SAG-AFTRA Health SPD

Health Plan Glossary

Age and Service – A type of Earned Eligibility available under certain Collective Bargaining Agreements based upon meeting a minimum earnings requirement, provided the Participant meets a minimum age requirement and has a minimum number of Age and Service Credits. Participants with Age and Service eligibility qualify for Plan II coverage.

Age and Service Credit – A credit toward Age and Service eligibility under the Plan which is established through obtaining a certain amount of Covered Earnings under certain Collective Bargaining Agreements during a Participant’s Base Earnings Period. 

Allowable Charges/Allowed Amount/Allowance – The maximum amount the Plan will allow for a covered service. In the case of charges billed by an In-network Provider (except for in-network chiropractic care), the Plan’s Allowance will be equal to the Contract Rate. In the case of charges billed by an Out-ofnetwork Provider (or an in-network chiropractor), the Plan’s Allowance is determined in the sole discretion of the Board of Trustees and is established based on the area in which the charges are incurred. The Plan’s Allowance is updated periodically. The Plan’s Allowance is not based on the amount billed by the Provider and will never be more than the incurred charges.

Alternative Days – A type of Earned Eligibility available under certain Collective Bargaining Agreements based upon obtaining a minimum number of Eligibility Days during a Participant’s Base Earnings Period. Participants with Alternative Days eligibility qualify for Plan II coverage. 

Base Earnings Period – The period spanning four consecutive Calendar Quarters during which the Participant satisfies the Plan’s eligibility requirements. The Participant must continue to meet the annual eligibility requirements in each consecutive Base Earnings Period to remain qualified for coverage. Benefit Period – The 12-month period during which the Participant is eligible for Plan coverage. Benefits Manager – Your personal online account for managing your benefits online. Registration is required.

Calendar Quarter – Any one of four three-month periods throughout the calendar year which are defined as follows: January 1 – March 31; April 1– June 30; July 1 – September 30; and October 1 – December 31. The Plan uses Calendar Quarters to determine initial and continued qualification for coverage.

Case Management – A program in which a care coordinator works with the patient, his or her Physician, the patient’s family, and the Plan to meet the patient’s comprehensive health needs using available resources in the event of catastrophic or chronic sickness or injury.

Claim – A request for a benefit made in accordance with the Plan’s Claims procedures.

COBRA Continuation Coverage – Continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986 (and subsequent amendments), or COBRA Continuation Coverage, is a temporary extension of coverage under the Plan. It
can become available when a Participant loses Earned Eligibility or when a Dependent no longer meets the Plan’s definition of a Dependent. A premium is required for COBRA Continuation Coverage and the premium amount is determined in accordance with federal law.

Coinsurance – The percentage of Covered Expenses that you must pay, in addition to the Deductible and any Copay. For example, if the Plan pays 90% of Covered Expenses from an In-network Provider, the 10% of Covered Expenses you have to pay is your Coinsurance.

Collective Bargaining Agreement (CBA) – The agreement or agreements between SAG-AFTRA and Contributing Employers that govern Covered Employment, including the requirement for Contributing Employers to make contributions to the Plan.

Concurrent Care Claim – A Claim that involves an approved, ongoing course of treatment for a specific period of time or a specific number of treatments. 

Contract Rate – The amount an In-network Provider must accept as the total charge for a covered service. In-network Providers cannot bill you for Covered Expenses in excess of the Contract Rate.

Contributing Employer – Any employer who is required and permitted under the Trust Agreement to contribute to the Plan under the terms of a Collective Bargaining Agreement with SAG-AFTRA or a written agreement with the Plan.

Coordination of Benefits (COB) –The method of dividing responsibility for payment among multiple health plans that cover an individual so that the amount paid by all plans will never exceed 100% of the allowable expenses.

Copay – The flat dollar amount that you pay for some common covered services under the Plan, such as Hospital admissions or prescription drugs. Copays are applied after your Deductible and before the Coinsurance, where applicable.

Cosmetic Surgery – Any surgery or procedure that is directed at improving the patient’s appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease. 

Covered Earnings – Earnings paid to you and reported to the Plan by a Contributing Employer for Covered Employment performed under a Collective Bargaining Agreement which requires the employer to contribute to the Plan on your behalf with respect to those earnings.

Covered Employment – Work performed for employers under a Collective Bargaining Agreement that requires the employer to make contributions to the Plan. Contributions may only be made by signatory employers in accordance with the Trust Agreement.

Covered Expenses – The Allowable Charges for covered services that the Plan will pay in full or in part.

Covered Roster Artist – A vocal recording artist whose qualification for Earned Eligibility is based on the artist’s exclusive recording agreement with a record label. Covered Roster Artists qualify for coverage under the applicable Covered Roster Artists side letter agreement to the SAG-AFTRA National Code of Fair Practice for Sound Recordings.

Custodial Care – Treatment or services, regardless of who recommends them or where they are provided, that could be given safely and reasonably by a person not medically skilled and are designed mainly to help the patient with the activities of daily living. Examples include help with walking, bathing, dressing and using the toilet.

Deductible – The amount of Covered Expenses you must pay each calendar year before the Plan begins to pay certain benefits. There are separate Deductibles for Hospital, medical, prescription drug and dental coverage. Deductibles may be higher when you use Out-of-network Providers.

Dentist – A person duly licensed to practice dentistry by the government authority having jurisdiction over the licensing and practice of dentistry where the service is rendered.

Dependent – An individual who may be covered under the Plan based upon his or her relationship with the Participant, including:

  • A legal spouse;
  • Children under age 26, including:
    • Biological children;
    • Legally adopted children and children placed for adoption;
    • Stepchildren;
    • Foster children;
    • Children for whom the Participant or spouse are the legal guardian; and
  • Unmarried children age 26 or older who continue to be dependent on the Participant or spouse due to an inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental permanent disability. Such an older child may qualify as a Dependent if he or she was disabled prior to turning age 26 and the Participant was eligible for coverage when the child became disabled, regardless of whether or not the Participant was enrolled in the Plan at that time.

Disability Claim – A Claim that requires a finding of total disability as a condition of eligibility. Under the Plan, this would be a Claim for the waiver of the life insurance premium or coverage under the total disability extension.

Durable Medical Equipment (DME) – Medical supplies such as oxygen and equipment for the administration of oxygen, wheelchairs or Hospital-type beds, mechanical equipment for the treatment of respiratory paralysis and surgical supplies such as appliances to replace lost physical organs or parts or to aid in their functions when impaired.

Earned Active Eligibility – A sub-category of Earned Eligibility applied to Participants who are eligible for Medicare. If a Participant (or Dependent) who is eligible for Medicare has Earned Active Eligibility, the Plan pays benefits before Medicare.

Earned Eligibility – Eligibility for health coverage when the Participant has satisfied one of the earnings requirements (Plan I, Plan II, Age and Service) or special qualification requirements (Alternative Days, Network/Station Staff or Covered Roster Artist).

Earned Inactive Eligibility – A sub-category of Earned Eligibility applied to Participants who are eligible for Medicare. If a Participant (or Dependent) who is eligible for Medicare has Earned Inactive Eligibility, the Plan pays benefits after Medicare.

Eligibility Days – Days worked during a Participant’s Base Earnings Period that are used to determine qualification for Alternative Days eligibility. A Participant’s number of Eligibility Days is determined by dividing the Participant’s total applicable sessional Covered Earnings under certain Collective Bargaining Agreements by the SAG-AFTRA minimum daily rate, which is based on the type of production. 

Entertainment Industry Coordination of Benefits (EICOB) – Special rules for Coordination of Benefits for individuals who are covered under the Plan and another entertainment industry health plan(s). ERISA – The Employee Retirement Income Security Act of 1974 (and subsequent amendments). ERISA is the federal law that governs the administration of this Plan.

Experimental or Investigative Procedure – A drug, device, medical treatment or procedure is considered experimental or investigative if any of the following apply:

  1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA), and approval for marketing has not been granted at the time the drug or device is furnished; or
  2. The drug, device, medical treatment or procedure (or the patient-informed consent document utilized with the drug, device, treatment or procedure) was reviewed and approved by the treating facility’s Institutional Review Board,
    or another body serving a similar function, or if federal law requires such review or approval; or
  3. Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase I or phase II clinical trials, or in the research, experimental, study or investigative arm of ongoing phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, toxicity, safety, efficacy or efficacy as compared with a standard means of treatment or diagnosis; or
  4. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, efficacy or efficacy as compared with a standard means of treatment or diagnosis.

Explanation of Benefits (EOB) – A statement that summarizes the services provided and the amounts paid by the Plan.

Hospital – An institution legally operating as a Hospital which (i) is primarily engaged in providing, for compensation from its patients, inpatient medical and surgical facilities for diagnosis and treatment of sickness or injury and the care of pregnancy and (ii) is operated under the supervision of a staff of Physicians and (iii) continuously provides nursing services by graduate registered nurses 24 hours per day.

The term Hospital shall not include:

  • any institution which is operated primarily as a rest, nursing or convalescent home;
  • any institution or part thereof which is principally devoted to the care of the aged; or
  • any institution engaged in educating its patients.

Nor does it include any facility when used for the treatment of substance abuse, except for inpatient and alternative levels of care as authorized by Beacon Health Options.

In-network Level of Benefits – The level of benefits paid by the Plan when an In-network Provider is used. The in-network Deductibles and Coinsurance are lower than the out-of-network amounts. There are also certain times the Plan pays the In-network Level of Benefits when you use Out-of-network Providers (for example, if there are no In-network Providers in your area). In these cases, you are responsible for the in-network Copays, the lower Deductibles and Coinsurance, plus the difference between the Plan’s Allowance and the billed amount.

In-network Provider – A Provider who participates in one of the Plan’s networks, which are outlined on page 48. Services from In-network Providers result in lower out-of-pocket expenses for you.

Medically Necessary/Medical Necessity – The Plan determines if a service or supply is Medically Necessary (or meets Medical Necessity standards) for the diagnosis or treatment of an accidental injury, sickness, pregnancy or other medical condition. This determination is based on and consistent with standards approved by the Plan’s medical consultants. These standards are developed, in part, with consideration as to whether the service or supply meets all the following conditions:

  1. It is appropriate and required for the diagnosis or treatment of the accidental injury, sickness, pregnancy or other medical condition;
  2. It is safe and effective according to accepted clinical evidence reported by generally recognized medical professionals or publications;
  3. There is not a less intensive or more appropriate diagnostic or treatment alternative that could have been used in lieu of the service or supply provided; and
  4. It is ordered by a Physician (except where the treatment is rendered by a medical Provider and is generally recognized as not requiring a Physician’s order).

Network/Station Staff – A Participant whose initial qualification for Earned Eligbility is based on his or her status as a full-time staff employee of a radio or television station or network.

Open Enrollment Period – A period of approximately 45 days that begins when you qualify for coverage during which you may pay the premium and enroll in Plan coverage or make changes to the enrollment of your Dependents. The timing of your Open Enrollment Period depends on the start date of your Benefit Period and your type of eligibility.

Out-of-network Provider – A Provider who has not agreed to participate in one of the Plan’s Provider networks. Your out-of-pocket expenses are usually greater using Out-of-network Providers. 

Participant – An individual who performs SAG-AFTRA Covered Employment on whose behalf contributions to the SAG-AFTRA Health Plan are required to be made by one or more employers under terms of a Collective Bargaining Agreement.

Physician – A duly licensed doctor of medicine (MD) or doctor of osteopathic medicine (DO) authorized to perform a particular medical or surgical service within the lawful scope of his or her practice.

Post-service Claims – Post-service Claims are Claims (including those for which pre-authorization has been obtained) after medical treatment, services or supplies have been provided.

Pre-service Claims – Pre-service Claims are Claims that require you to obtain pre-authorization, that is, approval in advance of obtaining medical treatment, services or supplies. 

Provider – A licensed or board-certified Provider of medical or behavioral health services, including (but not limited to) Physicians, nurses, physiotherapists, speech therapists, Dentists, pharmacists, psychiatrists, counselors, chiropractors, acupuncturists, midwives, podiatrists and optometrists who act within the scope of their license or certification and perform services that are Medically Necessary.

Retiree Health Credit – A credit toward eligibility for future Senior Performers coverage under the Plan which is earned through Covered Employment during a calendar year. 

Senior Performer(s) – A Participant who meets the requirements for retiree health coverage under the Plan. Surviving Dependent – A Dependent of a deceased Participant who meets the requirements for continued Senior Performers coverage under the Plan.

Totally Disabled – With respect to an adult Participant or adult Dependent, a person who is prevented, solely because of sickness or accidental bodily injury, from performing the material and substantial duties of his or her regular occupation. With respect to a minor Participant or minor Dependent, Totally Disabled means a person who is presently suffering from a sickness or accidental bodily injury, the effects of which are likely to be of long or indefinite duration and which will prevent him or her from engaging in most of the normal activities of a person of like age and sex in good health.

Trust Agreement – The SAG-AFTRA Health Plan Trust Agreement entered into as of January 1, 2017 and any modification, amendment, extension or renewal thereof.

Trustees – The Board of Trustees (and its respective authorized agents) as established and constituted in accordance with the Trust Agreement. 

Urgent Care Claims – A Pre-service Claim for medical treatment, services or supplies where the application of the time periods for making pre-service determinations could seriously jeopardize the life, health or well-being of the patient.