Welcome!

Whether you are a new enrollee or currently going through our annual open enrollment held each fall, you now have the opportunity to enroll in benefits. Please understand the decisions you make now will remain in effect for the entire plan year unless you experience a qualifying life event A qualifying life event will allow

someone to change or enroll in coverage mid-year

Marsh, our plan administrator, must be notified within 30 days of the event date

Examples of Qualifying Life Events

Gaining or losing a dependent Marriage Divorce Birth / Adoption

Involuntary loss of other insurance coverage

HCTC eligibility coverage

Plan Year: 1.1.2012 – 12.31.2012

Overview

New for 2012!....................................................... 4 Eligibility……………………………………………. 7 Medical & Rx Benefits……………………………. 13 Health Savings Accounts………………………… 23 Medicare……………………………………………. 39 Dental Benefits……………………………………. 55 Vision Benefits…………………………………….. 57 Voluntary Life Benefits…………………………... 59 Enrollment............................................................ 61 Questions?............................................................. 70

New for 2012!

What’s Staying the Same?

Continued partnerships! Blue Cross Blue Shield of Michigan will continue to

administer the pre-65 medical/prescription as well as the dental benefits

The Hartford will continue to administer the post-65 medical/prescription benefits

Same great vision benefits through Superior Vision Partner with MetLife for voluntary life benefits

Continued DSRA-BT subsidy available for retirees who are not eligible for HCTC

Health Coverage Tax Credit (HCTC) for retirees who are age 55-64 & draw pension benefits from the PBGC

What’s New in 2012?

Two traditional PPO pre-65 medical/prescription plan options (GOLD, SILVER) along with a High Deductible Health Plan (BRONZE) which offers the opportunity to establish a Health Savings Account (HSA)

Decrease in the monthly premiums for the pre-65 medical plans Post-65 medical plan monthly premiums have a minimal

increase ($8/mo.)

Eligibility

Retirees

As a Delphi salaried and hourly retiree member, you are eligible for the medical/prescription, dental, and vision benefits unless you have previously terminated coverage

Salaried retiree members are also eligible for voluntary life insurance

For further details about coverage termination, please refer to the

“Eligibility” section in the

2012 Guide to Benefits

Spouse / Domestic Partner

As a Retiree, your legal spouse or domestic partner is also eligible for medical/prescription, dental, and vision benefits Spouse/domestic partner

must have the same medical/Rx coverage as the Retiree if both are enrolled and in the same age category: Under Age 65 Post-65

Surviving Spouse Surviving spouse is eligible

for medical/prescription, dental, and vision coverage

Former Spouse Marsh will send an

enrollment kit to the former spouse who is required to provide a statement from the PBGC confirming that he/she has become a pension recipient in their own right due to the divorce.

Child(ren)

Dependent children are eligible for medical/prescription, dental, and vision benefits Child(ren) can remain

on the coverage through the end of the calendar year during which they were no longer eligible i.e. March 29th birthday

can continue until December 31st

Child(ren) must have same medical/Rx coverage as the retiree

Definition of Dependent Child

A dependent child is defined as an unmarried child up to age 19 (or, if a full-time student, until the earlier of age 25 or student status ends)

Disabled Child

A disabled child is not subject to the age limitation but cannot be on Medicare (child must have been on coverage prior to becoming disabled if beyond maximum age limitations) A disabled child on Medicare must enroll

in the BCBSM Medicare Disabled COMP plan

For More Information

For further details including what happens upon termination of coverage, refer to the 2012 Guide to Benefits

Medical & Rx Benefits

Deductible A dollar value that you are responsible to pay for a covered medical expense before the coinsurance begins.

Understanding Terminology

Coinsurance Once you have satisfied your deductible, you will begin to pay coinsurance. In other words you will pay a % – such as 20% of the claim and the plan will pick up the rest – such as 80%.

Understanding terminology.

Out-of-Pocket Maximum The most you will be responsible for out-of-pocket for during the calendar year. This includes your deductible and coinsurance.

Copay A fixed fee paid for office visits and prescription drugs. For the BRONZE medical plan, copays only apply to prescriptions drugs after the deductible has been met.

Embedded v. Non-Embedded Deductibles

EMBEDDED NON-

EMBEDDED

GOLD SILVER BRONZE

Individual Deductible $250 $500 $2,000

Family Deductible

$250 per person (capped at $500)

$500 per person (capped at $1,000)

$4,000

If you cover dependents on this medical plan option, the entire family deductible of $4,000 must be met before benefit plan coverage takes effect – by any one or combination of family members.

If you cover dependents, under the GOLD or SILVER medical plans, when any one individual family member reaches the individual deductible in expenses, their benefit plan coverage takes effect.

Your Deductibles, cont’d

$ NON-EMBEDDED

Individual Family

Medical cov’d 100%

EMBEDDED

Medical cov’d 100%

Individual Family

$ $

Retirees Under Age 65 Blue Cross Blue Shield of Michigan

Your Rx Benefit, cont’d

$2,000 / $4,000

Medical $$$

Rx $$$

Medical cov’d 80% Rx copays $15 / $50 / $70

$1,000 / $2,000 2012 BRONZE PLAN

Retirees Post-65 Group Retiree Insurance Plan (GRIP)

IMPORTANT If you are a resident of

Kansas, Maryland, Montana, New York, or Oregon and will be a new enrollee with an effective date of 1/1/2012 and later, a unique plan is available to you

Further details will be

discussed on the next

slide

Retirees Post-65 Senior Medical Insurance Plan (SMIP)

IMPORTANT This plan is only

available for residents of Kansas, Maryland, Montana, New York, or Oregon

This applies to new enrollees only with effective dates of 1/1/2012 and later

For More Information

For further details about the medical plan options including rates, refer to the 2012 Guide to Benefits

Carrier plan summaries can also be found on our website – www.dsrabenefittrust.net

Health Savings Accounts NOTE: The following slides only apply to the BRONZE medical plan

Health Savings Accounts (HSA)

Bank account for eligible health care expenses

You may open a HSA at the bank of your choice!

Money is yours You own the account You name a beneficiary for the

funds You control when it’s spent You can change your

contributions throughout the year

Triple tax savings Tax credit for contributions to

the account Tax-free earnings Tax-free withdrawals for

qualified medical expenses, as per IRS cod 213(d)

What is a HSA? Benefits of HSAs

HSA Eligibility & Contributions

You must be enrolled in a qualified High Deductible Health Plan

The BRONZE medical plan is the only qualified plan

You cannot be enrolled in another health plan elsewhere: e.g.:

Spouse’s employer-sponsored non-qualified HDHP

Individual health plan

Medicare enrollment

Retiree military benefit plan (e.g. TRICARE)

Once you set up your HSA, you can begin making deposits into your account by check or cash Keep track of your contributions

so you can deduct them from your income tax return

The IRS maximums for 2012 are as follows:

Eligibility Contributions

HSA Distributions

As long as the money is used for an eligible expense, HSA funds are tax-free

If money used for non-eligible

expenses, a 20% penalty applies (unless you are over age 65), along with applicable taxes

Visit www.irs.gov to view a full list of eligible expenses!

HSA Distributions

MEDICAL

Out-of-pocket expenses (like deductibles, coinsurance)

Hospital, lab, and diagnostic services

Diabetic supplies

Chiropractic care

Prescription drugs

DENTAL

Artificial teeth

Dental treatment (like cleanings, fillings, extractions, orthodontics)

VISION

Contact lenses, eyeglasses, and reading glasses

Eye exams

Laser eye surgery

Health insurance premiums

Medigap premiums

Cosmetic surgery

Over-the-counter products for general health (e.g. vitamins, toothpaste, lotion)

Teeth whitening

Over-the-counter medications without a prescription

Eligible Expenses Ineligible Expenses

For a complete list of eligible expenses, visit www.irs.gov

Using Your HSA

Always present your

medical ID card Ensures you are getting the

in-network discounted rate

Expenses track toward your deductible

Pay for your services Use your HSA debit card

–OR– Pay out-of-pocket, allowing you to build

up the funds in your HSA

Member Name: John Doe Group #: 000000

Member ID #: 000000000000

Medical ID Card

Sample HSA Consumer Experience Doctor Service

1. Consumer visits doctor

2. Doctor submits claim to BCBSM

3. BCBSM applies benefits and notifies doctor of the amount the consumer is responsible for paying

5. Doctor sends bill to consumer

6. Consumer uses HSA funds to pay doctor

4. BCBSM sends consumer an Explanation of Benefits (EOB)

EOB

YOU

YOU HSA

Sample HSA Consumer Experience Pharmacy Service

1. Consumer visits pharmacy to fill a prescription

2. Pharmacy connects to BCBSM to determine consumer’s benefit

3. BCBSM determines consumer’s benefits “real-time” and passes

back to pharmacy the amount the consumer is responsible for paying

4. Pharmacy provides consumer with prescription and charges them the appropriate amount

5. Consumer uses HSA funds to pay pharmacy

YOU

YOU HSA

Setting Up Your HSA

In order to make HSA contributions, you must set up your account You may open a HSA at

the bank of your choice!

YOU are responsible for

setting up your own HSA

HSA Financial Institution

Fees Is there a set up fee?

Is there a monthly maintenance fee?

Distribution access Will I be issued a debit card or

checks?

Will I be able to access my funds via an ATM?

Interest rate Will my money gain interest over

time?

Investment options Can I invest my money?

Is there an account minimum?

What investment funds are available?

Online access Will I be able to access my funds

online?

Reporting What type of statements will I

receive? How often?

Contact your bank or financial institution to see if they offer HSAs

Stay educated.

Why do HSAs work?

Tax Savings

Triple tax savings opportunity through contributions to your HSA, investments made with HSA money, and using HSA money for qualified medical expenses

Consumerism

Become more engaged and buy health care like you might buy a TV, car, etc.

Tax Savings

TRIPLE Tax Savings

1. Contributions you make to your HSA are tax deductible

2. If you make investments with your HSA funds, any interest and investment earnings are tax-free

3. Qualified medical expenses paid for with your HSA funds are tax-free

Consumerism:

Shop Smart

Where do you buy your meds? Did you know that brand-name prescription drug prices vary at each pharmacy? Shop smart and research the prices for your prescription drugs before purchasing them.

If you can, switch to generic prescription drugs! Many retail pharmacies offer special prices for generics.

CVS Kroger Walgreen’s KMart

Lipitor (10mg 30-

day supply)

$73.59 $57.81 $11.92 $54.58

Consumerism:

Shop Smart

Retail Rx Options Here are a few merchants that have established low-cost prescription drug programs:

More than 300 generic prescription drugs at only $4 for a 30-day supply; select drugs at only $10 for a 90-day supply

Over 360 generic prescription drugs at only $4 for a 30-day supply; select drugs at only $10 for a 90-day supply

Over 500 generic prescription drugs at only $5 for a 30-day supply and $10 for a 90-day supply

Offers a FREE 14-day supply of selected generic antibiotics with a prescription and 5 leading brands of pre-natal vitamins for FREE

More than 300 generic prescription drugs for only $4 for a 30-day supply, or get a 90-day supply for only $10

Consumerism: Make Smart Decisions

Practice prevention – it pays off

Keep up-to-date on immunizations and

tests

Eat smart & exercise – the benefits of living well

Use the emergency room only for real emergencies

Save money by requesting generic drugs

Double-check bills from your doctor

For More Information

For basic information about Health Savings Accounts, refer to the 2012 Guide to Benefits

For further details, refer to the Health Savings Account FAQ which can be found on the DSRA-BT website

Medicare

What is Medicare?

Medicare Cost & Enrollment

Part A is free if you or your spouse have worked & paid Social Security taxes for at least 10 years

Part B has a monthly premium that is based on your incomes

Part C monthly premium is determined by the individual insurance carrier or HMO

Part D monthly premium is determined by the drug plan provider & the prescriptions you take

Two ways to enroll: 1. Automatic enrollment

happens whenever you sign up to receive Social Security income

2. Active enrollment occurs when you call Social Security to enroll or enroll online at www.socialsecurity.gov You can enroll during your Initial

Enrollment Period or Special Enrollment Period

Cost Enrollment

Regardless of when you enroll, Medicare is always effective on the

1st day of the month

Initial & Special Enrollment

Your initial Medicare effective date is the first day of the month of your 65th birthday. If you want Medicare to be effective when you turn 65, your Initial Enrollment Period is 7 months long and begins with the 3rd month BEFORE the month of your 65th birthday and lasts during the month OF your 65th birthday through the 3 months AFTER your 65th birthday

Once you lose active employee coverage, you have a protected right to enroll in Medicare, called a Special Enrollment Period

Your Special Enrollment Period begins at the end of active employment or the end of health plan coverage, whichever occurs first, and lasts for 8 months

But wait......

Initial Enrollment Special Enrollment

Special Enrollment Period, con’t.

Although you have an 8-month Special Enrollment Period to enroll in Medicare Parts A and B, you only have a 60 day Special Enrollment Period to enroll in a Part C (Medicare Advantage) plan, a Part D drug plan and purchase a Medicare supplement You must have at least Part A BEFORE

you can enroll in a Part D drug plan You must have both Parts A and B

BEFORE you can purchase a Medicare Advantage plan or buy a Medicare supplement

It is better to think of your Special Enrollment Period as 60 days

At Age 65: Initial & Special Enrollment

If you plan to retire or reduce your working hours so that you aren’t eligible for your employer’s group health plan, you can enroll in Medicare Parts A, B, C and D during your Initial Enrollment Period

If you delay past your Initial Enrollment Period, you may have to pay a penalty for that delay unless you qualify for a Special Enrollment Period, which is described next

Initial Enrollment Special Enrollment

If you enroll during the 3 months before your 65th birthday, your Medicare will be effective the first day of the month in which you turn 65. If you enroll during the month of your 65th birthday (or any of the next 3 months), your Medicare will be effective the first day of the next month.

After Age 65: Initial & Special Enrollment

If you (or your spouse) are still working and covered in an employer’s group health plan, due to active employment, you do not have to enroll in any part of Medicare until you lose that coverage

Once you lose active employee coverage, you have a protected right to enroll in Medicare

Your Special Enrollment Period begins at the end of active employment or the end of health plan coverage, whichever occurs first, and lasts for 8 months

Initial Enrollment Special Enrollment

Medicare will be effective the first day of the month after you enroll

Medicare Coverage Choices

Medicare Part D

Medicare Part D is prescription drug coverage Added in 2005 in order to address complaints that

prescription drug costs were not covered by Original Medicare

Once you are enrolled in any part of Medicare, you are required to have drug coverage

You can buy Part D drug coverage one of three ways: 1. Standalone 2. As part of a Medicare Advantage plan 3. As part of the DSRA-BT post-65 medical/prescription

plan

Medicare Part D, con’t.

To join a Medicare prescription drug plan, you must have Medicare Part A and/or Part B

To get prescription drug coverage through a Medicare Advantage Plan, you must have both Parts A and B

To get prescription drug coverage (with medical supplement coverage) through the DSRA-BT post-65 medical/prescription plan, you must have both Parts A and B

For more information about Medicare Part D, visit www.medicare.gov

Medicare Part D, con’t.

The cost of Medicare Part D plans are specific to the types of drugs you are taking Plan monthly premiums can range from

$15 to over $300

If your Part D drug coverage is with your Medicare Advantage plan, your cost is bundled into the cost of that plan

In addition to monthly premiums, plans can have a deductible, copays and co-insurance

The cost of your DSRA-BT post-65 medical/Rx plan includes prescription drug coverage as

well as medical supplement coverage

Medicare Supplement Policy

Medicare supplement policies pay for Medicare covered expenses and services that are not paid by Medicare, like deductibles and co-pays

Medicare Supplement Policy, con’t.

Both of the DSRA-BT Medicare options provide medical supplement coverage close to the standardized Plan D.

Medicare Advantage Plans

Medicare Advantage (Medicare Part C) plans are health plans that are approved by Medicare but run by private insurance carriers and HMOs

Many Medicare Advantage plans include prescription drugs (Part D)

When you join a Medicare Advantage plan, you are substituting the plan for

Original Medicare (Parts A and B and D, if the Medicare Advantage plan includes prescription drug coverage)

You must continue to pay your Medicare Part B premium in addition to any premium charged by the Medicare Advantage plan.

Medicare Advantage Plans, con’t.

In most cases, when you enroll in a Medicare Advantage plan, you must stay enrolled for that calendar year In certain situations, you may

be able to join, switch, or drop a Medicare Advantage Plan

There is a special Medicare Advantage Disenrollment Period that allows people to disenroll from a Medicare Advantage plan back to Original Medicare. January 1 through February

14 of each year

Note: If your doctor drops from your plan’s network, you can’t change plans until the next Open Enrollment. Open Enrollment begins October 15 and ends December 7 for a January 1 effective date.

For More Information

For further details about Medicare, refer to the 2012 Guide to Benefits

Check out other Medicare resources, such as www.medicare.gov or www.socialsecurity.gov

Dental Benefits

Dental

Vision Benefits

Vision

Voluntary Life Benefits

Voluntary Life

Delphi hourly retirees are not eligible for this voluntary benefit

Enrollment

2012 Open Enrollment: Enrollment Process

If you do not want to make any changes, no action is required

The new premium levels will go into effect January 1, 2012. (For rate information, refer to the 2012 Guide to Benefits. Rates can also be found on the benefit enrollment form.)

2012 Open Enrollment: Enrollment Process

Your current coverage will continue automatically next year as follows: Under Age 65 If you are currently enrolled in the GOLD plan, you will remain

enrolled in the GOLD plan for 2012 If you are currently enrolled in the SILVER OR BRONZE plan,

you will be enrolled in the comparable BRONZE plan for 2012

If you want to enroll in the new SILVER plan, you must complete a benefit enrollment form

Post-65 If you are currently enrolled in the PREMIUM plan, you will

remain enrolled in the PREMIUM plan for 2012

If you want to enroll in the new CHOICE plan, you must complete a benefit enrollment form

Enrollment Process

If you wish to make a change to your elections during our annual open enrollment period or due to a life qualifying event, please follow these simple steps…

Enrollment Process #1

Complete the benefit enrollment form

There are 5 variations: <65 & Not HCTC

Eligible <65 & HCTC Eligible <65 & Medicare Disabled Post-65 GRIP Post-65 SMIP

Enrollment Process #2

If you are newly

eligible for the HCTC, complete the IRS Form 13441-A Monthly Health Coverage Tax Credit (HCTC) Group Registration

If you are already

enrolled in the HCTC and want to change your benefit elections for 2012, complete the IRS Form 13704 Monthly HCTC Registration Update

Enrollment Process #3

Return your completed enrollment form and the first month’s premium payment (made payable to

DSRA Benefit Trust) to Marsh, our plan administrator:

Mail: Marsh, a service of Seabury & Smith PO Box 14464 Des Moines, IA 50306

Email: customerservice@marshpm.com

Overnight Mail:

Marsh, a service of Seabury & Smith ATTN: Application Processing 12421 Meredith Dr. Urbandale, IA 50398

Fax: (515) 365-1520

Billing

If you elect any of the benefit plans, you will be billed monthly by Marsh, our plan administrator.

Payments can be made via direct bill or electronic funds transfer (for non-HCTC insured only)

HCTC-insured members can pay their monthly invoice online to the HCTC Program To register and submit an electronic payment, go to

http://arcout.com/hctc

Members are highly encouraged to set up an automatic electronic-funds transfer to

make health premium payments

Premium Payments Received After the Due Date

If you do not pay your monthly premium by the 1st of the month* for which coverage is provided, you run the risk of your coverage being terminated

If premiums are not paid by the due date, coverage will be terminated as of the last day of the

preceding month

All benefits including medical, dental and prescription drug coverage will cease and no claims will be paid.

* NOTE: HCTC covered members need to meet the HCTC premium payment due date, which is usually 7-10 days before the 1st of the month.

Questions?

Questions?

If you have questions about the benefit plans or the enrollment process, please contact Marsh, our plan administrator

Download this contact sheet at

www.dsrabenefittrust.net

1-877-336-DSRA (3772)

Thank You!