pre-65 insurance information and plans

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2020 plan information

The DSRA BT offers Health, Dental, and Vision insurance for Salaried and Hourly retirees of Delphi. Life insurance (Term Plan) is also offered for Salaried retirees. Review the information below for plan coverages available, premium rates, co-pays, annual deductibles, and coinsurance responsibility each of which impact your total out of pocket medical services cost. Eligibility qualification and enrollment is administered for all coverages offered by the Trust through Benistar, our new Plan Administrator. Benistar will handle all pre-65 and post 65 plans for medical, dental, vision and life coverage. BCBS of Michigan will remain the insurance carrier for all pre-65 medical plans and no matter the age, for all dental and vision coverage.  

2020 Pre-65 Plan Information

eligible for benefits

Retiree

As a Delphi salaried or hourly retiree member, you are eligible for the medical/prescription, dental, and vision benefits. Salaried retiree members are also eligible for voluntary term life insurance. Each benefit is outlined within this benefit guide.

Dependents

Spouse

As a Retiree, your legal spouse is also eligible for medical/prescription, dental, and vision benefits. Spouse only life coverage is NOT available. Spouse is not required to have the same medical/prescription coverage as the Retiree if both are individually enrolled in Pre-65 medical/ prescription drug policies.

Surviving Spouse

A surviving spouse is eligible for medical/prescription, dental, and vision coverage.  

Former Spouse

Benistar Admin Services (Benistar), our plan administrator, will send an enrollment kit to the former spouse who is required to provide a statement from the Pension Benefit & Guaranty Corporation (PBGC) confirming that he/she has become a pension recipient in their own right due to the divorce. A former spouse is not eligible for voluntary term life insurance coverage.

Child(ren)

Dependent children are eligible for medical/prescription, dental, and vision benefits. The dependent child can remain on the coverage until they are no longer eligible to be claimed as a dependent on the eligile retirees federal income tax return. A disabled child loses eligibility for DSRA-BT subsidies once retiree becomes 67.

Child(ren) are not required to have the same medical/prescription coverage as Retiree and/or spouse if both are enrolled in Pre-65 medical/prescription drug plans.

A disabled child on Medicare must enroll in the BCBSM Pre-65 Medicare Disabled plan. Child(ren) may have dental and/or vision with or without Retiree coverage.

Qualified Family Members

A Qualified Family Member (QFM) is also eligible to elect medical/prescription, dental, and vision benefits. A QFM is defined as a spouse and/or dependent child(ren) of an HCTC-eligible Retiree, who is claimed on the individual’s federal income tax return.

NOTE: The HCTC is only available to a QFM for 24 months after the retiree reaches age 65.

what is the

WHAT IS HCTC?

The Health Coverage Tax Credit (HCTC) was established by Congress as part of the 2002 Trade Act and is a federal program authorized to pay a 72.5% Subsidy for the health insurance premiums for Retirees and TAA-ATAA workers that meet the requirements established by Congress.

 

The HCTC was established to help cover the cost of health care for:

⇒  Workers who lost their jobs due to foreign trade

⇒  Retirees whose pensions have been trusteed/turned over to the Pension Benefit Guaranty Corporation (PBGC)

In February of 2009, with the passage by Congress, of the American Recovery and Reinvestment Act (ARRA), Retirees of bankrupt companies were allowed to immediately establish Insurance programs providing access to healthcare, for workers that had lost or had their healthcare benefits greatly reduced, in the bankruptcy process .  The formation of these vehicles to provide access to healthcare are called a Voluntary Employee Benefit Associations (VEBA’s ).  The immediate access to the contact information of a company allowed the workers the ability to make the former employees aware of the group healthcare options available to them that included a subsidy to help offset the cost of their healthcare insurance.

HCTC INSURANCE 

For pre-65 retirees, dependents and surviving spouses, BCBS of Michigan provides the Trust with four health care plans, at the Gold, Silver, Bronze and the Copper level. The Bronze and Copper plans are our (HDHP) high deductible health plan offering and are eligible to work in conjunction with your Health Savings Account (HSA).  The Gold plan is a bundled plan that includes dental and vision coverage.
The HCTC Advance Monthly Payment (AMP) process will continue to be available through the IRS for 2020. Once enrolled, the enrollee pays 27.5% of the premium to the IRS each month. The IRS will then pay 100% of the premium to BCBSM. If you are enrolling in the HCTC AMP, all four of the plan options available to you ie…Gold/Silver/Bronze and Copper, will all be automatically bundled with Dental and Vision coverage. Unbundling dental and vision is not an option. The total premium for these bundled plans is eligible for the AMP at the 72.5% subsidy level.
- Gold Plan - Summary of Benefits & Coverage's
- Silver Plan - Summary of Benefits & Coverage's
- Bronze Plan - Summary of Benefits & Coverage's
- Copper Plan - Summary of Benefits & Coverage's
- BCBSM Med Disabled Plan Coverage - Summary of Benefits & Coverage's

4 PLAN OPTIONS

IS YOUR INFORMATION UP TO DATE?

PLEASE MAKE SURE ALL OF YOUR INFORMATION IS UP TO DATE! 

CONTACT INFORMATION

BENEFICIARY INFORMATION

ADDRESS CHANGES

ELECTRONIC FUNDS TRANSFER FORM 

 
 
HCTC amp pre-65 eligible plan rates
Gold Plan
monthly rates

Single              $    398.62

Two-Person     $    941.13 Family              $ 1,194.49

3(+) People 

bundled
rates
Silver plan
monthly rates

Single              $    337.64

Two-Person     $    794.69 

Family              $ 1,011.54

3(+) People 

bundled
rates
bronze plan
monthly rates

Single              $    263.62

Two-Person     $   617.04 

Family              $   789.47 

3(+) People 

bundled
rates
copper plan
monthly rates

Single              $    230.47

Two-Person     $    537.50

Family              $    690.04

3(+) People 

bundled
rates
HCTC pre-65 eligible
plan rates
amp - Advanced monthly pay 
hctc pre-65 Rates
bundled
rates

2020 GROSS PRICE

2020  PRICE WITH 72.5% HCTC SUBSIDY

HSA (bronze and copper plans only)

Health Savings Account

A Health Savings Account, commonly known as an “HSA,” is an individual account you can open, add money to, and spend on eligible health care expenses. An HSA is unique because you’ll receive a tax credit for any money you add to the account, investment earnings are not taxed, money spent on eligible expenses is not taxed, and the money rolls over year to year.

Eligibility

In order to open an HSA, you must be covered by health insurance that meets the definition of a High Deductible Health Plan (HDHP). The DSRA-BT BRONZE and COPPER medical plans are the only plans that meet these requirements.  

Setting Up Your HSA

Once you are covered by an HDHP you may set up your HSA. It is important to get your HSA set up as quickly as possible since you can’t turn in expenses that you had before the account was set up. It is your responsibility to open your HSA and you choose where. Many banks and credit unions now offer HSAs.

Adding Money

Once you set up your HSA, you can begin making deposits into your account by check or cash. Keep track of your contributions so that you can deduct them from your income tax return. The government sets the annual dollar maximum that can be made to an HSA depending on the level of coverage you have under your health insurance. Coverage of two or more people is considered family coverage. People who are age 55 or older can make additional catch-up contributions.

 
eligible retirees under 65

For other plan options and pricing, please review the 2020 Premium Sheet Document below or the 2020 Benefit Guide.

 
eligible retirees under 65 dsra - bt subsidy
(not eligible for hctc)

DSRA-BT Subsidy

One subsidy is available per family with the exception of dual Delphi retiree households who carry separate policies. When a subsidy is available, it is automatically applied by Benistar, our pre-65 plan administrator.

 

Eligibility for a Trust subsidy is generally defined as being a Delphi Salaried Retiree (including spouse and eligible dependents) who retired on or before April 1, 2009. The DSRA-BT will continue to provide a health premium subsidy to eligible pre-65 salaried retirees, spouses and dependents who purchase medical insurance from the Trust in 2020. If the HCTC program is not extended, all eligible retirees must submit a new enrollment form to request to receive the DSRA-BT subsidy. *Available to QFMs of a retiree who is age 67 or 68 only. 

Special Circumstance subsidies are available to those members who are family members of a Medicare disabled retiree who is <65 and has been on Medicare for more than two years. The family member(s) will be eligible for the Special Circumstance subsidy until the retiree turns 67 or they turn 65, whichever comes first. If they are still under 65 when the retiree turns 67 they will be eligible for the QFM subsidy for 24 months.

There are pre-65 salaried retirees that retired before 4-2-09 that have not initiated their PBGC pension payout. This makes them ineligible for the Trust subsidy. We cannot approve a subsidy for these retirees.

Under Age 65 QFM - The provision in the HCTC law limiting eligibility to 24 months for the pre-65 spouse/dependents of a post-65 retiree remains in effect. The DSRA-BT is again offering an additional maximum of 24 months subsidy paid from the DSRA Benefit Trust funds to eligible QFM’s of retirees that are either age 65, 66, 67 or 68 (24 months in a 4 year time period).

• Eligibility for this subsidy ends in all cases the first of the month the retiree achieves age 69.

• To receive this subsidy, you must be a QFM of a salaried retiree retired by April 1, 2009;

• You must submit a new enrollment form to our pre-65 medical plan administrator Benistar to qualify for this subsidy. If you are currently receiving a QFM subsidy, you do not need to submit a new enrollment form unless you are changing plans.

• Please submit 30 days prior to eligibility date. No retroactive subsidies will be allowed.

• One subsidy is available per family with the exception of dual Delphi retiree households who carry separate policies.

*Available to QFM's of a retiree who is age 67 or 68 only

medicare disabled 
 
hardship grants

Hardship Grants - Please review 2020 Guide to Benefits 

dental plans
 

We understand the importance of good dental health. Good oral hygiene is important to your overall health. Regular visits to the dentist can help detect problems like gingivitis and even oral cancer. Plan on visiting your dentist once every six months. DSRA-BT offers dental coverage through Blue Cross Blue Shield of Michigan (BCBSM). The dental plan provides a wide 

dental - 2 plan options

variety of covered services – either covered in full or partially by the plan. Members will continue to have the choice to enroll in dental and/or vision which requires an application to be completed.

BCBS of Michigan provides the Trust with dental insurance for pre 65 retirees, their dependents and surviving spouses.  If you are in a BCBS of Michigan Bundled Plan, your coverage is automatically the "High" dental plan.  Dental insurance may also be purchased separately.  As of May 1st 2020, there are two dental plans available to you and your dependent(s).  There is a "High" or a "Low" coverage plan option from which you can choose.

low dental plan

high dental plan

Deductible - $50 per member/ $150 for a family   (applies to class II and III services only)

Annual Maximum - $3,000 per member   (applies to class I, II and III services only)

* Differences in Class coverage's for the Low Dental Plan and the High Dental Plan

pre-65 DENTAL ONLY monthly rates 
 
VISION PLANS
vision

Click here for plan coverage details or for Summary of Benefits and Premiums.

Vision- For both pre and post-65 retirees, their dependents and surviving spouses, again for 2020, BCBS of Michigan provides the Trust with vision coverage for exams, frames and lenses.  Vision insurance may be purchased separately.   All Summaries state Effective Date as of 1/1/2016. They continue to be effective for 2020.

Your eyes are your windows to wellness. Routine eye exams each year allows your eye doctor to detect symptoms of serious eye disease – such as cataracts, glaucoma, and macular degeneration – and health conditions – such as diabetes, cardiovascular disease, and high blood pressure. Caught early, many of these diseases are treatable. However, left undetected and untreated, these conditions can result in vision loss, a lower quality of life, and higher overall health care costs. DSRA-BT will continue to offer vision benefits through Blue Cross Blue Shield of Michigan (BCBSM). The vision plan offers you comprehensive coverage – including eye exams and materials – through VSP, the nation’s largest vision care network, with 27,000 doctors and 41,000 locations. Members will continue to have the choice to enroll in vision and/or dental which requires an application to be completed. The table below provides an overview of the vision plan benefit. For specific details about the plan, please refer to the Summary of Benefits.  To find a VSP doctor, call 1-800- 877-7195 or log on to the VSP website at www.vsp.com.

vision benefits
dental & vision
bundled rates
dental & vision

DENTAL

BCBSM  through BCBSM

www.bcbsm.com

VISION

Vision Service Plan (VSP)

www.vsp.com

Contact Benistar to Enroll Today!

1-888-588-6682

IMPORTANT UPDATES ON THE

RE-AUTHORIZATION OF THE HCTC

ACTION REQUIRED BY ALL PARTICIPANTS!

 

FREQUENTLY ASKED QUESTIONS—HCTC Updated 03/23/20

 

The Board of the DSRA-BT has already received many questions regarding the HCTC. If you don't see an answer to your question, please send an e-mail to Benistar: 

     Email:  memelig@Benistar.com

DSRA Benefit Trust HCTC FAQ

2020 open enrollment

FAQ #1:  Will I have to submit a new 13441-A enrollment form for 2020?

ANSWER: Yes, the IRS is requiring a new 13441-A enrollment form for all HCTC AMP participants for 2020 due to the temporary termination of the HCTC program at the end of 2019.  The 13441-A form should be submitted to Benistar Retiree Services 6-8 weeks before enrollment into the HCTC program. 

FAQ #2:  Do I need to submit a new 13441-A form if I am changing my level of     

               coverage in 2020? 

ANSWER:  Yes, you must complete and submit an updated 13441-A form with the new plan level premium amount if you are changing your plan level.  The update form should be sent to the Benistar Retiree Service Center 6-8 weeks prior to the change in coverage level.

FAQ #3: If I am enrolled in the DSRA-BT BCBSM medical plans but not the AMP

              (Advance Monthly Payment Program) for December 2019, and want to

              enroll in the AMP for the first time effective January 2020, what do I need

              to do?

ANSWER:

  1. Review the 13441-A Sample forms available on this website.  A sample form is available at the following link to help guide you (use New AMP Enrollees file): https://www.dsrabenefittrust.net/dsrabene/index.php/document-center/Health-Coverage-Tax-Credit-(HCTC)/Sample-Documents/

  2. Print a blank 13441-A form available at https://www.irs.gov/pub/irs-pdf/f13441a.pdf

  3. Using the Sample form, complete the 13441-A enrollment form

  4. Locate and make a copy of your Proof of Eligibility (i.e.- PBGC Payment Notice Letter, PBGC payment check stub, Bank Statement with your name and PBGC payment made into your account)

  5. Print and complete the DSRA Enrollment form available at www.DSRABenefitTrust.net

  6. Mail, fax or email the signed and completed 13441-A form, the signed and completed DSRA Enrollment form along with your Proof of Eligibility to the Benistar Retiree Service Center, 10 Tower Lane, Suite 100, Avon CT 06001,

     (Fax) 1-860-408-7025, (Email) memelig@Benistar.com

The IRS/HCTC may take up to 8 weeks to process your enrollment forms.  As soon as you receive the “Enrolled Letter” from the IRS, call the Benistar Retiree Service Center  1-888-588-6682 and provide them with your Participant Identification Number (PIN).  You must continue to pay 100% of the BCBSM premium to Benistar until you have received the “Enrolled Letter”.  The 27.5% payment for the BCBSM premiums are due by the 10th of each month to the IRS.  Print out IRS form #13973 and mail with your payment.  If you miss the HCTC AMP premium payment deadline or if you have already paid the 100% BCBSM premium payment to Benistar for the month, you will begin the HCTC AMP 27.5% payment process the following month.

FAQ #4If I am not an enrollee in the DSRA-BT medical plans for December 2019,

  and I want to enroll in a HCTC AMP DSRA-BT medical/dental/vision 

  bundled plan from BCBSM for 2020, what do I need to do?

ANSWER:

  1. Review the 13441-A Sample forms available on this website.  A sample form is available at the following link to help guide you (use New AMP Enrollees file): https://www.dsrabenefittrust.net/dsrabene/index.php/document-center/Health-Coverage-Tax-Credit-(HCTC)/Sample-Documents/

  2. Print a blank 13441-A form available at https://www.irs.gov/pub/irs-pdf/f13441a.pdf

  3. Using the Sample form, complete the 13441-A enrollment form

  4. Locate and make a copy of your Proof of Eligibility (i.e.- PBGC Payment Notice Letter, PBGC payment check stub, Bank Statement with your name and PBGC payment made into your account)

  5. Print and complete the DSRA Enrollment form available at www.DSRABenefitTrust.net

  6. Mail, fax or email the signed and completed 13441-A form, the signed and completed DSRA Enrollment form along with your Proof of Eligibility to the Benistar Retiree Service Center, 10 Tower Lane, Suite 100, Avon CT 06001, (Fax) 1-860-408-7025, (Email) memelig@Benistar.com

The IRS/HCTC may take up to 8 weeks to process your enrollment forms.  As soon as you receive the “Enrolled Letter” from the IRS, call the Benistar Retiree Service Center 1-888-588-6682 and provide them with your Participant Identification Number (PIN).    You must continue to pay 100% of the BCBSM premium to Benistar until you have received the “Enrolled Letter”.  The 27.5% payment for the BCBSM premiums are due by the 10th of each month to the IRS.  Print out IRS form #13973 and mail with your premium payment. 

subsidies

FAQ #1: Why is the DSRA-BT subsidy limited to those salaried retirees who retired

              on or before April 1, 2009?

ANSWER: The Trust Agreement approved during the Delphi bankruptcy clearly stipulates that the limited funds paid to the Trust by Delphi were specifically for the benefit of those retired and receiving their pension as of April 1, 2009. Please see the Trust agreement posted at the DSRA BT website

FAQ #2:  Are the DSRA BT subsidy guidelines changing for 2020?

ANSWER: Yes, the guidelines for who is eligible for a DSRA BT subsidy were expanded to include HCTC eligible participants for January and February of 2020 to accommodate the delay in reauthorization of the HCTC program.  The DSRA BT guidelines from March 2020 through the end of the year then reverted back to the 2019 guidelines.  See the 2020 Subsidy section of the Guide for more details.

FAQ #3: I am the retiree from Delphi and I am over 65 but my spouse is under 65. 

       Do they qualify for the HCTC?  If they don’t, is a subsidy offered to help

offset their premium cost?

ANSWER: Your spouse is eligible for the HCTC until you reach age 67 if they are under 65.  At age 67, when HCTC eligibility ends, the pre-65 spouse will be eligible for a DSRA-BT QFM subsidy for 24 months (if you are a salaried retiree and retired on or before April 1, 2009) until the retiree reaches the age of 69 or the spouse reaches age 65, whichever comes first. The DSRA-BT does not offer a subsidy for the QFM once the retiree reaches age 69.  To receive this DSRA-BT subsidy, a new enrollment form must be submitted to Benistar requesting the subsidy.  This is required, even from current enrollees.

FAQ #4I retired before April 2, 2009 but have delayed drawing my PBGC

pension.  Do I qualify for a subsidy since I am not eligible for the HCTC?

ANSWER: No, you must have started drawing your PBGC pension prior to April 2, 2009 to be eligible for a subsidy.

general questions

FAQ #1When does the HCTC expire?

ANSWER: The reauthorized HCTC is set to expire 12-31-2020.

FAQ #2Is Dental and Vision insurance eligible for the HCTC?

ANSWER: Yes, they are eligible if you also have bundled medical coverage from BCBSM.  In fact, if you are in the HCTC AMP you are required to have dental & vision. If you have stand-alone dental and vision, the HCTC does not cover their premium cost.

FAQ #3:  If I'm still working, can I sign up for health care and the HCTC when I retire

 and not wait for the next open enrollment window?

ANSWER: YES. Retirement (involuntary loss of other insurance coverage) is a "Qualifying Event" and as a result makes you eligible to change your medical coverage without waiting for the annual open enrollment window.

FAQ #4Do I have to enroll in the HCTC AMP to get the HCTC?

ANSWER: NO, you can purchase a Non-HCTC plan from the Trust and recoup the HCTC on your tax return through IRS form 8885. Or you can buy an HCTC eligible plan from another carrier and recoup the HCTC on your tax return. If you plan to use the tax return method to recoup the HCTC, you do not have to buy a bundled plan. In this situation, you have the flexibility to decide if you want to bundle dental and or vision coverage.

hctc eligibility

FAQ #1Who qualifies for the HCTC?

ANSWER: You qualify for the HCTC if you receive your pension from the PBGC, you are 55-64 years of age and you are not receiving coverage through Medicare. There are other ways to meet the eligibility requirements for the HCTC. They can be found at the IRS website. We suggest that you bookmark the following link from the IRS and review periodically for any new updates: https://www.irs.gov/Credits-&-Deductions/Individuals/HCTC.

FAQ #2Are all four medical plans offered by the DSRA-BT, through BCBSM,

eligible for the HCTC?

ANSWER: YES, all pre-65 medical plans offered by the VEBA in Non-Medicare situations are HCTC eligible.

FAQ #3If I buy my healthcare through the government health insurance

marketplace (Obamacare), do I qualify for the HCTC?

ANSWER: No, the plans in Obamacare are not eligible.

FAQ #4Will the HCTC apply to those over 65?

ANSWER: The HCTC does not apply to individuals that are 65 or older, or on Medicare.

FAQ #5What happens to our eligibility for the HCTC if we win our pension battle?

ANSWER: We clearly want to maintain HCTC eligibility when we win the pension battle.  All of our current scenarios take this into account according to our legal team.  Maintaining the HCTC is a priority.

FAQ #6If I'm not eligible for the QFM subsidy, can my spouse change their

medical plan when they lose the HCTC?

ANSWER: Yes, loss of the HCTC is considered a “Qualifying Life Event” (QLE).  As such, you are eligible to downgrade your plan (i.e. from Gold to Copper) if you wish.  We also asked the IRS if the government would consider it a QLE so a person could enroll in an ACA plan in the Marketplace mid-year.  Their response was that it would make sense that the loss of the majority of funding would be a qualifying event.  That said, the IRS would not give us an answer, and instead indicated that the member would need to contact the Marketplace in the state where they are purchasing a policy and get an individual determination.

FAQ #7I am a Surviving Spouse of a retiree whose pension is administered by the

PBGC. Am I eligible for the HCTC?

ANSWER: If your retired spouse had the surviving spouse (SS) option as a part of his/her pension, once you initiate the SS option and become the pensioner of record with the PBGC and start receiving benefits, you are now eligible for the HCTC for as long as the HCTC is in effect. You must purchase qualified medical insurance and be age 55-64. In this situation, the QFM guidelines and limitations do not apply.

FAQ #8What happens to coverage in the event of a change in marital status

(spouse)?

 ANSWER: An acquired spouse may be added to your coverage upon marriage. A former spouse is eligible if he or she provides a statement from the PBGC confirming that he/she has become a pension recipient in his or her own right due to the divorce (under a QDRO). A former spouse is not eligible for coverage in the medical, dental or vision plans unless eligible for PBGC pension, except for a former spouse who is a QFM within 24 months of divorce. A former spouse is NOT eligible for voluntary term life insurance.

FAQ #9 I am divorced from a Delphi retiree and as part of the divorce decree I am

receiving a portion of their PBGC pension.  Do I qualify for the HCTC?

ANSWER: Yes, if you meet the eligibility requirements of the HCTC program; being between the ages of 55-64, drawing a pension check from the PBGC and enrolled in a qualified insurance plan, you qualify for the HCTC. You are considered a PBGC pensioner, just like your ex-spouse, so long as the HCTC is in effect, you can take advantage of this benefit. The qualified family member limitations do not apply any longer.  The PBGC uploads eligibility records monthly but depending on when you are identified as a pensioner, your Social Security Number (SSN) may come up as ineligible. To help avoid any issues, we strongly encourage attaching a letter of eligibility (from PBGC) or a 1099-R (showing pension distribution) so if your SSN does show up as ineligible, it can be overridden.

FAQ #10Is COBRA coverage thru GM or Delphi eligible coverage for the HCTC

  subsidy? What about from other auto employers that purchased Delphi operations?

    ANSWER: YES, if you pay more than 50% of the cost of your COBRA insurance, and meet the eligibility requirements of the HCTC program, you qualify for the HCTC.  However,  these plans are not eligible for the HCTC AMP program.  You must file form 8885 on your tax return the following year to recoup the 72.5% of premiums paid.

FAQ #11If I have COBRA coverage from any previous employer, can I sign up for a

   DSRA-BT plan when this expires, even if it’s mid-year?

    ANSWER: Yes, expiration of COBRA coverage would be considered a “Qualifying Life Event”.

FAQ #12Can my spouse go on one of your plans and utilize the HCTC while I stay

   on COBRA?

    ANSWER: YES, spouses have the ability to enroll in the HCTC program and qualified     

    insurance plan as an individual without the retiree enrolling. 

FAQ #13Must you be drawing your pension from the PBGC to receive the HCTC?

    ANSWER: YES, you must be drawing your PBGC pension to qualify.

FAQ #14If I retire mid-year, is the HCTC retroactive back to the first of the year?

   ANSWER: No, the HCTC will be available effective the 1st day of the month you start   

  drawing your pension from the PBGC.

FAQ #15: We have Delphi Hughes retirees in California that chose to take their

  Delphi/GM pension over a fixed period of 5 or 10 years. They were also   

  promised health insurance until age 65. Will they continue to be eligible

  for the HCTC until age 65 once their pension has been paid to them in

  full by the PBGC?

  ANSWER: Current interpretation is that once you no longer receive a PBGC pension, you are

  no longer eligible for the HCTC.  However, these people will be eligible for a DSRA-BT   

  subsidy if they satisfy the following conditions:

  1. Delphi Salaried retiree

  2. Retirement date previous to 4-2-2009

  3. Be the Age of 55 to 64

  4. Provide proof of lump sum distribution or agreement between both parties to a defined time period of pension payments.

FAQ #16 I am a Delphi salaried retiree who is Medicare Disabled and under 65. 

   Does my under 65 spouse qualify for the HCTC or a DSRA-BT subsidy?

   ANSWER:  Your spouse qualifies for the HCTC until you have been on Medicare for 24

   months.  At that point, they qualify for a DSRA-BT Special Circumstance subsidy if you

   retired on or before April 1, 2009 and they are still under 65.

Sample 13441-A Forms for various situations can be found at the following link: https://www.dsrabenefittrust.net/dsrabene/index.php/document-center/Health-Coverage-Tax-Credit-(HCTC)/Sample-Documents/

Refer to the Questions and Answers (https://www.irs.gov/individuals/hctc-health-plans-q-and-a) on the IRS website for further guidance on the types of health insurance coverage that qualify for the HCTC in 2020.

 

Sample 13441-A Forms for various situations can be found below:

Refer to the Questions and Answers (https://www.irs.gov/individuals/hctc-health-plans-q-and-a) on the IRS website for further guidance on the types of health insurance coverage that qualify for the HCTC in 2020.

Medical Plan Footnotes

1 All covered services are subject to deductible, except preventive care services.

2 Calendar year deductible runs from 1.1 to 12.31.

3 Out-of-network deductible amounts also apply toward the in-network deductible.

4 Your deductible combines the deductible amounts paid under your medical coverage and your prescription drug coverage. 5 The full family deductible must be met under a two-person or family contract before benefits are paid for any person.

6 Coinsurance kicks in once the calendar-year deductible has been met.

7 For private duty nursing, your coinsurance % is 50%, in-network and out-of-network.

8 Annual coinsurance dollar maximum applies to coinsurance amounts for all covered services – including mental health and substance abuse services. For the GOLD and SILVER medical plans, it does not apply to fixed dollar copays and private duty nursing coinsurance amounts. For the BRONZE and COPPER medical plans, your coinsurance dollar maximum combines coinsurance and copay amounts paid under your Simply Blue HSA medical coverage and your Simply Blue prescription drug coverage.

9 Hearing care coverage includes: audiometric exam (once every 36 months), hearing aid evaluation (once every 36 months), ordering and fitting the hearing aid (once every 36 months), and hearing aid conformity test (once every 36 months). Refer to the BCBSM Summary of Benefits for additional details.

10 For mental health and substance abuse treatment, refer to the BCBSM Summary of Benefits for additional details including limits on the number of visits.

11 Specified human organ transplants and bone marrow transplants are allowed in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program – (800) 242-3504.

12 Specified human organ transplants are limited to $1 million lifetime maximum per member per transplant type for transplant procedure(s) and related professional, hospital and pharmacy service.

13 The 20% prescription drug out-of-network copay will not be applied toward your calendar year deductible, out-of-pocket maximum or lifetime maximum.

14 BCBSM custom formulary. A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the formulary is to provide members with the greatest therapeutic value at the lowest possible cost. Tier 1 (generic) – Tier 1 includes generic drugs made with the same active ingredients, available in the same strengths and dosage forms, and administered in the same way as equivalent brand-name drugs. They also require the lowest copay, making them the most cost-effective option for the treatment. Tier 2 (formulary brand) – Tier 2 includes brand-name drugs from the Custom Formulary. Formulary options are also safe and effective, but require a higher copay. Tier 3 (nonformulary brand) – Tier 3 contains brand-name drugs not included in the Custom Formulary. Members pay the highest copay for these drugs.

15 Mandatory preauthorization. A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring preauthorization) will be covered. Step Therapy, an initial step in the “Prior Authorization” process, applies criteria to select drugs to determine if a less costly prescription drug may be used for the same drug therapy. Some over-the-counter medications may be covered under step therapy guidelines. This also applies to mail order drugs. Only claims that do not meet Step Therapy criteria require preauthorization. Details about which drugs require preauthorization or step therapy are available online site at bcbsm.com. Log in under “I am a Member” and click on “Prescription Drugs.”

16 Mandatory maximum allowable Cost (MAC) drugs. If your prescription is filled by any type of network pharmacy, and the pharmacist fills it with a generic equivalent drug, you pay only the copay. If you obtain a formulary brand name drug when a generic equivalent drug is available, you MUST pay the difference in cost between the formulary brand name drug dispensed and the maximum allowable cost for the generic drug plus your copay regardless of whether you or your doctor requests the formulary brand name drug. If you obtain a nonformulary brand-name drug when a generic equivalent is available, the nonformulary brand-name drug is not a covered benefit. Exception: If your physician requests and receives authorization for a nonformulary brand-name drug with a generic equivalent from BCBSM and writes “Dispense as Written” or “DAW” on the prescription order, you pay only your applicable copay

17 Physician-administered injectable drugs. Injectable drugs administered by a health care professional (not self-administered) are not covered under the pharmacy benefit, but may be covered under your medical benefit.

18 Drug interchange and generic copay waiver. Certain drugs may not be covered for a second prescription if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver

19 Quantity limits. Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com.

20 No more than $100.

21 Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, and any other tests or preventive measures determined to be appropriate by the attending physician.

22 If any of the cancer screening tests are not covered by Medicare, the plan will pay the usual and customary charges incurred.

23 Semi-private room and board, general nursing, and miscellaneous services and supplies

24 A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

25 In or out of the hospital and out-patient hospital treatment, such as physician’s services, in-patient and out-patient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment.

26 Blood deductible applies to hospital confinement and out-patient medical expenses, when furnished by a hospital or skilled nursing facility during a covered stay.

27 Semi-private room and board, skilled nursing and rehabilitative services and other services and supplies.

28 You must meet Medicare requirements, including having been in a hospital for at least three consecutive days and having entered a Medicare-approved facility within 30 days of discharge from the hospital.

29 Supportive services needed for care and pain relief for terminally ill patients provided by a Medicare-participating hospice program when the patient elects this type of care.

30 BCBSM custom formulary. A continually updated list of FDA-approved medications that represent each therapeutic class. The drugs on the list are chosen by the BCBSM Pharmacy and Therapeutics Committee for their effectiveness, safety, uniqueness and cost efficiency. The goal of the formulary is to provide members with the greatest therapeutic value at the lowest possible cost. Tier 1 (generic) – Tier 1 includes generic drugs made with the same active ingredients, available in the same strengths and dosage forms, and administered in the same way as equivalent brand-name drugs. They also require the lowest copay, making them the most cost-effective option for the treatment. Tier 2 (formulary brand) – Tier 2 includes brand-name drugs from the Custom Formulary. Formulary options are also safe and effective, but require a higher copay. Tier 3 (nonformulary brand) – Tier 3 contains brand-name drugs not included in the Custom Formulary. Members pay the highest copay for these drugs.

31 Mandatory preauthorization. A process that requires a physician to obtain approval from BCBSM before select prescription drugs (drugs identified by BCBSM as requiring preauthorization) will be covered. Step Therapy, an initial step in the “Prior Authorization” process, applies criteria to select drugs to determine if a less costly prescription drug may be used for the same drug therapy. Some over-the-counter medications may be covered under step therapy guidelines. This also applies to mail order drugs. Only claims that do not meet Step Therapy criteria require preauthorization. Details about which drugs require preauthorization or step therapy are available online site at bcbsm.com. Log in under “I am a Member” and click on “Prescription Drugs.”

32 Mandatory maximum allowable Cost (MAC) drugs. If your prescription is filled by any type of network pharmacy, and the pharmacist fills it with a generic equivalent drug, you pay only the copay. If you obtain a formulary brand name drug when a generic equivalent drug is available, you MUST pay the difference in cost between the formulary brand name drug dispensed and the maximum allowable cost for the generic drug plus your copay regardless of whether you or your doctor requests the formulary brand name drug. If you obtain a nonformulary brand-name drug when a generic equivalent is available, the nonformulary brand-name drug is not a covered benefit. Exception: If your physician requests and receives authorization for a nonformulary brand-name drug with a generic equivalent from BCBSM and writes “Dispense as Written” or “DAW” on the prescription order, you pay only your applicable copay

33 Physician-administered injectable drugs. Injectable drugs administered by a health care professional (not self-administered) are not covered under the pharmacy benefit, but may be covered under your medical benefit.

34 Drug interchange and generic copay waiver. Certain drugs may not be covered for a second prescription if a suitable alternate drug is identified by BCBSM, unless the prescribing physician demonstrates that the drug is medically necessary. A list of drugs that may require authorization is available at bcbsm.com. If your physician rewrites your prescription for the recommended generic or OTC alternate drug, you will only have to pay a generic copay. If your physician rewrites your prescription for the recommended brand-name alternate drug, you will have to pay a brand-name copay. In select cases BCBSM may waive the initial copay after your prescription has been rewritten. BCBSM will notify you if you are eligible for a waiver

35 Quantity limits. Select drugs may have limitations related to quantity and doses allowed per prescription unless the prescribing physician obtains preauthorization from BCBSM. A list of these drugs is available at bcbsm.com.

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Contact Benistar DSRA Benefit Trust

Customer Service/Call Center

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DSRA Benefit Trust website  - 2020

Benistar DSRA Benefit Trust Customer Service/Call Center

1-888-588-6682