Centers Only

MetLife-affiliated Dental Health Care Service Plan (SafeGuard DHMO)

Western Dental DHMO Plan Plus

No Dental Coverage

VISION

EyeMed Vision Care

VSP

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

M

Relationship

Date of

Sex

I

Birth

 

 

 

 

 

 

 

 

 

Spouse

 

Male

 

 

 

 

Domestic Partner

 

Female

 

 

 

 

 

 

Male

 

 

 

 

 

 

Female

MEDICARE INFORMATION (Mandatory if you and/or your spouse is age 65 or older)

 

Participant

 

 

Medicare Claim Number

 

 

Medicare A (Hospital)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date

 

 

 

 

 

 

 

 

 

 

 

 

Retiree

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/ Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare B (Medical)

Effective Date

Is your spouse/Domestic Partner an LAUSD employee or retiree?

Yes

No

Employee #_______________________

NO DUAL COVERAGE ALLOWED

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

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 those eligible members of my family 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.

Applicant’s

Signature

Date

HI-22 2012

*HB2*

Rev. 10/12

 

NOTE: 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.

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 retire from District service in accordance with the rules and regulations of your retirement system. (This includes disability allowance under STRS.)

3.You must receive a monthly retirement payment from your retirement system.

4.If you were hired before March 11, 1984, you must have been eligible for coverage for 5 consecutive years immediately prior to your retirement effective date.

If you were hired on or after March 11, 1984, but before July 1, 1987, you must have been eligible for coverage for at least 10 consecutive years immediately prior to your retirement effective date.

If you were hired on or after July 1, 1987 but before June 1, 1992, you must have been eligible for coverage for at least 15 consecutive years immediately prior to your retirement effective date or have been eligible for coverage for 10 consecutive years before your retirement effective date plus and additional 10 years which need not to be consecutive.

If you were hired on or after June 1, 1992, but prior to March 1, 2007, to qualify for District-paid benefits at retirement, the employee’s age plus the number of consecutive qualifying years of service, when added together, must equal 80. For employees who have a break in service, this must include at least ten (10) consecutive years immediately prior to retirement.

If you were hired on or after March 1, 2007, but prior to April 1, 2009 to qualify for District-paid benefits at retirement, the employee’s age plus the number of consecutive qualifying years of service, when added together, must equal 80 and you must have fifteen (15) consecutive years of qualifying service immediately prior to retirement.

If you were hired on or after April 1, 2009, to qualify for District-paid benefits at retirement, the employee’s age plus the number of consecutive qualifying years of service, when added together, must equal 85 and you must have twenty-five (25) consecutive years of qualifying service immediately prior to retirement.

For School Police (sworn personnel), if you were hired on or after April 1, 2009, to qualify for District-paid benefits at retirement, 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. If you do not comply with Medicare A requirements, it will negatively

impact you health coverage.

If you are a member of Kaiser, you must join Senior Advantage (Kaiser’s Medicare Advantage Plan) in order to maintain your Kaiser

health care coverage. If you are a member of Health Net HMO, you must join Seniority Plus (Health Nets Medicare Advantage Plan) in

order to maintain your Health Net HMO health care coverage. All enrollees in United Healthcare retiree plan or Health Net Seniority Plus

plan must have parts A and B of Medicare.

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 Metropolitan Life Insurance Company (MetLife) at (866) 492-6983.

7.If you meet the above requirements, you will receive benefits for yourself and your eligible dependents. 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 health benefits.

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

Fax: (213) 241-4247 Phone: (213) 241-4262

Email: benefits@lausd.net