SAG-AFTRA Health SPD

Network Providers

The Plan’s Provider Networks Offer Savings and Convenience

For medical and Hospital care, the Plan uses the Anthem Blue Cross Preferred Provider Organization (PPO) network, which includes the nationwide BlueCard PPO network. Physicians and facilities within The Industry Health Network (TIHN), operated by UCLA Health, are also In-network Providers under the Plan. Beacon Health Options provides the network for mental health and substance abuse care. Additionally, Express Scripts, Delta Dental and VSP provide the networks for pharmacy, dental and vision care respectively.

The Plan’s Hospital Benefit Is Limited to Care From In-network Hospitals Only

This means you must seek medical care from Hospitals in the BlueCard PPO or TIHN networks to receive coverage. No coverage will be provided for services provided by out-of-network Hospitals and facilities under any circumstances, except for emergencies. Similarly, inpatient and alternative levels of care for mental health and substance abuse services are limited to facilities within the Beacon Health Options network, except for emergencies.

For outpatient services covered under the medical benefits, the Plan pays different levels of benefits for services from In-network and Out-of-network Providers. As such, you minimize out-of-pocket costs by using Providers within the Plan’s networks.

When you choose In-network Providers, in addition to receiving a higher level of benefits, you will also avoid surprises like “balance billing” for amounts over the Allowable Charge. Balance billing occurs when a Provider bills you for an amount above the Plan’s Allowance. While In-network Providers are contractually prohibited from balance billing you, the practice is common when you receive care from Out-of-network Providers. Some states have protections for patients against such surprise billing by Out-of-network Providers, but you can avoid balance billing by using In-network Providers. Choosing In-network Providers saves money for you and the Plan, which benefits all Participants.

In-network Providers also offer the convenience of completing and submitting Claims for you. All you must do is verify that the Provider is in the network prior to each visit and show your health care ID card when you arrive for your appointment. The Provider will also usually collect your Copay at this time.

After the Claim is processed, the Plan’s payment will be made directly to the Provider. You will receive a notification from the Plan that the payment has been made, which is called an Explanation of Benefits (EOB). EOBs are not bills. They simply provide information to help you understand how your Claims are processed.

Remember that just because you obtain care from an In-network Provider, it does not mean all services are automatically covered. If you have questions regarding coverage for a particular procedure, treatment, diagnostic test or medical supply item, contact the Plan at (800) 777-4013.

In addition to the BlueCard PPO and TIHN networks for Hospital and medical care, the Plan also uses other networks of preferred Providers for different benefits, as described below. Providers in all of these networks are credentialed and carefully monitored to ensure that they continue to meet high professional standards and that they provide appropriate care.

Important Note:
The Providers in these networks can change on an ongoing basis. New Providers are added and
sometimes other Providers drop out. Some Providers offer services at more than one location and not all locations may be in-network. Also, not all Providers within a facility or practice may participate in the network. It is your responsibility to make sure that the Provider you are using is in the network at the location where you receive services at the time you receive care.

If you need Hospital or medical services and the nearest two BlueCard PPO Providers of any type are more than 25 miles from where you live, you are considered to be outside a network area; as such, you will receive the Plan’s In-network Level of Benefits for these services even when obtained from Out-of-network Providers. However, if you travel to an in-network area, you must use In-network Providers to obtain the higher level of benefits. These same rules apply if you need mental health or substance abuse treatment and live more than 25 miles from two facilities or Providers of any type who participate in the Beacon Health Options network.

If an individual who lives in an in-network area is being treated for a serious condition that requires a specialist’s care, and there are no in-network specialists in his or her area, the individual will receive the In-network Level of Benefits for services rendered by that specialist. Conditions such as cancer, cardiac disease, eating disorders and schizophrenia are considered serious conditions under this provision. It does not include situations of a non-serious nature, such as those requiring chiropractic services, acupuncture services or treatment for generalized anxiety disorder. The preference for a Provider who will be present during a home birth also does not qualify as a serious condition. In order for you to receive the In-network Level of Benefits for home births, the Provider must be an In-network Provider.

You are responsible for the lower in-network Deductibles, Copays and Coinsurance – plus the difference between the Plan’s Allowance and the billed amount. For Out-of-network Providers, the Plan’s Allowance will be used to determine the amount the Plan will consider in determining the benefits payable, instead of the lower in-network contracted amount which is used for In-network Providers. While Plan staff will do its best to answer any questions you have concerning the Plan’s Allowance over the phone, you may not rely on any information obtained in that manner. Only information in writing signed on behalf of the Board of Trustees can be considered  official.

Plan Ahead to Avoid Surprises When Using Out-of-network Providers

Seeking care outside of the Plan’s networks can be costly since Out-of-network Providers may charge whatever they wish for services. However, if you choose to use Out-of-network Providers, the FAIR Health website offers helpful information and planning tools. The FAIR Health site estimates your potential medical expenses based on actual Provider charges in your local area. 

www.fairhealthconsumer.org

FAIR Health is a national independent, not-for-profit corporation whose database of medical and dental services powers a free website for consumers. You can use this tool to get a real-world cost estimate that you can use to gain an informed understanding of how much you might need to pay in out-of-network costs for specific treatments and procedures.

It is important to note, however, that some Out-of-network Providers charge far more than the FAIR Health amount. It is important to ask your Provider how much he or she will charge for a service or procedure before services are rendered.

Also note that the FAIR Health site does not take into account the Plan’s benefits, limitations or exclusions. Therefore, you must treat the information as an estimate only.

The Industry Health Network (TIHN)

The Plan has also contracted with The Industry Health Network (TIHN), UCLA’s network of area Hospitals, specialists and primary care Physicians centered around UCLA/Motion Picture & Television Fund (MPTF) Health Centers. It is available to all Participants and covered Dependents, although its Health Centers are located only in Southern California. Its network of Physicians and outpatient Health Centers offers the least expensive option for quality care because when you use a TIHN primary care Physician (PCP), the Plan’s annual Deductible does not apply. Also, if you use TIHN facilities for non-emergency care, you will have a lower annual Hospital Deductible. Please note that TIHN facilities do not provide emergency care.

To take advantage of these benefits, make an appointment with a PCP at one of the UCLA/MPTF Health Centers. The PCP will coordinate your care and, if necessary, will refer you to a specialist in TIHN. Without the PCP’s referral, TIHN level of benefits will not apply. This means you will have higher Deductibles. You must see the PCP in person to receive a referral to a specialist; you cannot just call the PCP.

In order to receive services through UCLA/MPTF Health Centers you must be at least 13 years of age. For children under 13, you may obtain a TIHN referral to a pediatrician by calling TIHN customer service at (800) 876-8320.

To establish a relationship with a PCP, please contact one of the conveniently located Health Centers and make an appointment.

  • Bob Hope Health Center
    335 North La Brea Avenue
    Los Angeles, CA 90036
    (323) 634-3850
  • Jack H. Skirball Health Center
    MPTF Wasserman Campus
    23388 Mulholland Drive
    Woodland Hills, CA 91364
    (818) 876-1050
  • Santa Clarita Health Center
    25751 McBean Parkway, #210
    Valencia, CA 91355
    (661) 284-3100
  • Simi Valley Health Center
    2655 First Street, #360
    Simi Valley, CA 93065
    (805) 583-7640
  • Toluca Lake Health Center
    4323 Riverside Drive
    Burbank, CA 91505
    (818) 556-2700
  • Westside Health Center
    1950 Sawtelle Boulevard, #130
    Los Angeles, CA 90025
    (310) 996-9355