Free Lausd Hi 22 Form in PDF

Instructions on Writing Lausd Hi 22

Completing the Los Angeles Unified School District HI-22 Benefits Administration Application for Continuation of Health Benefits is a critical step for employees approaching retirement. This form ensures that you and your dependents maintain health coverage during this transition. It is advisable to fill out and submit this document at least three months before retiring. The process involves providing personal information, selecting health plans, detailing dependent information, and providing Medicare details if applicable. Careful attention to accuracy and completeness will facilitate a seamless transition to retirement benefits.

1. Start with the "Employee Information" section. Enter your Employee Number, Last Name, First Name, Middle Initial (M.I.), complete Address (including City, State, and Zip Code), Phone Number, Social Security Number, and Date of Birth. Indicate your gender by checking the appropriate box.
2. In the "Retirement Information" section, specify your retirement type by selecting either Service or Disability Retirement. Indicate your Retirement Date. For type, check either Classified or Certificated according to your position.
3. Select your desired health plans under "HEALTH PLANS." Choose your medical plan by checking the respective box next to the plan you want. If opting for dental and vision coverage, also select your preferences in these categories.
4. Fill out the "DEPENDENT INFORMATION" section. Provide the Social Security Number, Last Name, First Name, Middle Initial, Relationship, Date of Birth, and Sex for each dependent. Attach additional pages if more space is needed. For dependents between ages 19-25, contact Benefits Administration for eligibility requirements.
5. Complete the "MEDICARE INFORMATION" section if you or your spouse/domestic partner is 65 years of age or older. Include Medicare Claim Numbers and effective dates for Medicare Parts A and B as applicable. Attach a copy of the Medicare card(s).
6. Answer the question regarding your spouse/domestic partner’s employment status with LAUSD and provide their Employee Number if applicable.
7. Indicate your retirement system by selecting either the State Teachers Retirement System (STRS) or Public Employees Retirement System (PERS). Remember to forward the "Notice of Benefit Approval" from PERS or the "Award Letter" from STRS to Benefits Administration upon receipt.
8. Review the provided information for accuracy. The shaded boxes are for office use only and should not be filled.
9. Sign and date the form at the bottom to certify that all information provided is true to the best of your knowledge. You are also agreeing to the terms set forth in the Retirement with Health Benefits Eligibility Guidelines.
10. Ensure that you have attached all required documents before submitting the form to the Los Angeles Unified School District - Benefits Administration at the provided address or via email.

Upon completion and submission of the HI-22 form, it will be processed by the Benefits Administration. They will review your application and documentation to ensure you meet the eligibility criteria for continued health coverage after retirement. Once approved, you will receive a "Notice of Benefit Approval," which signifies that your health benefits as a retired employee are in place. Remember, it's crucial to update Benefits Administration with any changes in your information or your dependents' eligibility to avoid any disruption in your coverage.

What is the LAUSD HI-22 Form?

The LAUSD HI-22 Form is an Application for Continuation of Health Benefits by the Los Angeles Unified School District. It is designed for employees who are about to retire and wish to continue receiving health benefits through LAUSD. It must be completed at least three months before retirement.

Who needs to complete the HI-22 Form?

Any LAUSD employee approaching retirement who wishes to continue their health benefits into retirement needs to complete the form. This includes those planning for service or disability retirement.

What information do I need to provide on the HI-22 Form?

Applicants need to provide personal information, including their employee number, social security number, contact details, and health plan selection for medical, dental, and vision coverage. Retirement details, dependent information, and Medicare information, if applicable, are also required.

When should I submit the HI-22 Form?

The form should be submitted to the Benefits Administration at least three months prior to your retirement date to ensure a smooth transition of your health benefits.

How do I choose the right health plans on the HI-22 Form?

Review the health plans available and consider your and your dependents' healthcare needs. Plans vary by coverage and eligibility conditions, especially regarding age and Medicare enrollment. For more personalized advice, contact the Benefits Administration.

What if I have dependents?

For dependents' coverage, provide their social security numbers, names, relationships, and other requested details in the designated section. Contact Benefits Administration for eligibility requirements for dependents aged 19-25.

What about Medicare information?

If you or your dependent is 65 or older, enrollment in Medicare Parts A & B is mandatory. Proof of enrollment should be attached. This section must be completed to ensure your health coverage aligns with Medicare requirements.

Can I change my health plan selections after submitting the HI-22 Form?

Once retired, you may only change your health plan elections during annual enrollment periods or if you experience a qualifying life event. You are responsible for notifying the District of any eligibility changes.

What happens if I do not submit the HI-22 Form on time?

Failure to submit the form timely may disrupt your health benefits continuation. To avoid loss of coverage, ensure the form is submitted well in advance of your retirement date.

Filling out the Los Angeles Unified School District HI-22 Benefits Administration form necessitates a high level of attention to detail to ensure retirees can transition smoothly into their new status without any hitch in their health benefit coverage. A common mistake made is failing to submit the form at least three months before retirement, as recommended. This timing is crucial for the seamless processing of health benefits, ensuring no gaps in coverage occur during this significant life transition.

Another frequent error occurs in the selection of health plans, particularly when individuals do not carefully verify their eligibility based on age or Medicare enrollment before making their choices. For example, choosing the Anthem Medicare Preferred (PPO) Medical Plan without being enrolled in Medicare Parts A & B can lead to enrollment in an incorrect plan, causing unnecessary complications and possibly even lapses in coverage.

Additionally, retirees sometimes inaccurately report dependent information, especially the social security numbers, which are mandatory for all dependents listed in the application. Incorrect or incomplete dependent information can lead to delays in dependent coverage, impacting their access to necessary healthcare services.

A critical oversight in the application process is neglecting to attach a copy of the Medicare card for those 65 or older. This step is mandatory for the processing of the application, and forgetting to include this document can stall the entire process, resulting in delayed or denied health benefit coverage.

Often, applicants do not forward the "Notice of Benefit Approval" from their retirement system to the Benefits Administration, as instructed. This documentation is essential for confirming eligibility and finalizing the benefits process, and its absence can put the retiree's health benefits in a pending, uncertain status.

Misunderstanding the complex eligibility guidelines for retirement health benefits results in another common pitfall. The requirements vary significantly based on hire date and years of service, leading some to assume eligibility when they may not meet the specific criteria outlined for their circumstances. This misunderstanding can lead to unexpected outcomes in their benefit coverage.

A failure to sign and date the form is a simple yet significant error that renders the application unprocessed. The certification under penalty of perjury that the information provided is accurate and true is a legal requirement, and overlooking this step can void the entire application.

Not notifying the Benefits Administration of an address change is a mistake that can cause retirees to miss crucial information regarding their benefits. Communication is key in maintaining benefit coverage, and any changes in contact information need to be promptly shared with the administration.

Incorrectly assuming coverage for specific dental and vision plans without verifying eligibility and plan specifics can also be problematic. For example, choosing a dental or vision plan not compatible with the retiree's needs or failing to recognize that no coverage was selected can lead to unexpected out-of-pocket expenses.

Last, a considerable number of applicants do not thoroughly review the Retirement with Health Benefits Eligibility Guidelines before submitting their application. Understanding these guidelines is crucial for a correct and informed application process, ensuring that all selections made are valid and in line with the retiree's needs and eligibility.

When preparing for retirement from the Los Angeles Unified School District (LAUSD) and completing the HI-22 Application for Continuation of Health Benefits form, retirees may find they need to submit additional forms and documents. The necessity for these documents arises from various requirements laid out by LAUSD Benefits Administration and can range from demonstrating proof of age to confirming specific health plan eligibility. Understanding the purpose and requirement of these documents can simplify the process for retirees aiming to ensure a smooth transition into their retirement benefits. Below is a list of forms and documents commonly used alongside the LAusd HI-22 form, each briefly described to highlight its importance and relevance to the retiree's application.

• Copy of Medicare Card: Essential for retirees over the age of 65, this document proves enrollment in Medicare Parts A and B, which is a requirement for enrolling in certain health plans offered by LAUSD post-retirement.
• Notice of Benefit Approval (PERS) or Award Letter (STRS): These documents from the California Public Employees' Retirement System (PERS) or State Teachers Retirement System (STRS) verify the retiree's eligibility for pension benefits, an essential factor for continuing health benefits.
• Birth Certificate: Often requested to confirm the retiree's date of birth, an important factor for eligibility and plan selection, especially when considering age-based plans such as those requiring Medicare enrollment.
• Spouse/Domestic Partner's Medicare Card (if applicable): For retirees who wish to also enroll their spouse or domestic partner in their health plan, proving the spouse/domestic partner's enrollment in Medicare is necessary for those age 65 and older.
• Dependents' Birth Certificates or Legal Documents: Required for adding dependents to the retiree's health plan, demonstrating the relationship and, if relevant, the dependents' ages for coverage eligibility purposes.
• Proof of Previous Health Coverage: May be necessary if the retiree or their dependents are transitioning from an individual plan to one offered by LAUSD in retirement, to show continuous coverage.
• Change of Address Form: Important if the retiree moves during the transition to retirement, ensuring that all correspondence and necessary documentation reach them without delay.
• Proof of Power of Attorney or Legal Guardianship: Relevant for retirees or dependents who may have a legal guardian or have granted someone power of attorney, impacting decisions regarding health benefits.
• Death Certificate (for survivor benefits): Required for surviving spouses or dependents claiming benefits under the retiree's plan, demonstrating eligibility for continued coverage.
• Flexible Spending Account (FSA) Reimbursement Form: For retirees who participated in an FSA and have remaining balance eligible for reimbursement, provided the claims fall within the allowed submission period post-employment.

Collecting and submitting the proper documentation alongside the LAUSD HI-22 form is crucial for a seamless transition into retirement. It ensures that retirees and their dependents have access to their health benefits without interruption. By acquainting themselves with these documents, LAUSD employees can prepare more effectively for the retirement process, ensuring they meet all necessary criteria for their benefits continuation. Understanding each document's role can offer peace of mind during what is often a significant life change.

One similar document to the LAUSD HI-22 form is the Federal Employee Health Benefits (FEHB) Program application. Like the LAUSD form, the FEHB application allows retiring or retiring federal employees to choose their health plans for retirement, encompassing medical, dental, and vision options. Both documents guide retirees through selecting applicable health plans based on their age, retirement status, and Medicare eligibility, ensuring they understand their post-retirement benefits.

The COBRA Election Notice is another document bearing resemblance to the HI-22 form. It's provided to employees and their families when they experience a qualifying event that results in the loss of health coverage. Much like the HI-22, this document informs individuals of their right to choose continuation coverage, provides detailed instructions on how to elect for this coverage, and outlines the costs associated. Both documents are pivotal at transition points, ensuring continued health coverage.

An Employment Separation Form, provided to employees upon ending their service with a company, mirrors the HI-22 form’s purpose in the aspect of transitioning from active employment to retirement. These forms often include options or instructions for continuing benefits post-employment, a crucial step for those entering retirement, similar to the process detailed in the HI-22 for LAUSD employees choosing their retirement health benefits.

The Application for Enrollment in Medicare, while a federal document, is similar to the LAUSD HI-22 form as both involve the important step of transitioning to different health coverage plans at a critical life stage. The Medicare Enrollment Application is specifically necessary for individuals turning 65, guiding them through selecting Medicare Parts A and B, while the HI-22 form includes sections for retirees over 65 to provide their Medicare information, linking the documents in the realm of healthcare planning for retirement.

The CalPERS Health Benefits Application shares similarities with the LAUSD HI-22 form, as it is also aimed at individuals entering retirement. This application allows retirees from California public services to select or change their health plans. Both documents play crucial roles in ensuring retirees make informed decisions about their health coverage options, emphasizing the importance of understanding one's benefits.

The 401(k) Plan Distribution Request Form is akin to the HI-22 in guiding individuals through major financial and health decisions at retirement. Though it focuses on retirement savings distribution, it parallels the importance of the HI-22's role in selecting health benefits, underscoring retirement as a crucial period for arranging financial and health-related affairs.

The Benefits Claim Form, used for claiming benefits under existing health, dental, or vision plans, shares functionalities with the HI-22 form in the broader context of managing health benefits. While the HI-22 is specific to retirement election of health benefits, claim forms are essential for utilizing the chosen benefits, making them complementary components in the management of health coverage.

An Insurance Enrollment/Change Form that allows active employees to make changes to their insurance coverages due to life events (e.g., marriage, birth of a child) has similarities to the HI-22. Both forms facilitate the transition into different health coverage states, emphasizing the importance of aligning health benefits with current life stages and ensuring coverage meets the individual's or family's needs.

The Disability Retirement Application, specifically for public employees, also parallels the LAUSD HI-22 form. It caters to employees transitioning to retirement due to disability, detailing the process to maintain or elect new health benefits in light of their retirement status. Both documents guide employees through significant changes in their professional status and its impact on benefits, evidencing their critical transitional nature.

Lastly, the State Continuation Coverage Election Notice, similar to the COBRA notification but at a state level, can be likened to the HI-22 form. It informs employees of their right to elect continuation of health coverage upon experiencing qualifying events. Like the HI-22, this document ensures individuals are aware of their options for maintaining health benefits during periods of change, echoing the theme of transition and the importance of informed health benefit decisions.

When filling out the LAUSD HI-22 form, there are several important do's and don'ts you should keep in mind to ensure the process goes smoothly. Here is a list to guide you:

• Do start the application process at least 3 months before your retirement date. This timing is crucial for a seamless transition into your retirement benefits.
• Do carefully review all health plans available and choose the one that best fits your needs upon retirement, especially considering your age and Medicare enrollment status.
• Do ensure all your dependent information is correct and complete, including their Social Security numbers, which are mandatory for the application.
• Do attach a copy of your Medicare card if you or your spouse is 65 years or older, as this is mandatory.
• Don't neglect to sign and date the form. Unsigned forms will not be processed and can delay your benefits.
• Don't forget to forward a "Notice of Benefit Approval" from your retirement system to the Benefits Administration. Your retirement benefits will remain pending until they receive this document.

Following these guidelines can help ensure that your application for continuation of health benefits with the Los Angeles Unified School District is completed accurately and submitted timely. This careful attention to detail will help in avoiding delays or problems with your health benefit coverage as you transition into retirement.

Understanding the Los Angeles Unified School District (LAUSD) HI-22 Benefits Administration application form is crucial for employees nearing retirement. However, several misconceptions may lead to confusion or errors during the application process. This article aims to clarify these misunderstandings.

• Misconception 1: The form needs to be submitted only at the time of retirement.

  This misunderstanding could cause delays in benefits activation. In reality, the form should be completed at least three months before retiring to ensure a smooth transition of health benefits.

• Misconception 2: All retirees receive the same health plan options.

  Health plan eligibility varies significantly depending on whether the retiree and/or their dependents are under or over 65, and whether they are enrolled in Medicare Parts A & B. Options differ to cater to these variables.

• Misconception 3: Medicare information is optional.

  For retirees and dependents aged 65 and older, providing Medicare information is mandatory. Failure to do so can result in loss of coverage until the information is provided.

• Misconception 4: Dependent children are always covered regardless of age.

  LAUSD has specific eligibility requirements for dependent children, particularly those between ages 19-25. Benefits Administration must be contacted to verify eligibility.

• Misconception 5: You can choose any health plan at retirement, regardless of your current plan.

  The selection of a different plan at retirement is subject to eligibility and may have an effective date tied to your retirement date or the following month.

• Misconception 6: The HI-22 form is only for selecting health plans.

  Beyond health plans, retirees must indicate their life insurance choice and existing Flexible Spending Account (FSA) details if applicable. It's a comprehensive form covering various benefits aspects.

• Misconception 7: Submission of the HI-22 form guarantees the continuation of benefits.

  Eligibility for continued health benefits depends on satisfying several criteria, such as resigning to retire with eligibility for a retirement allowance and meeting specific service requirements. Simply submitting the form without meeting these criteria does not ensure benefits continuation.

Understanding these points can significantly streamline the process of applying for continuation of health benefits through the LAUSD HI-22 form. Employees are encouraged to read all instructions carefully and contact Benefits Administration with any questions to ensure a smooth transition to retirement.

Understanding the Los Angeles Unified School District's (LAUSD) HI-22 form is essential for employees as they prepare for retirement. This form is vital for ensuring that health benefits continue seamlessly into retirement. Here are key takeaways that employees should keep in mind:

• Early Preparation: Employees are encouraged to complete the HI-22 form at least 3 months before their retirement date. This allows ample time for processing and ensures that health benefits continue without interruption.
• Health Plan Selection: The form allows retirees to select their desired health plans for retirement. It is important to carefully review the options, which include different plans for those under and over 65 years old, taking into consideration Medicare eligibility.
• Dependent Information: Accurate dependent information is mandatory, including Social Security numbers for all dependents. This ensures that all eligible dependents are covered under the selected health plans.
• Medicare Requirements: For retirees and/or their dependents aged 65 or older, enrollment in Medicare Parts A & B is required. This is crucial for maintaining eligibility for certain health plans offered by LAUSD.
• Proof of Retirement Eligibility: Submission of a “Notice of Benefit Approval” from either CalSTRS or CalPERS is necessary. This document confirms the employee's retirement status and is a prerequisite for the continuation of health benefits.
• Understanding Eligibility Conditions: The form outlines specific conditions related to service years and retirement eligibility dates, including requirements for employees hired at different times. Meeting these conditions is crucial for the continuation of health benefits into retirement.
• Notification Responsibilities: Retirees are responsible for notifying the District of any changes in dependent eligibility and for ensuring premiums and claims are managed for ineligible dependents. Additionally, retirees must keep their address current with Benefits Administration to avoid missing important information.

Completing the HI-22 form is a critical step for LAUSD employees approaching retirement. Understanding the form’s requirements and deadlines helps ensure that retirees and their dependents enjoy uninterrupted health coverage during this new chapter of their lives.