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pre-65 insurance information and plans

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2022 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, provided to the right, 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 Plan Administrator. Benistar handles 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.  

2022 Pre-65 Plan Information

PRE65 ENROLLMENT FORMS

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”.  If the Reconciliation Bill is passed with the current language suggesting a permanent 80% tax credit, the 20% 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. 

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.

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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 an 80% Subsidy for the health insurance premiums for Retirees and TAA-ATAA workers that meet the requirements established by Congress.  

The Health Coverage Tax Credit (HCTC) has been put in the Reconciliation Bill and if passed by Congress it would be made PERMANENT. (October 2021).  The Section 137508 states:  Permanent Credit for Health Insurance Costs.  This Section would make the health coverage tax credit permanent, removing the uncertainty of annual extensions, and increase the amount of the qualified health insurance premium covered by the credit from 72.5% to 80%.

 

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 on a permanent basis. Once enrolled, the enrollee pays 20% 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 80% 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 

 
 
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Gold Plan
monthly rates

Single              $    304.45

Family              $    904.63

3(+) People 

bundled
rates
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Silver plan
monthly rates

Single              $    270.71

Family              $    803.43

3(+) People 

bundled
rates
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bronze plan
monthly rates

Single              $    215.22

Family              $   636.96 

3(+) People 

bundled
rates
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copper plan

Open enrollment Form

Copper Plan

monthly rates

Single              $    176.83

Family              $    521.80

3(+) People 

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

MEMBER PAYS MONTHLY

IF the HCTC is made PERMANENT through the Reconciliation Bill to be voted on by year end.

bundled
rates
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

MONTHLY RATES FOR UNDER 65  - ALTERNATE COVERAGE OPTIONS

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HCTC NON-AMP / Under Age 65

You may elect different coverage pairings if you are not electing the AMP payment option.  Please see charts below for pairings with High Dental coverage and Low Dental coverage. 

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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.  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.

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

medicare disabled 
 
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hardship grants

Hardship Grants - Please review 2020 Guide to Benefits 

2022 Hardship Grant Information
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 

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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.

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)

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

pre-65 DENTAL ONLY monthly rates 
 
VISION PLANS
vision
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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 2021, 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 2022.

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.

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vision benefits
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dental & vision
dental & vision
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DENTAL

BCBSM  through BCBSM

www.bcbsm.com

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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!

 

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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today

Contact Benistar DSRA Benefit Trust

Customer Service/Call Center

1-888-588-6682