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Fill in Your Lausd Hi 22 Template

The LAUSD HI-22 form is an essential document for employees of the Los Angeles Unified School District looking to continue their health benefits into retirement. This form must be completed and submitted at least three months before your retirement date to ensure a smooth transition. Understanding its requirements and processes can help you secure the health coverage you need as you embark on this new chapter of your life.

Table of Contents

The LAUSD HI-22 form is a crucial document for employees planning to retire from the Los Angeles Unified School District. It serves as the application for the continuation of health benefits, allowing retirees to select their desired medical, dental, and vision plans. Completing this form is essential and should be done at least three months prior to retirement. The form requires personal information such as employee number, social security number, and date of birth. It also mandates the selection of specific health plans based on age and Medicare enrollment status. Additionally, the form includes sections for dependent information and Medicare details, which are mandatory for retirees aged 65 and older. It is important to note that the form must be signed and dated to be processed. Eligibility criteria for health benefits are outlined, emphasizing the need for consecutive years of qualifying service and compliance with Medicare requirements. Retirees must also be aware of their responsibilities regarding dependent eligibility and premium payments. Failure to provide accurate information or notify Benefits Administration of any changes could jeopardize health benefits. Timely submission of the HI-22 form is vital for a smooth transition into retirement health coverage.

Sample - Lausd Hi 22 Form

Los Angeles Unified School District	HI-22
Los Angeles Unified School District
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
SSN	Last Name	First Name	MI	Relationship	Birth	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

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: [email protected] Website: benefits.lausd.net

↓ Lausd Hi 22 PDF

File Specs

Fact Name	Details
Form Purpose	The HI-22 form is used to apply for the continuation of health benefits upon retirement from the Los Angeles Unified School District (LAUSD).
Submission Timeline	Employees must complete this form at least three months before their retirement date to ensure coverage.
Eligibility Requirements	To qualify for health benefits, retirees must meet specific service and retirement criteria based on their hire date.
Medical Plan Options	Retirees can choose from various medical plans, including Anthem Blue Cross and Kaiser Permanente, depending on their age and Medicare enrollment.
Dependent Information	Social Security numbers are required for all dependents listed on the form, ensuring eligibility for coverage.
Medicare Requirements	Retirees and eligible dependents aged 65 or older must enroll in Medicare Parts A and B to maintain health benefits.
Retirement Systems	Retirees must receive a monthly retirement payment from either the State Teachers Retirement System (STRS) or the Public Employees Retirement System (PERS).
Life Insurance Options	Upon retirement, conversion plans for life insurance are available, allowing retirees to maintain coverage through MetLife.
Flexible Spending Account (FSA)	Retirees can submit claims for reimbursement for up to 90 days post-employment for expenses incurred during their employment.
Contact Information	For assistance, retirees can contact LAUSD Benefits Administration via phone at 213-241-4262 or email at [email protected].

Lausd Hi 22 - Usage Guidelines

To proceed with your retirement health benefits, you need to complete the LAUSD HI-22 form. Ensure that you fill it out accurately and submit it at least three months before your retirement date. Follow these steps to fill out the form correctly.

Locate the form and make sure you have the latest version.
Fill in your Employee Number, Last Name, First Name, and M.I..
Provide your Address, City, State, and Zip Code.
Enter your Phone Number and Social Security Number.
Fill in your Date of Birth and select your Gender (Male or Female).
Indicate whether you are applying for Service Retirement or Disability Retirement.
Enter your Retirement Date.
Choose your desired Health Plans for medical, dental, and vision coverage.
Complete the Dependent Information section, providing mandatory details for each dependent.
If applicable, fill out the Medicare Information section and attach a copy of your Medicare card.
Indicate if your spouse or domestic partner is an LAUSD employee or retiree.
Specify your Retirement System (STRS or PERS).
Sign and date the form to certify that the information provided is accurate.
Make a copy of the completed form for your records.
Submit the form along with any required documents to the Los Angeles Unified School District - Benefits Administration.

Once submitted, your application will be reviewed. It is important to follow up if you do not receive confirmation of your application status. This ensures that you remain informed about your health benefits as you transition into retirement.

Your Questions, Answered

What is the LAUSD HI-22 form?

The LAUSD HI-22 form is an application for the continuation of health benefits for employees retiring from the Los Angeles Unified School District. It must be completed at least three months before your retirement date to ensure coverage starts as expected.

Who needs to fill out the HI-22 form?

Employees who are planning to retire and wish to continue their health benefits must fill out the HI-22 form. This includes both certificated and classified employees who meet the eligibility requirements for retirement health benefits.

What information do I need to provide on the form?

You will need to provide personal details such as your employee number, name, address, phone number, social security number, date of birth, and gender. Additionally, you must select your desired health plans and provide information about any dependents who will also be covered.

When should I submit the HI-22 form?

It is recommended that you submit the HI-22 form at least three months prior to your retirement date. This allows ample time for processing and ensures that your health benefits will be effective on your retirement date.

What happens if I do not submit the form on time?

If you do not submit the HI-22 form in time, you may experience a gap in your health coverage after retirement. It is crucial to adhere to the timeline to avoid losing benefits.

Can I change my health plan after I submit the HI-22 form?

Once you submit the HI-22 form, your selected plans will remain in effect as long as you remain eligible. However, you can make changes during annual enrollment periods. It's important to stay informed about these periods to ensure your preferences are updated.

What if I have dependents who are over 65?

If you or your dependents are over 65, you must enroll in Medicare Parts A and B to maintain your health benefits. Attach a copy of your Medicare card to the HI-22 form when submitting it.

What are the eligibility requirements for health benefits after retirement?

To qualify for health benefits, you must resign from the District, receive a monthly retirement payment, and meet specific service requirements based on your hire date. These requirements vary, so review them carefully to ensure you qualify.

How can I contact Benefits Administration if I have questions?

You can reach the LAUSD Benefits Administration by phone at 213-241-4262, by fax at 213-241-4247, or via email at [email protected]. Additionally, you can visit their website at benefits.lausd.net for more information.

Common mistakes

Failing to complete the form at least three months before retirement can lead to delays in processing.
Not providing a social security number for all dependents may result in incomplete applications.
Leaving the retirement date section blank can cause significant processing issues.
Overlooking the requirement to attach a copy of the Medicare card if applicable can lead to denial of benefits.
Choosing a health plan that does not align with eligibility criteria can result in a loss of coverage.
Not signing and dating the form will prevent it from being processed.
Failing to notify Benefits Administration of an address change may lead to missing important information.
Neglecting to provide accurate dependent information, including relationships and birth dates, can cause complications.
Not verifying eligibility for Medicare A and B can negatively impact health coverage.

Documents used along the form

The LAUSD HI-22 form is an important document for employees seeking to continue their health benefits upon retirement. Along with this form, several other documents may be required to ensure a smooth transition into retirement benefits. Below is a list of commonly used forms and documents that accompany the HI-22 form.

Medicare Card: A copy of the Medicare card is necessary for retirees aged 65 or older. It verifies enrollment in Medicare Parts A and B, which is essential for maintaining health benefits.
Retirement System Notice: This document, such as a “Notice of Benefit Approval” from PERS or an “Award Letter” from STRS, confirms eligibility for retirement benefits. It must be submitted to Benefits Administration.
Dependent Information Form: This form collects information about dependents who will also receive health benefits. It includes Social Security numbers and relationships to the retiree.
Life Insurance Conversion Application: Upon retirement, retirees may receive a conversion application from MetLife for life insurance plans. This document allows retirees to convert their coverage to an individual policy.
Flexible Spending Account (FSA) Claims Submission: Retirees must submit any outstanding claims for reimbursement from their FSA within 90 days of retirement. This document outlines the claims process.
Health Benefits Eligibility Guidelines: This document details the requirements for continuing health benefits after retirement. It provides crucial information about eligibility criteria and necessary steps.
Address Change Notification: If a retiree changes their address, they must notify Benefits Administration to ensure they receive all important benefits information. This document is vital to avoid disruptions in coverage.
Retirement Application Form: This form is often required to formally initiate the retirement process. It serves as an official request to retire from the District.

Gathering these documents along with the HI-22 form can help facilitate a smoother transition into retirement and ensure that all necessary benefits are received without delay.

Similar forms

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is a critical document that governs the privacy of health information. Similar to the LAUSD HI-22 form, HIPAA ensures that individuals have rights over their health information and sets rules for who can access it. Both documents emphasize the importance of personal information security and outline the necessary steps for individuals to maintain their privacy. While the HI-22 form focuses on health benefits enrollment, HIPAA provides a broader framework for protecting health information across various contexts.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) offers another point of comparison. COBRA allows employees to continue their health insurance coverage after leaving a job, much like the HI-22 form facilitates the continuation of health benefits upon retirement. Both documents require individuals to make informed decisions about their health coverage. While the HI-22 form is specific to retirement benefits, COBRA applies to a wider range of employment separations, providing essential protections for employees and their families.

The Employee Retirement Income Security Act (ERISA) is also relevant. ERISA sets minimum standards for pension and health plans in private industry, ensuring that participants receive their promised benefits. The HI-22 form, while specific to a public school district, shares ERISA's goal of protecting employee benefits. Both documents require clear communication about eligibility and enrollment processes, reinforcing the importance of transparency in benefits administration.

The Medicare Enrollment Application is another document that parallels the HI-22 form. This application is used by individuals to enroll in Medicare, which is often a crucial part of retirement planning. Just like the HI-22 form, the Medicare Enrollment Application requires personal information and outlines eligibility criteria. Both documents highlight the significance of timely enrollment to avoid gaps in coverage, underscoring the interconnectedness of health benefits and retirement planning.

The Social Security Administration's Application for Benefits is similar as well. This application is essential for retirees seeking Social Security benefits, which often complement health benefits. Both the HI-22 form and the Social Security application require detailed personal information and adherence to specific timelines. They serve as critical tools for individuals navigating the transition into retirement, ensuring that necessary benefits are secured.

The Veterans Affairs (VA) Health Benefits Application is another document that shares similarities with the HI-22 form. This application allows veterans to apply for health care benefits, similar to how the HI-22 form facilitates health benefits for retiring employees. Both documents require the submission of personal information and proof of eligibility, emphasizing the importance of access to health care for individuals in different employment sectors.

The Flexible Spending Account (FSA) Enrollment Form also aligns with the HI-22 form. This form allows employees to set aside pre-tax dollars for eligible health expenses. Like the HI-22, the FSA form requires individuals to make informed choices about their health benefits. Both documents highlight the importance of planning for health care costs, especially during the transition to retirement when expenses may shift.

Lastly, the Retirement Plan Distribution Request Form provides a relevant comparison. This form allows individuals to request distributions from their retirement accounts, ensuring they receive the benefits they have earned. Similar to the HI-22 form, it requires careful attention to detail and adherence to specific guidelines. Both documents play a crucial role in the retirement process, helping individuals secure their financial future while managing their health benefits.

Dos and Don'ts

When filling out the LAUSD HI-22 form, it is important to follow specific guidelines to ensure your application is processed smoothly. Here are ten things you should and shouldn't do:

Do complete the form at least three months before your retirement date.
Do provide accurate personal information, including your employee number, last name, first name, and Social Security number.
Do select the health plans you wish to enroll in at the time of retirement.
Do attach any necessary documents, such as a copy of your Medicare card if applicable.
Do ensure that your retirement date and resignation date are consecutive.
Don't leave any sections of the form blank; incomplete forms may delay processing.
Don't forget to sign and date the form; it will not be processed without your signature.
Don't submit the form without verifying that all information is correct and complete.
Don't ignore the eligibility requirements for health benefits; ensure you meet them before submitting.
Don't wait until the last minute to submit your form; allow time for any potential issues to be resolved.

By following these guidelines, you can help ensure that your application for health benefits is processed efficiently and accurately.

Misconceptions

Misconceptions about the LAUSD HI-22 form can lead to confusion and potential issues when applying for health benefits upon retirement. Here are six common misconceptions along with clarifications:

Misconception 1: The HI-22 form can be submitted at any time before retirement.

In reality, it is important to complete the HI-22 form at least three months before your retirement date. This timeline ensures that the necessary processing can occur without delays.

Misconception 2: Anyone can retire and receive health benefits regardless of their service duration.

Eligibility for health benefits requires specific years of service based on your hire date. For example, employees hired after certain dates must meet varying criteria regarding consecutive years of service.

Misconception 3: Once you retire, you do not need to worry about Medicare enrollment.

This is not accurate. If you or your dependents are 65 or older, enrollment in Medicare Parts A and B is mandatory to maintain health benefits. Failing to enroll can result in losing coverage.

Misconception 4: The HI-22 form does not require any supporting documents.

Supporting documents are essential, especially for Medicare enrollment and dependent information. Ensure that all necessary documents are attached to avoid processing delays.

Misconception 5: You can choose any health plan regardless of your current enrollment.

While you can select a different plan, the effective date for any new plan will be the first of the month following your retirement date. It is crucial to understand the options available at that time.

Misconception 6: If you do not receive important information from Benefits Administration, it is not a concern.

It is vital to notify Benefits Administration of any address changes. Not receiving information can lead to misunderstandings and potential loss of benefits.

Key takeaways

Filling out the LAUSD HI-22 form can seem daunting, but understanding the key aspects can make the process smoother. Here are some essential takeaways to keep in mind:

Start Early: Complete the HI-22 form at least three months before your retirement date to ensure all benefits are in place.
Choose Your Plans: Select the medical, dental, and vision plans you wish to enroll in. Remember, the effective date will be the first of the month after your retirement date.
Eligibility Matters: To qualify for health benefits, you must resign and be eligible for retirement from CalSTRS or CalPERS on consecutive dates.
Document Dependents: Provide Social Security numbers for all dependents, as this information is mandatory for enrollment.
Medicare Enrollment: If you or your dependents are 65 or older, ensure you enroll in Medicare Parts A and B to maintain your health benefits.
Life Insurance Options: Upon retirement, you may convert your life insurance plans. Keep an eye out for conversion applications from MetLife.
Flexible Spending Accounts: If you retire before the end of the plan year, you have 90 days to submit claims for reimbursement for expenses incurred during employment.
Stay Informed: Notify Benefits Administration of any address changes to ensure you receive important information regarding your benefits.

By keeping these points in mind, you can navigate the HI-22 form with confidence and ease. Planning ahead will help ensure a smooth transition into retirement.