*HBA2TA* Rev 6/2021
Unit F (Teacher Assistants)
Benefits Opt-Out Cash Back Attestation Form
a. I understand that I have been offered the opportunity to enroll myself and my eligible dependents in
LAUSD sponsored medical plan(s) and that the medical plan(s) are considered to be minimum essential
coverage (MEC) in accordance with the Affordable Care Act (Health Reform).
b. I understand that without medical plan coverage I (and my dependents, if any) could have a financial
penalty applied when my/our personal income taxes are filed with the Internal Revenue Service (IRS).
I understand I can learn more about the financial penalty, called the Individual Mandate penalty, at this
government website: https://www.healthcare.gov/fees-exemptions/fee-for-not-being-covered/.
c. I understand that without an IRS-approved mid-year life change event (a Special Enrollment event), if
I decline coverage now, I will not be permitted the opportunity to enroll myself or my eligible
dependents in my employer’s medical plan option(s) again until my employer’s next annual open
enrollment time (if I am benefits-eligible at that time).
d. I understand that there is additional compensation of $1,000 per plan year provided to me if I decline
all medical, dental, and vision coverages. I understand that I am only able to receive this additional
compensation for declining coverage if I, and all members of my expected tax family (tax family
refers to dependents on the employee’s tax return), have or will have other minimum essential
coverage through another employer’s group medical plan, Medicare, Medicaid, Tricare, VA or Indian
Health Services (IHS) medical plan coverage for the 2021-2022 plan year.
I also understand that I am not eligible to receive this compensation if I or any member of my
expected tax family is enrolled in individual market coverage, whether obtained through Covered
California, another Marketplace established under Health Reform, or outside of the Marketplaces
established under Health Reform.
I also understand that LAUSD will not make any payment to me if LAUSD knows or has reason to
know that I or any member of my expected tax family (tax family refers to dependents on the
employee’s tax return), does not have or will not have the required alternative coverage.
I agree to notify LAUSD promptly if I or any member of my expected tax family (tax family refers
to dependents on the employee’s tax return), loses this alternative coverage, and I understand that
compensation payments will be stopped at that time.
I also understand that I will be required to attest to this alternative coverage each plan year that I
decline coverage under LAUSD’s group medical plan.
My signature below means that I have read and understand the above statements.
Print Name: _________________________________________ Employee #: _________________
Signed: ____________________________________________ Date: ________________, 20____
Please keep a copy of this form for your records and return it (fax or email preferred) to:
Fax: (213) 241-4247
Email: benefits@lausd.net
Los Angeles Unified School District - Benefits Administration
P.O. Box 513307
Los Angeles, CA 90051-1307
Phone: (213) 241-4262
Website: http://benefits.lausd.net
