The SAG-AFTRA Health Plan is listening and we are here to help.
These FAQs are intended to answer questions we are receiving from our participants. They are being updated periodically to add new questions and clarify others. These FAQs were last updated on July 9, 2021.
The new premium to cover my dependents seems high. How do the new premium rates break down monthly?
On January 1st, premiums will be as follows:
$375/quarter or 125/month for participant only
$531/quarter or 177/month for a participant plus one dependent
$747/quarter or 249/month for a participant plus two or more dependents
These new premiums also adjust the existing dependent structure to better reflect the additional costs of covering dependents. If you have more dependents, then we are asking you to pay more because it costs the plan more to cover more dependents. Here is how it breaks down:
- If you are single, only covering yourself and have no dependents, we are asking you to pay $75 more per quarter, or $25 more per month.
- A participant plus one dependent will now pay $531 per quarter, or $30.50 more per month per person
- A participant plus two or more dependents will now pay $747 per quarter. For a three-person household that is around $41 more per month per person (you can cover more than two dependents without an additional premium)
With the transition to CVS/Caremark, do I now have to go to a CVS Pharmacy? If I don’t, what other pharmacies can I get my prescriptions at?
You do not have to use CVS pharmacies. Like Express Scripts before them, CVS/Caremark has a large network of pharmacies. A full list is coming soon, but it includes Duane Reade, Walgreens, Vons, etc. Information regarding formularies and how to access personalized tools will be posted to the Health Plan’s website in late October.
How does the launch of the two new group Medicare Advantage plans offered by the AFL-CIO Mutual Benefit Fund work?
SAG-AFTRA (the Union) recently announced the launch of two new group Medicare Advantage plans offered by the AFL-CIO Mutual Benefit Fund. While you will not be able to enroll in these plans through ViaBenefits, the AFL-CIO and SAG-AFTRA made an arrangement with EHIS (Entertainment Health Insurance Solutions) and AHIRC (Artists Health Insurance Resource Center) to help SAG-AFTRA members enroll in these plans.
To enroll in the Group Medicare Advantage (MA) plans offered through the AFL-CIO, contact EHIS (Entertainment Health Insurance Solutions) if you live in the Western region (CA, AZ, OR, WA, etc.) or AHIRC (Artists Health Insurance Resource Center) if you live in the Eastern region (NY, NJ, IL, etc.). If you enroll in the AFL-CIO Group MA plan through EHIS or AHIRC, you are eligible to participate in the HRA Plan, provided you have enough Retiree Health Credits to qualify as a Senior Performer And you are a current or past member of SAG-AFTRA (union).
I'm a Senior Performer with 16 Retiree Health Credits. I'll enroll in a Medicare Marketplace plan with Via Benefits. My under age 65 spouse and my 20-year-old are on SAG-AFTRA Health Plan. Do I need to continue to qualify for the Plan to keep the benefits
As a Senior Performer, you do not need to meet any ongoing requirements to continue to qualify for the Health Reimbursement Account plan or work with Via Benefits advisors to enroll into a plan. You also do not need to meet any ongoing qualification requirements to continue to cover your under age 65 spouse and children under age 26 through the SAG-AFTRA Health Plan for the $250/month premium.
I am a Retiree. What can I expect when I call Via Benefits?
- Before October 1, 2020
- Via Benefits can only give out basic information.
- You can schedule an appointment with a Benefits Advisor at Via benefits for after Oct 1st.
- You can watch a webinar that explains all about what Via Benefits does and what types of plans are offered. Here is the schedule and link to sign up.
- You can register on the website, so your account is ready to go for when you start officially shopping for plans in October.
- You can check out current plans. ** Please note that Participants can’t shop for 2021 plans until Medicare releases those plans on 10/1/21. Prior to that, you can see what plans are currently offered in 2020, but costs and options may change for 2021.
- After October 1, 2020.
- Discuss all aspects of the plans including the HRA with your personal Via Benefits advisor.
- Via Benefits can help you find a plan that best suits your needs and enroll you in it.
When do the new earnings requirements become effective and what if I don’t meet them?
The new earnings requirements are effective for Benefit Periods beginning January 1, 2021. This means that you must meet the new $25,950 or 100 days requirements by September 30, 2020 to earn coverage effective January 1, 2021.
If you are currently covered and your Benefit Period ends April 1, 2021 or later, you will be able to run out your coverage at the new premium rates. This means you can keep your coverage through the end of your Benefit Period, although the benefit changes (other than the working spouse rule) and higher premiums will go into effect as of January 1, 2021. You can find the new premiums here.
If you do not meet the new earning requirements, you may be eligible for one of the reduced COBRA premium programs or you will be able to receive help from Via Benefits to find a new plan.
If you lose coverage effective on or after January 1, 2021, and are not a Retiree, the Health Plan will review your last twelve months’ earnings at the end of each subsequent quarter to see if you had enough covered earnings or days to qualify for coverage.
How do sessional and residual earnings work?
If you are under 65 (regardless of whether you are taking a pension or not), both sessional (active) and residual (inactive) earnings continue to count towards the January 1, 2021, $25,950 earnings requirement.
If you are 65 or older and are not taking a pension, you can continue to use a combination of sessional (active) and residual (inactive) earnings to meet the new $25,950 earnings requirement. This is the current rule in the SAG-AFTRA Health Plan. If you have only residual earnings and no sessional earnings, you will no longer be covered by the SAG-AFTRA Health Plan as secondary to Medicare. Instead, you will continue to be covered by Medicare, and Via Benefits will help you choose a supplemental plan for secondary coverage or, it may help you find a Medicare Advantage plan that can combine traditional Medicare and secondary coverage in one plan.
If you are 65 or older and are taking a pension, you must meet the new $25,950 earnings requirement with sessional (active) earnings only.
I use the EIMG (MPTF/UCLA) clinics (Bob Hope, Toluca Lake, etc.). I can’t afford COBRA or I am losing COBRA. Will I be able to continue to go to these clinics if I lose coverage?
From EIMG: Patients receiving services at the EIMG clinics within the last 3 years will remain eligible for services to ensure continuity of care. Patients who no longer meet the eligibility requirement and have not received services at the EIMG clinics in the last 3 years will have to re-qualify for eligibility in order to receive services.
What are the premiums in the new plan? What if I am over 65 and currently pay the lower premium? What if I have Plan II? What if I have already paid into 2021?
These are the new premiums, effective January 1, 2021:
$375/quarter: Participant only
$531/quarter: Participant plus one dependent
$747/quarter: Participant plus two or more dependents
All participants, including those running out Plan II coverage and Senior Performers who regain active coverage will pay the new premiums, effective January 1, 2021.
Note, if you are age 65 or older and receiving a pension and you do not satisfy the new earnings requirement, you will no longer have to pay premiums to the Health Plan. Instead, you will able to find a plan with the concierge assistance of Via Benefits on its Private Medicare Exchange.
If you have already paid into 2021, the Plan will recalculate your premiums due and send you a billing statement for any outstanding balance.
What benefits are changing in the new plan?
The benefits offered under the new plan are the same as the current Plan I level of benefits, with the exception of the combined deductible and elimination of the out-of-network out-of-pocket maximum.
Out-of-network benefits will still be covered at the in-network level of benefits in emergencies and if there are not at least two in-network providers available within a 25 mile radius. Other out-of-network benefits will still be covered at the out-of-network allowances.
Please explain how the reduced COBRA premium programs work.
There are two COBRA assistance programs. The first is temporary and is intended to help give transitional relief to participants losing coverage October 1, 2020, January 1, 2021 and April 1, 2021. This program allows qualified participants to receive COBRA extension coverage at a highly discounted rate for up to twelve months (9 months for those losing coverage April 1, 2021). For more information and the qualification requirements click here.
The second program is long-term and offers up to eighteen months of highly discounted COBRA coverage to qualified participants. It is called Extended Career COBRA. Click here for more information and the qualification requirements
For anyone losing coverage, the Health Plan has partnered with Via Benefits to offer personalized assistance to help find and enroll you in a Marketplace or private health plan.
Is Age and Service Eligibility going away?
Participants will no longer be able to qualify for coverage under the Age and Service Eligibility rules. Instead, the Trustees have introduced Extended Career COBRA to help participants with 12 or more Extended Career Credits who lose coverage due to not meeting the earned eligibility requirements.
Your Age and Service Credits will be converted to Extended Career Credits. You will earn new Extended Career Credits each time you qualify for earned eligibility.
Please call the Plan to find out how many Credits you have.
I am over age 65 and receiving my pension. Does the temporary COBRA Relief apply to me? Do I need to meet the $13,000 earnings requirement in all sessional earnings?
As long as you meet the $13,000 earnings requirement with any combination of sessional and residual earnings during your most recent Base Earnings Period, lose coverage October 1, 2020, January 1, 2021 or April 1, 2021, and enroll in COBRA and pay your premium within 30 days of losing coverage, you qualify for the temporary COBRA Relief. This benefit is not available to you if you are an employee of SAG-AFTRA, the SAG-AFTRA Foundation, the SAG-Producers Pension Plan, and the AFTRA Retirement Fund.
Please note: COBRA coverage is considered Inactive coverage and is secondary to Medicare if you are age 65 or over. Please see page 99 of the 2017 Health Plan Summary Plan Description.
I am a Senior Performer. Do I have to enroll in a plan through Via Benefits to access my HRA?
Via Benefits also administers the SAG-AFTRA Health Plan HRA, so it is a requirement that you enroll in a Medicare Marketplace plan through Via Benefits. Doing this ensures that your HRA is set up properly and allows for more seamless use of your HRA account, including being able to submit claims electronically. However, we recognize that some participants already have relationships with the Actors Fund and the MPTF, so enrollments through AHIRC and EHIS will also allow you access to your HRA account. We also understand that some of our participants have retiree coverage through the entertainment industry and other retiree group health plans, so if you want that plan to be secondary to Medicare instead of enrolling in a Medicare Exchange plan, please contact the Plan Office so we can work with Via Benefits to make sure you still have access to an HRA.
What is a Retiree? What is a Senior Performer?
You are a Retiree if you are age 65 or older and receiving your SAG or AFTRA pension benefit. A Retiree has Senior Performer status if they have 20 or more Retiree Health Credits (or meet the grandfathering requirements) and do not meet the minimum Health Plan earnings requirement with all sessional earnings.
All Retirees will be able to work with Via Benefits advisors who can find and enroll them in the Medicare and supplemental plans that best fit their needs. Senior Performers will also receive a Health Reimbursement Account (HRA) allocation for themselves and their spouses over age 65. The HRA allocation can be used to pay premiums and other eligible healthcare expenses. Please click here for information on the different allocation amounts. Senior Performers can also continue to cover their eligible dependents under age 65 on the SAG-AFTRA Health Plan, subject to the Working Spouse rule. The cost of this coverage is $250/month for the family, regardless of the number of eligible dependents.
How do I qualify for SAG-AFTRA Health Plan coverage if I am a Retiree? What if I am over 65 but not taking a pension?
Retirees must meet the earned eligibility requirement with all sessional earnings in order to qualify for SAG-AFTRA Health Plan coverage. If you are over 65 but not taking a pension, the current rule that requires a combination of sessional (active) and residual (inactive) earnings still applies.
The distinction is made based on whether a person is receiving a pension or not. Not receiving a pension allows residuals to be counted towards active coverage, but receiving a pension is a requirement for Senior Performers to receive an HRA allocation and to cover their under-age 65 dependents under the SAG-AFTRA Health Plan even if you do not meet the requirements for Active coverage.
I’ve been taking my SAG-AFTRA pension for a couple of years but I’m still actively working. I just turned 65 last month so which plan would I fall under? Active Plan or the Retiree Plan with Via Benefits?
Generally, you would need to meet the earnings requirement in all sessional earnings to qualify for the SAG-AFTRA Health Plan as an active participant. However, since you just attained Retiree status (65 and taking a pension) this year, your residuals will be counted for this year only.
What if I am under age 65? How do sessional and residual earnings apply?
Sessional and residual earnings will both continue to count towards earned eligibility in the SAG-AFTRA Health Plan and towards the Extended Career COBRA and temporary COBRA Relief for everyone under age 65.
What if I am under age 65 and have already begun taking my pension? How do sessional and residual earnings apply?
Sessional and residual earnings will both continue to count towards earned eligibility in the SAG-AFTRA Health Plan if you are under age 65.
If I have Senior Performer Status, what do I qualify for?
Senior Performers age 65 and over will receive an HRA allocation when they enroll in Medicare coverage through Via Benefits. Their spouse who is age 65 or older will also receive an HRA allocation in the same amount. If they have any dependents under age 65, those dependents may be enrolled in the SAG-AFTRA Health Plan (subject to the Working Spouse rule) at a premium of $250 per month for all dependents.
The life insurance benefit through the SAG-AFTRA Health Plan will also continue for Senior Performers.
Will a dependent spouse of a deceased Senior Performer participant continue to have coverage as they do now (Surviving Dependent benefit)?
If the surviving spouse is age 65 or over, they will receive an HRA allocation if they enroll in a Medicare plan through Via Benefits. If they are under age 65, they can be covered under the SAG-AFTRA Health Plan at $250/month until they become eligible for Medicare at which time, they will be transitioned to the Via Benefits marketplace and receive an HRA allocation. Consistent with the current rule, any coverage for the surviving spouse of a deceased participant terminates if and when they remarry. Surviving children under age 26 will also continue to be covered under the SAG-AFTRA Health Plan even if there is no surviving spouse or the surviving spouse is 65 or over. The $250/month premium applies
Regarding the working spouse rule, will married participants who are both offered SAG-AFTRA health but currently choose to be covered as a dependent under one spouse’s SAG-AFTRA health plan be required to enroll in their own SAG-AFTRA insurance plan?
No. The choice of whether to cover both spouses under one of them or for each spouse to have their own coverage will remain. The Working Spouse rule will not apply to married participants who are each qualified for coverage under the SAG-AFTRA Health Plan.
My spouse has a high deductible plan with their employer. I have added them to my SAG AFTRA Health Plan participant plus one coverage plan for secondary coverage. Are the out-of-pocket costs up to their deductible reimbursable under my Health Plan?
The spouse’s coverage with their employer-sponsored plan will be the primary payer of benefits for the spouse (they will pay claims first), and the coverage under the SAG-AFTRA Health Plan will be the secondary payer of benefits for the spouse (we will pay claims after the employer-sponsored plan pays). As secondary payer, the SAG-AFTRA Health Plan will pay for anything that the primary plan does not pay for, as long as it is a covered benefit under the SAG-AFTRA Health Plan’s benefits, up to the Plan’s allowed amount.
In this example, when the primary coverage is a high-deductible health plan with an individual deductible of $5,000, the SAG-AFTRA Health Plan may cover the majority of the $5,000 deductible applied by the primary employer-sponsored plan, after the application of the SAG-AFTRA Health Plan’s deductible and co-insurance rates, if applicable, and based on SAG-AFTRA Health Plan’s allowance.
When will my working spouse need to enroll in their employer’s health plan?
When you enroll in your next benefit period ending after December 31, 2020, you will be asked to state in writing that your spouse is either: 1) enrolled in their employer’s coverage: 2) not offered health coverage through their employment; or 3) are not employed. For example, if your Benefit Period ends March 31, 2021 and you requalify for coverage beginning April 1, 2021, your working spouse will be required to take their employer’s coverage as of April 1, 2021, unless you show that the spouse is not employed or does not have access to coverage through their employer. The fact that your working spouse will no longer have coverage under this Plan triggers a qualifying event and their employer should allow them to enroll, even if it is outside of the employer-sponsored plan’s open enrollment period. Contact the Plan if there is a problem with your spouse enrolling in their employer’s plan at that time.