SAG-AFTRA Health SPD

Beginning Coverage

After you become eligible for Plan coverage, you may enroll and must pay the premium to receive coverage. If you are eligible for coverage, you may enroll your Qualified Dependents. Documentation and verification by the Plan are required for any Dependents you want covered.

When the Plan has verified the documentation, your Dependent is considered a Qualified Dependent. Enrolling (or disenrolling) Dependents also affects the amount of your premium. You can find the current Plan premiums here.

Enrollment

You initially enroll in coverage during your Open Enrollment Period. The timing is based on when you qualify for coverage. As long as you continue to qualify for coverage, each subsequent Open Enrollment Period presents an annual opportunity to add or drop Qualified Dependents.

Additionally, the Plan extends special enrollment opportunities to Participants following certain life events, as described later in this section. These opportunities allow you to enroll or make changes to your Dependent elections outside of the Open Enrollment Period. 

Open Enrollment Period

You may enroll or make changes to your covered Dependent elections during your Open Enrollment Period, which begins when you qualify for coverage. Your Open Enrollment Period is based on your Benefit Period dates, as noted in the table below. The changes made during your Open Enrollment Period will be effective as of your Benefit Period Start Date.

Note that Retirees (including Senior Performers) are transitioning to the January 1 Benefit Period and the corresponding Open Enrollment Period, as are Dependents covered under the Senior Performer Surviving Dependent benefit.

Open Enrollment Period

January 1 December 1 through January 15
April 1 March 1 through April 15
July 1 June 1 through July 15
October 1 September 1 through October 15

The Plan will offer an Open Enrollment Period to all eligible Staff Employees in November of each year. The changes made by Staff Employees during their Open Enrollment Period will be effective as of the following January 1st. Each year, a second Open Enrollment Period is offered to Staff Employees based upon the individual employee’s Benefit Period start date. Staff Employees with a January 1 Benefit Period start date will only have one open enrollment opportunity because their Benefit Period start date coincides with the annual Open Enrollment Period. Generally, four weeks prior to the Benefit Period start date, Staff Employees will be notified by the Plan of this Benefit Period open enrollment.

You will receive an enrollment packet with your Qualified Dependents listed. It will include information about your Benefit Period, your Open Enrollment Period, your premiums, and how to enroll and disenroll Dependents. You may make changes to your covered Dependents for any reason during the Open Enrollment Period by completing an enrollment packet, paying your premium online through Benefits Manager and providing the required Dependent documentation. After the Open Enrollment Period, you may not make changes to enrollment for you or your covered Dependents, except in the case of life events that change the eligibility for you or your Dependents.

Once your premium is processed, a Notice of Coverage (NOC) will be sent to you within seven to ten business days. The NOC mailing includes your Plan ID cards, information regarding your benefit coverage and a list of your enrolled Dependents. You may also print Plan ID cards by logging in to Benefits Manager. The ID cards reflect only the Participant’s name but are also valid for covered Dependents.

If you think you met the Earned Eligibility requirements but you do not receive an enrollment packet, contact the Plan at (800) 777-4013 or through Benefits Manager’s secure message center. Earnings are sometimes reported late by Contributing Employers, which may delay the Plan’s notification. If this happens to you, Plan staff can help you determine if your earnings have been accurately reported. If we verify that your earnings have not been reported, you will need to provide copies of your pay stubs and / or contracts for review. Once the Plan reviews your proof of earnings and verifies with the employer that the earnings are reportable, you will receive written notification of your eligibility for benefits. You can also keep track of your reported earnings through your Benefits Manager account. Please remember that Benefits Manager may not reflect total Covered Earnings for any particular Calendar Quarter until approximately 60 days after the quarter ends.

Dependent Coverage

Once you qualify for Earned Eligibility as a Participant, coverage is also available to your Eligible Dependents.
To cover Dependents, you must enroll the Dependents(including providing the necessary documentation) and pay the applicable premium. Please note that due to reporting requirements under the ACA, you will also be asked to provide your Dependent(s)’ Social Security number(s) at the time of enrollment.

Coverage for Dependents will begin the later of:

  • The date your coverage begins;
  • The date you add your Dependent to your coverage as part of open enrollment; or
  • The date the person becomes your Dependent as a result of a life event such as marriage, birth or adoption.

If you qualify for coverage as a Participant, the following individuals are Dependents based on their relationship to you:

  • Your legal spouse;
  • Your children under age 26, including:
    • Biological children;
    • Legally adopted children and children placed for adoption;
    • Stepchildren;
    • Foster children;
    • Children for whom you or your spouse are the legal guardian; and
  • Your unmarried children age 26 or older who continue to be dependent on you or your 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 you were eligible for coverage when your child became disabled – regardless of whether or not you were enrolled in the Plan at that time. The Plan requires periodic certification of permanent disability status by the child’s attending Physician. Note: Even if a Senior Performer does not qualify for Active Plan coverage, their permanently disabled Medicare-eligible child will have access to the SAG-AFTRA Health Plan / Via Benefits program (with no HRA) or can remain on this Plan with coverage secondary to Medicare, subject to payment of this Plan’s Dependent premium.

No family members other than your spouse or children qualify for Dependent coverage. The Plan requires documentation for the Dependents you want to cover to verify their status as a Dependent; refer to the section below to learn more.

Enrollment of an individual who does not meet the Plan’s eligibility requirements will be treated as an intentional misrepresentation of a material fact or fraud. You and any individual who obtains benefits from the Plan through misrepresentation or fraud will be held jointly and severally liable for such overpayment, and coverage may be rescinded retroactively to the date the individual was not eligible for coverage.

Working Spouse Rule Effective January 1, 2021

The Plan requires periodic certification of permanent disability status by the child’s attending Physician. If your spouse is working for an employer who offers a health plan, the Plan requires them to enroll in that employer-sponsored coverage in order to be eligible for Plan coverage.

If your spouse is enrolled with their employer, you may then choose to cover them under the Plan as well. The spouse’s employer’s plan will pay benefits first; then, the Plan’s cost-sharing may apply for remaining eligible expenses. Please see the Coordination of Benefits section for more information.

If your spouse is not working, or their employer doesn’t offer a health plan, you may enroll them with the Plan. Note that if your spouse then becomes eligible for or obtains other employer-sponsored health coverage while covered under this Plan, you must notify the Plan within 30 days of the date of their eligibility for that coverage.

If your spouse is eligible for, or becomes eligible for, but does not enroll in available employer-sponsored health coverage, they will not be eligible for coverage under this Plan, and the Plan will not pay benefits on their behalf.

Action Required!
You must complete a spouse coverage attestation when you qualify for your next annual Benefit Period. The attestation establishes your spouse’s eligibility for benefits. The deadline for returning your attestation will be noted in your Notice of Coverage letter. If you do not complete the attestation and return it by the deadline, your spouse’s coverage under the Plan will terminate.

 

Important Note for Senior Performers: Covering Your Dependents

If you do not meet the Plan’s Earned Eligibility requirements, and you enroll in an individual Marketplace plan through the SAG-AFTRA Health Plan / Via Benefits program:

  • You can cover your Medicare-eligible spouse (and other Medicare-eligible Dependents) through the Via Benefits marketplace plan(s);
  • You can cover your spouse under age 65, and your eligible children under age 26, through the Plan, subject to payment of a monthly premium. The Working Spouse rule applies to your spouse. You must complete a spousal coverage attestation (as described above) and submit all required verifications to the Plan before enrolling your eligible family members.

Enrollment of an individual who does not meet the Plan’s eligibility requirements will be treated as an intentional misrepresentation of a material fact or fraud. You and any individual who obtains benefits from the Plan through misrepresentation or fraud will be held jointly and severally liable for such overpayment, and coverage may be rescinded retroactively to the date the individual was not eligible for coverage.

Life Events and Dependent Coverage

As a Participant, it is your responsibility to notify the Plan of any life events or other changes that could affect your health coverage, such as those described in this section. You have 60 days to notify us of these life events; otherwise you may miss certain opportunities available to you, such as enrolling a new Dependent outside the Open Enrollment Period or preserving your former Dependent’s rights under COBRA.

The following are examples of common life events and other changes that may affect your health coverage:

  • A new child.
  • Marriage.
  • Divorce.
  • A change in your spouse's employment status/employer-provided health coverage
  • Death of a Participant or Dependent.

Notify the Plan of life events or changes to your contact information separately from any notifications to other organizations.

The SAG-AFTRA Health Plan is separate from SAG-AFTRA (the union) and from the SAG-Producers Pension Plan and the AFTRA Retirement Plan. Notification of changes of address or other information provided to SAG-AFTRA, the SAG-Producers Pension Plan or the AFTRA Retirement Plan does not automatically update your information with the SAG-AFTRA Health Plan – you must contact us separately. Please notify us promptly of any changes to your address or contact information and of any qualifying life events by the required deadline described in this section.

Life Events and Documentation / Notification Requirements

Listed below are the life events that may affect your Plan coverage, along with the required documentation.

Life Events and Documentation

Marriage* A completed Dependent Enrollment Form and a copy of the official, state-issued marriage certificate.
Divorce** A copy of the recorded final divorce decree.
Birth A completed Dependent Enrollment Form and a copy of the official, state-issued birth certificate. Exception: the Plan will accept a copy of the birth certificate from the Hospital to add your biological child who is younger than one year of age for a
period of up to 120 days while you obtain an official copy.
Adoption or placement for adoption A completed Dependent Enrollment Form and a copy of the adoption/placement papers issued by the court.
Legal guardianship A completed Dependent Enrollment Form and a copy of the guardianship papers issued by the court.
Physically and/or mentally disabled Dependents age 26 or older A completed application for permanent disability status and a copy of the attending Physician’s history and physical report. Periodic certification of permanent disability status is also required.
Death A copy of the recorded death certificate.
Loss of other group health coverage Documentation which shows evidence of the loss of other coverage.
* If you are covered under the Surviving Dependent benefit following the death of a Participant and you remarry, your Plan coverage will terminate.
** In the event of a divorce, medical expenses incurred by your ex-spouse or stepchild who no longer qualifies as your Dependent on or after the date of the divorce are not covered by the Plan unless they elect and pay for COBRA Continuation Coverage. You and your ex-spouse will be held jointly and severally liable for any overpayment of expenses paid by the Plan from the date of divorce. Learn more information regarding overpayment of benefits and the Plan’s right of recovery.

Health Coverage Under a Court Order

A medical child support order is a court order that requires a Participant to provide health coverage for a child or children, typically following a divorce. For the Plan to provide benefits in accordance with a medical child support order, the Plan must first determine that the order is a qualified medical child support order (QMCSO). If this applies to you, contact the Plan at (800) 777-4013 to request the current procedures and requirements for enrolling a child as your Dependent under a QMCSO.

Special Enrollment Opportunities

Special enrollment opportunities triggered by certain life events allow you to enroll or make changes to your Dependent elections outside the Open Enrollment Period. Traveling is not considered a life event or special exception; in other words, you cannot enroll yourself or a Dependent outside of the Open Enrollment Period because you intend to travel, even if it is for an extended period of time.

The special enrollment opportunities are described below:

  • Enrolling a new Dependent – If you gain a new Dependent as a result of marriage, or the birth, adoption, placement for adoption or legal guardianship of a child, you may enroll the Dependent in your coverage provided you notify the Plan within 60 days of the life event and you submit the required documentation as described above.
  • Senior Performers – Spouse turns 65 – Senior Performers also have the opportunity to make changes to their covered Dependents in the event their spouse turns age 65. In the case of Surviving Dependent coverage, the eligible Dependents have the opportunity to re-enroll in the Plan when the spouse turns age 65.
  • Loss of other group health plan coverage – If you do not enroll in the Plan because you have other group health coverage, you may be allowed to enroll outside your Open Enrollment Period if your other coverage ends because of a termination of employment or reduction in hours, legal separation, loss of Dependent status under the other plan, divorce or death (but not if you lost coverage because you failed to pay required premiums). If the other coverage is under COBRA and you exhaust your COBRA Continuation Coverage, you may also be allowed to enroll in the Plan.
    You must submit a written request for coverage to the Plan within 60 days after your other coverage ends, along with documentation of the loss of coverage. If your Plan coverage is under the Surviving Dependent benefit, the only special enrollment opportunity available to you under this provision is when your other coverage ends because of termination of employment or a reduction in hours.
  • CHIP/Medicaid – CHIP and Medicaid are government programs designed to provide health care coverage for uninsured children and some adults. One of the benefits offered by some state Medicaid or CHIP programs is assistance with paying for health plan premiums. Special enrollment opportunities are available to:
    • Participants and their Dependents who lose coverage under Medicaid or CHIP; and
    • Participants and their Dependents who are determined eligible for premium assistance under Medicaid or CHIP.
  • If you experience either of these CHIP/Medicaid enrollment events and you would like to enroll in this Plan, you must submit a written request to the Plan within 60 days of the event. If you think you or any of your Dependents might be eligible for Medicaid or CHIP, or if you or your Dependents are already enrolled in Medicaid or CHIP but not receiving premium assistance, contact your state Medicaid or CHIP office or call (877) KIDSNOW or visit www.insurekidsnow.gov to learn how to apply. If you qualify, ask if there is a program that might help you pay the Plan’s premium.

For the latest version of the Dependent Enrollment Form and other forms or procedures necessary to enroll during a special enrollment opportunity, visit the Forms section.

Important Note:

Enrolling and disenrolling Dependents can affect the amount of your premium. Premium changes will be effective on the 1st of the month in which the event occurred if enrolling a new Dependent(s) or the 1st of the following month if you are disenrolling a Dependent(s).

Disenrolling Dependents

If you are disenrolling a Dependent due to divorce or death, you must submit a copy of the final judgment of divorce or recorded death certificate. In the event of divorce, you must notify the Plan in writing within 60 days of the date of your divorce for your ex-spouse or former stepchildren to receive the right to COBRA Continuation Coverage. Medical expenses incurred by your ex-spouse or former stepchildren on or after the date of divorce are not covered by the Plan. You will be billed for any expenses paid by the Plan following the date of divorce if your ex-spouse or former stepchildren do not elect COBRA Continuation Coverage. For additional information, refer to the COBRA section.

You may also want to update your life insurance beneficiaries after a life event. The Plan will use the last beneficiaries on file in determining who should receive any benefits that may be payable, even if you have divorced or married since filing the Designation of Beneficiaries Form. Therefore, it is important to file a new form with the Plan immediately if you wish to change your beneficiaries.

Also note that naming your beneficiaries in your will or revoking a beneficiary in a divorce decree does not change your beneficiaries for the Plan’s life insurance or accidental death and dismemberment benefits. You must complete a new Designation of Beneficiaries Form, which is available from the Forms section.