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”
www.ct.gov/trb
I elect to have the following coverage become effective _________________ / 01 / 20 ______.
Plan selection
Cost per person
per month
Check One
Anthem Medicare Advantage (PPO) Plan
with Vision & Hearing, Dental and Prescriptions
$125.00
Anthem Medicare Supplement
with Vision & Hearing, Dental and Prescriptions
$228.00
Enrollee Information:
Last Name:
First Name:
M.I.
Home Phone:
Gender
Male
Female
City:
State:
Zip Code:
Social Security Number:
Date of Birth:
Email Address:
Enrollee’s Signature:
Date:
If enrollee is the spouse or the disabled dependent of a retired teacher, please have the retiree complete below:
Retired Teacher’s Name
Retired Teacher’s Social Security #
Retired Teacher’s Signature
Date:
Please attach proof of Medicare Part A and B and copy of marriage certificate (if enrollee is spouse) and submit to:
CT Teachers’ Retirement Board
165 CAPITOL AVENUE
Hartford, CT 06106-1659
You may also Fax to (860) 622 2849 or email to healthinsurance.trb@ct.gov
NOTE: All correspondence will be sent through email unless otherwise specified
0 5 0 0 6
HI_INSAPP_210226
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”
www.ct.gov/trb
www
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 members dependent
One form per enrollee must be received by the 25
th
of the 2
nd
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.
http://www.medicare.gov
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.