Criterios Específicos.

A benefit recipient’s premium will be based upon his or her residence and accessibility to a man- aged care plan. Premiums are deducted from the annuitant’s monthly annuity received at the end of the month of coverage. If the annuity is not sufficient to cover the premiums, the benefit recipient will receive a direct pay statement that requires monthly payments.

Employers may pay a portion or all of an annuitant’s share of the premium for participating in TRIP. TRS will accept the annuitant’s premium cost for each designated benefit recipient from the employer. In addition, the employer may also elect to pay premiums for a benefit recipi- ent’s dependents. The employer is responsible for notifying TRS of any coverage changes. If an employer makes premium payments for annuitants or dependents who have changed their TRIP coverage, CMS may refund a maximum of six months of prior payments.

The retiring member receives a TRIP enrollment form with the initial Retirement Application form. The enrollment form contains a section where the employer agrees to pay monthly premi- ums. The retiring member is responsible for contacting the employer to obtain the authorization. If the employer agrees to pay the monthly premium, the district representative must sign the enrollment form and identify the employer name and number.

If the school district offers a supplemental health insurance plan in addition to the TRIP plan,

please ask the member to include the information on the TRIP application under Section 6–Other

group health coverage.

The first time TRS receives a signed enrollment form, the employer will be sent a Health Insurance Premium Payment Agreement to be completed and returned to TRS. This authorizes TRS to bill the district monthly for the TRIP premium.

SAMPLE

Chapter 10 - Page 6 - Post-Retirement Matters

Teachers' Retirement Insurance Program (TRIP)

1. TRS member information. Be sure to check "yes" or "no" for deferred coverage. If enrolling based on retirement, you may delay the effective date of coverage up to four months after the effective date of your benefits. If you check "yes," indicate the month and year you wish the effective date of coverage to begin.

John Doe 123 Main St. Anytown, IL 12345

Social Security number: 123-45-6789

County of residence: Any County

Home telephone number: (123) 456-7890

Gender: Male

Date of birth: 01/02/1933

Email Address

Effective date of retirement

Marital status

 M  S  CU

Deferred coverage

 Yes  No

Effective date of deferred coverage

2. Complete this section ONLY if enrolling your spouse or civil union partner and/or qualifying dependents. As legal proof of your

relationship, you must enclose a copy of your valid marriage certificate for a dependent spouse or a civil union certificate for a dependent civil union partner and/or a birth certificate for a dependent child. The certificates are required for insurance coverage. Indicate the relationship of the dependents you wish to enroll in the insurance program. Enter your dependent's date of birth as a two-digit month, a two-digit day, and a four-digit year (Example: 02/09/1900). Indicate whether each dependent is covered by Medicare by selecting "Y" for yes or "N" for no.

Last name First name Relationship (xx/xx/xxxx) Date of birth Social Security number (Y) Yes Medicare (N) No

3. If you or your dependents are 65 or older, are you eligible for Medicare Part A and Part B?

 Yes. Please complete Section 4. No. Please attach a copy of written verification from the Social Security

Administration stating that you are not eligible for both Part A and Part B.

4. Complete this section for yourself and/or your spouse/civil union partner/qualifying dependents if eligible for Medicare.

Information may be found on your Medicare card. Please attach a copy of the Medicare card for each person. If you are Medicare

eligible and a copy of your Medicare card is not attached, this will cause a delay in the processing of your enrollment form.

Covered person's name Part A effective date Part B effective date Medicare number

5. Type of desired coverage – Member, spouse, civil union partner, and/or dependents must select the same coverage. Check the appropriate plan coverage desired. If you select Managed Care, provide the Managed Care Plan name and code and also complete the

primary care physician's name and provider number for each person. To acquire the provider number, please contact the HMO that

you are considering for enrollment.

Desired coverage – Check one: Medical Indemnity - TCHP (please go to Section 6)

Managed Care (please complete section below)

Provide Managed Care Plan name and code:

Medical Group # (3 digits) (Required for HMO Illinois and BlueAdvantage HMO only)

Covered person's name Physician Provider number

21004002 04/2012

SAMPLE

Member Name: John Doe Social Security number: 123-45-6789

6. Other group health coverage. If you, or any of your dependents who are covered under any State of Illinois health plan, are covered

under any other health plan(s), you must provide this information to ensure health claims are correctly processed (examples include non- state group health plans, and Medicaid).

You must complete Section A below. If you have other insurance, you must also complete Section B and provide a copy of the insurance identification card from the other coverage.

Section A - List coverage that will be effective during the same time as TRIP. Do not include Medicare or policies that will be

cancelled when TRIP coverage is effective.

 I and/or my dependent do not have other group health insurance coverage.

 I and/or my dependent do have other group health insurance coverage (you must complete Section B indicating the other coverage). You must list each insurance company separately. Please make copies if additional space is needed.

Section B – Only applies to members or dependents enrolling in TRIP.

Insurance company's name: Policy holder's name:

Identification number: Group Number:

Effective date:

Covered persons: Relationship:

Insurance company's name: Policy holder's name:

Identification number: Group Number:

Effective date:

Covered persons: Relationship:

7. Authorized signature

I hereby apply for the Teachers' Retirement Insurance Program (TRIP). All information furnished by me on this application is true and complete to the best of my knowledge. I authorize the Teachers' Retirement System to deduct the cost of this coverage from my annuity. I agree to abide by all rules and to furnish any additional information requested. It is my responsibility to ensure that accurate information is maintained and kept updated regarding my other health insurance. If other coverage is added or terminated for any individuals covered under my Teachers' Retirement Insurance Program, I must notify TRS immediately.

My signature below confirms that I understand all the options selected and authorize the release of information to the health plan I select and the State of Illinois. This authorization will remain in effect until further written notice.

Signature (member or legal representative) Date

8. School district authorization for paying premium. If the school district is paying your portion of the monthly premium or your

portion and your dependent's premium, the district representative must complete the appropriate information and sign the appropriate line. The district representative must also identify the district name and TRS code.

Are you paying for (select one):  Member  Member and spouseor civil union partner  Member and all dependents

Will you pay (select one):  Managed Care  Non-Accessible medical indemnity  Accessible medical indemnity

Will you pay rate increases?  Yes  No

If one of the above boxes is not selected, please indicate a specified dollar amount or percentage rate:

Monthly dollar amount Percentage rate of total premiums

Effective date of paying premium (required entry) Termination date of paying premium (required entry)

District name and TRS code District representative's signature Date

Remember, if you have dependents, you must enclose a copy of your valid marriage certificate for a dependent spouse or a civil union

certificate for a dependent civil union partner and/or a birth certificate for a dependent childas legal proof of your relationship. The

certificates are required for insurance coverage.

Complete and mail to:

Teachers' Retirement System of the State of Illinois 2815 West Washington

P. O. Box 19253 Springfield, IL 62794-9253

Chapter 11 - Page 1 - Retirement Benefits