CT TEACHERS’ RETIREMENT BOARD
165 CAPITOL AVENUE, HARTFORD, CT 06106-1659
Toll Free 1-800-504-1102 Fax (860) 622-2849
“An Affirmative Action/Equal Opportunity Employer”
HEALTH INSURANCE APPLICATION EFFECTIVE JANUARY 1, 2021
Mandatory Eligibility Requirements
• Participation in Medicare Part A and Medicare Part B
• A member collecting a retirement benefit or a disability allowance, or
• A spouse of a retired member, or
• A surviving spouse of a retired member who has not entered into another marriage, or
• A disabled dependent of a member collecting a retirement benefit or a disability allowance if there is no
spouse or surviving spouse.
• You must be a legal resident of the United States to participate in the TRB health plan.
Mandatory Filing Requirements
• Proof of participation in Medicare Part A and Medicare Part B (a copy of Medicare Card or a letter from
Social Security providing the Medicare I.D. Number and the effective dates for Medicare Part A and
Medicare Part B). Medicare ID Number required before enrollment is processed
• Copy of a marriage certificate or a marriage license from spouse if enrolling
• If the application includes coverage for a disabled dependent, a copy of the member’s most recent federal
income tax return documenting the disabled dependent’s status as the member’s dependent
• One form per enrollee must be received by the 25
of the 2
month preceding the effective date of coverage.
We will send an acknowledgement letter of the receipt of your application via email.
Cancelling Your TRB Coverage
• You may cancel all coverage at any time; however, you will not be able to reenroll for two years.
Important Information Regarding Our Plan
• Our health care coverage is offered as a package which includes Hospital, Medical, Major Medical,
Prescription Drug Benefits and Dental and Vision & Hearing.
• All plans are on a calendar year basis.
Some members may be required to pay an extra amount for Part B and Part D because of their yearly
income. This is known as the Income-Related Monthly Adjustment Amount (IRMAA) and it is paid
directly to the federal government not to the TRB. For more information on IRMAA you can visit the
Medicare website: or call Medicare at 800-633-4227.
• A spouse is not eligible for TRB coverage upon divorce or legal separation. In the event a former spouse is
participating in the TRB sponsored health insurance plan, the member must inform TRB and provide a copy
of the legal separation or dissolution of marriage as soon as possible.
• A surviving spouse is not eligible upon remarriage. Prompt notification is required.
• The TRB provides address changes to all of our health plan vendors. You must maintain your current
address with us at all times to ensure as little disruption as possible in the delivery of services and the
processing of claims.
• Post Retirement Reemployment (PRR) – If a member is reemployed as a public-school teacher following
their retirement, the member (and spouse or dependent) can elect to continue their TRB health plan
coverage while reemployed, but at no additional charge.
The detailed Plan Summaries are available on our website at www.ct.gov/trb.