SAG-AFTRA Health SPD

Loss of Coverage and Extended Coverage Opportunities

When you lose Earned Eligibility due to a reduction in Covered Earnings or because you no longer meet other eligibility criteria, you will receive a notice from the Plan which outlines available benefits and options for continued coverage. If you die, the Plan will mail this information to your covered Dependents or your beneficiaries.

All notices will be mailed to the address that the Plan has on file. This is one reason why it is important to keep us informed of your current address. If you move, log in to your Benefits Manager to update your contact information securely. You may also complete a Participant Information Form (PIF) and send it to the Plan as directed on the Form. The PIF is available online or by calling the Plan at (800) 777-4013.

When you lose Plan eligibility, you may be able to continue your coverage under one of these provisions:

  • The Extended Career COBRA program — for eligible Participants
  • COBRA
  • Total Disability Extension

Loss of Eligibility for Coverage

Loss of Earned Eligibility – Participants

The termination rules for Participants with Earned Eligibility vary depending on how you qualified for coverage. In addition, Plan coverage may be terminated because of a Plan amendment that changes the eligibility requirements.

Minimum Covered Earnings, Alternative Days

You will lose Earned Eligibility as a Participant at the end of your 12-month Benefit Period if you have not satisfied the minimum Covered Earnings requirement in your Base Earnings Period, or if you no longer meet one of the alternate requirements for Earned Eligibility.

Network/Station Staff

If you are a full-time employee of a radio or TV station or network, then the following rules determine the end of coverage:

  • If you have been continuously enrolled in the Plan for less than five years (not including COBRA or the total disability extension), your coverage will end on the last day of the Calendar Quarter following the quarter in which your employment ends.
  • If you have been continuously enrolled in the Plan for five or more years (not including COBRA or the total disability extension), your coverage will end on the last day of the last Benefit Period for which you qualify based on your Covered Earnings under the general rules for Participants.

Covered Roster Artists

If you are a Covered Roster Artist, your coverage will end on the date you are no longer a Covered Roster Artist, unless you qualify for coverage by meeting at least the minimum Covered Earnings requirement or one of the alternate requirements for Earned Eligibility.

Loss of Earned Eligibility - Dependents

In general, coverage for your Dependents ends when your coverage terminates – or sooner if a covered individual no longer qualifies as a Dependent. In the case of divorce, coverage for any individual who no longer qualifies as a Dependent will end on the date of the divorce. For any covered child who ages out of Dependent status, coverage ends on the last day of the month in which the individual turns 26. Any Dependents who lose eligibility for coverage may be eligible for one of the programs listed above.

In the event of your death during your Earned Eligibility Benefit Period, your covered Dependents may continue until the end of the Earned Eligibility Benefit Period that was accrued as a result of your reported Covered Earnings or employment, provided the Dependents pay the required Plan premium. Thereafter, coverage may be extended under the Surviving Dependent benefit or under one of the programs listed above. Please refer to Surviving Dependent eligibility for additional information.

Loss of Eligibility for Senior Performers Coverage

If you die while you have Senior Performers coverage, your covered Dependents will continue their health benefits until:

  • The end of the month in which your death occurs, if your Dependents qualify for Surviving Dependent coverage. Surviving Dependent coverage will begin on the first day of the month which follows the month in which your death occurs; or
  • The later of (i) the end of the calendar year in which your death occurs, or (ii) six months following your death, if your Dependents are not eligible for Surviving Dependent coverage.

Conversion of Life Insurance Benefit After the Loss of Earned Eligibility

A life insurance conversion policy is available through Metropolitan Life Insurance Company (MetLife) to Participants in Plan I who lose Earned Eligibility. If you are losing Plan I Earned Eligibility and gaining Senior Performers eligibility, you may convert $5,000 of your life insurance benefit. If you are not gaining Senior Performers eligibility, you may convert $10,000 of your life insurance benefit. However, if you have received an accelerated life insurance payment, the amount you may convert will be reduced by the amount of the benefit you have already received.

To convert your life insurance benefit as described above, you must submit an application and payment to MetLife within 31 days of the date you lose coverage. For applications call MetLife at (877) 275-6387.

Loss of Surviving Dependent Eligibility

If a surviving spouse has extended coverage as a Senior Performer Surviving Dependent and remarries, their coverage will end on the date they remarry. If the surviving spouse’s eligibility for the Senior Performer Surviving Dependent benefit ends, the surviving spouse may be eligible for COBRA.

Senior Performer Surviving Dependent coverage for Dependent children will end when they no longer meet the Plan’s definition of a Dependent. 

Extended Coverage Opportunities

In accordance with federal law, the Plan provide Participants and covered Dependents an opportunity to extend their coverage under COBRA once their eligibility ends. This and other extended coverage opportunities are described below.

Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage

When you lose Earned Eligibility because of a qualifying event (defined under “What is COBRA?”), you and your covered Dependents may choose to continue Plan benefits by enrolling in COBRA Continuation Coverage (COBRA).

The right to COBRA was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA can become available to you and other members of your family when group health coverage would otherwise end. The length of time you are allowed to have COBRA depends on several factors, including which qualifying event caused the loss of Earned Eligibility.

As you consider COBRA, note that you may be eligible for the Plan’s Extended Career COBRA benefit. Effective January 1, 2021, the Plan introduced the Extended Career COBRA benefit for performers with continuous, long-term service in the industry. If you lose Earned Eligibility, as noted above, you can continue Plan coverage through COBRA. If you qualify for the Extended Career COBRA benefit — and elect it within the deadline — you pay a reduced premium of 20% of the COBRA rate.

To qualify for Extended Career COBRA, you need to meet the following thresholds: 

Note: The reduced COBRA rate is subject to change. 

Covered Earnings During Your Most Recent Base Earnings Period

  • Currently $20,000

Extended Career Credits

  • With at least 12 Extended Career Credits, you will pay a reduced premium of 20% of the COBRA rate for up to 12 months.
  • If you have 20 or more Extended Career Credits, you will pay a reduced premium of 20% of the COBRA rate for up to 18 months.

You receive an Extended Career Credit each time you meet the Plan’s Covered Earnings Eligibility Threshold and qualify for 12 months of coverage. Age & Service credits (under the Plan’s prior Age & Service method of satisfying the Earned Eligibility requirement) earned through the last Base Earnings Period in 2020 will be converted to Extended Career Credits.

A Participant who elects COBRA at the reduced rate and subsequently meets the Plan’s Earned Eligibility requirements for another year may again be offered the reduced Extended Career COBRA rate if the Participant again loses Earned Eligibility in the future.

Retirees, Roster Artists, Station Staff, and employees of SAG-AFTRA, the SAG-AFTRA Foundation, the SAG-Producers Pension Plan and the AFTRA Retirement Fund are not eligible for the Extended Career COBRA benefit.

COBRA Is Not Your Only Option  

You may have additional choices when you lose group health coverage, as follows.

Through Via Benefits:

  • Medicare-eligible Participants and their Medicare-eligible Dependents can shop for supplemental Medicare coverage through the Via Benefits Medicare marketplace plans.
  • Participants under age 65 and their Dependents can explore different private health insurance options.
  • Participants and Dependents can connect with a personal Via Benefits advisor to compare Plan benefits to the alternatives that may be available.

Through the Actors Fund’s AHIRC program or through EHIS (the MPTF and Actors Fund’s joint program):

AHIRC and EHIS representatives can help you find coverage and can help find other financial assistance that may be available.

Through your spouse’s employer-sponsored plan:

Losing your Plan coverage may trigger a special enrollment period, which allows enrollment in your spouse’s or partner’s plan.

Medicare:

Don’t put off your Medicare enrollment. Be sure to enroll in Part A and Part B when you’re eligible! Remember that losing your Plan coverage triggers a Medicare special enrollment period for you. 

Medicaid / Medi-Cal / Children’s Health Insurance Program:

Your state’s Medicaid program (Medi-Cal in California) and Children’s Health Insurance Program (CHIP) provide low-cost health insurance to eligible individuals and families, based on family size and income level. Contact Via Benefits, and ask if your state-provided programs are an option for you.

Your state’s health insurance marketplace:

You can shop for an individual plan through the marketplace. Depending on where you live, you may have a wide variety of plans available. Also, based on your household income, you may be eligible for a tax credit that lowers your monthly premiums and cost-sharing. If you or your Dependents ever lose eligibility for coverage under this Plan, feel free to contact Via Benefits, and ask if your state’s marketplace plans might be right for you. 

Can I Enroll in Medicare Instead of COBRA After My Group Health Plan Coverage Ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an eight-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of:

  • The month after your employment ends; or
  • The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA instead, you may have to pay a Part B late enrollment penalty, and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA 
and later enroll in Medicare Part A or B before the COBRA ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA and Medicare, Medicare will generally pay first (primary payer), and COBRA will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled 
in Medicare.

For more information, visit https://www.medicare.gov/medicare-and-you.

What is COBRA Continuation Coverage?

COBRA Continuation Coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed below. After a qualifying event, COBRA Continuation Coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse and your Dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA Continuation Coverage must pay for that coverage.

Loss of coverage due to failure to pay the Plan premium is not a qualifying event, and neither is the termination of Earned Eligibility as the result of a contribution or Dependent verification audit. This means that COBRA Continuation Coverage is not available to you if your Earned Eligibility ends for these reasons.

You and your covered Dependents may have the right to COBRA Continuation Coverage when qualifying events occur as described below:

  • As a Participant, you may qualify for COBRA under the Plan because of the following qualifying events:
    • You lose Earned Eligibility due to:
      • a reduction in your Covered Earnings or Eligibility Days;
      • a change in your qualification as a Covered Roster Artist; or
      • the termination of your employment for any reason other than gross misconduct.
    • You change from Plan I to Plan II due to a reduction in your Covered Earnings.
  • As a Dependent spouse or child, you may qualify for COBRA when you lose Earned Eligibility coverage under the Plan because of the following qualifying events:
    • The Participant loses Earned Eligibility due to:
      • a reduction in his or her Covered Earnings or Eligibility Days;
      • a change in his or her qualification as a Covered Roster Artist;
      • the termination of his or her employment for any reason other than gross misconduct; or
      • his or her death.
    • A change from Plan I to Plan II due to a reduction in the Participant’s Covered Earnings.
    • A divorce from the Participant.
    • A loss of Dependent child status as defined by the Plan.

As a Dependent covered by the Plan when Earned Eligibility ends, you may be eligible to enroll individually in COBRA even if the Participant does not elect COBRA.

When is COBRA Available?

The Plan will offer COBRA  to qualified beneficiaries after the Plan has been notified that a qualifying event has occurred. The employer must notify the Plan of the following qualifying events within 30 days of their occurrence: the end of employment, reduction of hours of employment or the death of the employee. For purposes of the Plan, generally notice of these qualifying events is required from employers of full-time Network/Station Staff and Covered Roster Artists.

You or your Dependents (depending on the circumstances) must notify the Plan in writing in the event of a divorce or a child’s losing Dependent status under the Plan. Your Dependents may also want to notify the Plan in the event of your death, particularly if you were not a full-time Network/Station Staff, or a Covered Roster Artist.

For the Dependent to receive individual rights to COBRA Continuation Coverage, notification must be made within 60 days of the later of:

  • The date the event occurred; or
  • The date coverage terminates as a result of the qualifying event.

If you or your Dependents do not notify the Plan in writing within the required time period or if you do not submit the required documentation, the individual losing eligibility as a Dependent will forfeit his or her right to enroll in COBRA Continuation Coverage.

How Long is COBRA Continuation Coverage Provided?

Once the Plan receives notice that a qualifying event has occurred, COBRA Continuation Coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA Continuation Coverage. Participants may elect COBRA Continuation Coverage on behalf of their spouses, and parents may elect COBRA Continuation Coverage on behalf of their children. 

COBRA Continuation Coverage is a temporary continuation of coverage that generally lasts for 18 months due to loss of Earned Eligibility. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

Eighteen months of COBRA Continuation Coverage is available to Participants (and their covered Dependents) who lose eligibility or change from Plan I to Plan II due to a reduction in Covered Earnings or Eligibility Days, a change in the Participant’s qualification as a Covered Roster Artist, or the termination of employment for any reason except gross misconduct. Participants who are entitled to Medicare prior to the date they lose Earned Eligibility should call the Plan at (800) 777-4013 for information concerning their maximum COBRA period.

Thirty-six months of COBRA Continuation Coverage are available to qualified Dependents who lose their Dependent status due to the death of a Participant, a divorce from a Participant or loss of Dependent child status as defined by the Plan. 

There are ways in which the 18-month period of COBRA Continuation Coverage can be extended:

Social Security Disability Extension

If you or anyone in your family covered under the Plan is determined by Social Security to be totally disabled and you notify the Plan in a timely fashion, you and your entire family may be entitled to an additional 11 months of COBRA Continuation Coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage. You must provide the Plan with a copy of your determination letter from the Social Security Administration before the 18-month period of COBRA Continuation Coverage expires in order to receive this extension.

Second Qualifying Event Extension

If your family experiences another qualifying event during the 18 months of COBRA Continuation Coverage, the spouse and Dependent children in your family can get up to 18 additional months of COBRA Continuation Coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any Dependent children getting COBRA Continuation Coverage if the Participant dies, gets divorced, or if the Dependent child no longer meets the Plan’s definition of a Dependent child. This extension is only available if the second qualifying event would have caused the spouse or Dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Special Rules for Dependents

Individuals who became a Dependent after the Participant’s enrollment (for example, in the case of marriage, birth or adoption) may be added to the Participant’s coverage. However, except for newborn and adopted children, they will not be entitled to COBRA Continuation Coverage on an individual basis.

If your Dependents lose their status as eligible Dependents while you, the Participant, are enrolled in COBRA or Senior Performers coverage, they may also qualify for individual COBRA Continuation Coverage. Additionally, individual COBRA Continuation Coverage may be available if a Dependent loses Dependent status while enrolled in Surviving Dependent coverage. This would include situations in which a surviving spouse remarries.

Individual COBRA Continuation Coverage for your Dependents is only available if they were covered under the Plan on the date Earned Eligibility was lost and, if applicable, on the date Dependent status was lost. The maximum length of the individual Dependent COBRA Continuation Coverage is 36 months from the date Earned Eligibility was lost.

If you lose Earned Eligibility after you become entitled to Medicare, your Dependents will be entitled to COBRA Continuation Coverage. The maximum period of COBRA Continuation Coverage available will end on the later of:

  • 18 months from the loss of your Earned Eligibility; or
  • 36 months from your Medicare entitlement date.

Enrollment Options

If you lose coverage due to any of the Qualifying Events listed above, you will be offered a one-time opportunity 
to enroll in COBRA. 

COBRA is identical to the coverage provided to Participants with Earned Eligibility, except that COBRA Participants are not entitled to life insurance or accidental death and dismemberment benefits.

Enrollment Process

When you lose coverage due to a Qualifying Event, the Plan will send you a termination notice describing the available COBRA, along with enrollment materials. This is the time during which you can choose the Dependents you would like to cover and the corresponding premium. You can enroll Dependents who were not enrolled under your earned coverage, although these Dependents are not entitled to COBRA on an individual basis. If you do not enroll in COBRA following the loss of your Earned Eligibility or other Qualifying Event, the Dependents that were covered under the Plan when your coverage ended may enroll individually (and spouses may enroll their children with or without enrolling themselves), provided they enroll within the 60-day time limit described on this page.

COBRA enrollment forms may also be downloaded from the forms section of www.sagaftraplans.org/health

Your completed COBRA enrollment form must be received by the Plan within 60 days of the later of:

  • The date your coverage terminated; or
  • The date of your COBRA enrollment offer.

You will have additional opportunities to change your Dependent enrollment during the annual Open Enrollment Period or if you experience a change in family status or another special enrollment qualifying event. 

COBRA Premiums

The premium required for COBRA is determined by:

  • Your eligibility for the Plan’s Extended Career COBRA benefit versus regular COBRA; and
  • The number of Dependents you enroll.

COBRA premium rates are determined in accordance with federal law and are subject to change as permitted by law. The premium is based on a three-tier structure: individual only, individual plus one Dependent, or individual plus two or more Dependents. You can find the current COBRA premiums at www.sagaftraplans.org/health

The SAG-AFTRA Foundation offers financial grants to individuals who have a catastrophic illness or injury and who, due to financial need, cannot afford the COBRA premium. Visit https://sagaftra.foundation/. 

Time Limit for First COBRA Premium Payment

Your first COBRA premium payment is due on the first day of the month immediately following the date on which your Earned Eligibility terminates. You are encouraged to submit your first payment when you enroll in COBRA. However, you have 45 days from the last day of your 60-day enrollment period to make the payment. Coverage will not be granted and Claims will not be considered for payment until your premium is received.

Additionally, coverage will not be verified to any Hospital or Physician before your premium payment is received and processed, and Providers will be advised that you are still in your COBRA enrollment or grace period.

Your first payment must include all premiums required to keep your coverage continuous from the date you lost Earned Eligibility. For example, if you lost Earned Eligibility on December 31, and you make your first premium payment in February, your payment must include the premium for both January and February.

Once your premium is processed, your Notice of Coverage containing your Plan ID cards will be sent to you within 10 business days. You can also print Plan ID cards by logging in to your Benefits Manager at 
www.sagaftraplans.org/health.

COBRA Premium Due Dates

After the Plan processes your COBRA enrollment, a confirmation letter and payment coupons will be mailed to you. You will be sent a new set of payment coupons annually. After your first payment, all subsequent premium payments are due on the first of each month. As required by federal law, there is a 30-day grace period following each due date. However, you should submit the payment by the due date, as coverage will not be granted and Claims will not be considered for payment until your premium is received and posted.

If you make a change in your COBRA, you will receive new payment coupons which reflect your new coverage and premium amount. If you do not receive your coupons within 30 days after enrollment or a change in coverage, please contact the Plan. If you fail to pay your premium by the due date (plus the 30-day grace period) and you do not have an available late payment waiver, you will forfeit your rights to COBRA.

COBRA Premium Payment Procedures

There are several ways to pay your monthly COBRA Continuation Coverage premium. You may pay the premium for more than one month at a time. However, you may not pay the premium for any period beyond the current calendar year.

Automatic payment – The automatic payment plan deducts your monthly premium automatically each month from a U.S. checking or savings account. Payments are deducted on or about the 25th of the month prior to the due date on the 1st. The Plan will continue to deduct the monthly premium as long as you remain continuously eligible for COBRA Continuation Coverage, even if the premium changes. You can sign up online or download an enrollment form.

If you were previously enrolled in the automatic payment plan during your Earned Eligibility, your automatic payments will not continue under COBRA Continuation Coverage. You must complete a new enrollment form for automatic COBRA premium payments.

Pay online – You may pay your premium online with a check or a credit/debit card. Simply enter your checking or savings account number or your credit/ debit card information. You will receive an email confirmation that your payment has been received.

For your protection, online payments and phone payments are non-recurring. This means the Plan will not automatically charge your credit card or debit your account everytime a payment is due. For recurring payments that you do not have to initiate, choose the automatic payment option.

Pay by phone – You may pay your premium by telephone 24/7 with a credit/debit card by calling the Plan at (800) 777-4013 and following the prompts. You will receive a confirmation number indicating your payment has been received. For your security, this is an automated system; Plan staff will not be able to take your credit card information.

Pay by mail – Make your check, money order or cashier’s check from a U.S. bank payable to the SAGAFTRA Health Plan and send it with your coupon in the envelope provided to the address below.

SAG-AFTRA Health Plan Payment Center

P. O. Box 30110

Los Angeles, CA 90030-0110

To help ensure that your premium payment is processed correctly, please write your SAG-AFTRA Health Plan health care ID number (found on your premium billing statement) on your check. Your payment must be received no later than the due date to be on time.

Do not send your payment to the Plan’s regular mailing address or to the SAG-AFTRA union office.

Any check or debit returned to the Plan for any reason will be assessed a fee. You may replace the premium payment and pay the fee using any of the other payment options described previously.

COBRA Late Payment Waiver

If your COBRA Continuation Coverage is terminated because your payment was not received by the due date, including the 30-day grace period, you can reinstate your coverage by using a late payment waiver within 60 days after the premium due date. The Plan allows one late payment waiver per COBRA Continuation Coverage period.

To use a late payment waiver, simply make your payment:

  • Online;
  • By phone at (800) 777-4013; or
  • By submitting your payment with your billing coupon.

You must include payment for all the months required to bring your account current. When your payment is received after the grace period, the Plan will apply our late payment waiver (if available) and your coverage will be reinstated retroactively.

COBRA Changes 

Annual Open Enrollment

If you are enrolled in COBRA Continuation Coverage, your Benefit Period is January 1 through December 31 and your Open Enrollment Period will generally occur from December 1 through January 15. During open enrollment you will have an opportunity to change your Dependent enrollment. You can make these changes by visiting the Plan’s website at www.sagaftraplans.org/health or by completing the Dependent Enrollment Form you receive in your open enrollment packet and returning it to the Plan.

Change in Family Status

You may make Dependent enrollment changes outside of the Open Enrollment Period if you have a change in family status. A change in family status is defined as an increase or decrease in the number of your Dependents, which results from birth, adoption, marriage, divorce, death or loss of Dependent “child” status as defined by the Plan.

If one of these events occurs you will be permitted to change your Dependent’s enrollment status and change your premium tier, if applicable. Submit a written request within 60 days of the change in family status along with the documents establishing proof of Dependent status (see proof documents and special enrollment opportunities). Once the Plan receives your request and required documentation, your change will be processed and you will receive a new set of billing coupons and health care ID cards to confirm your new coverage and premium rate.

Coordinating COBRA Benefits With Other Plans

You and your Dependents may enroll in COBRA even if you or your Dependents are covered by another group health plan on the date Earned Eligibility is terminated in this Plan. You should contact the Plan to determine which plan will be primary and secondary.

If your Earned Eligibility changes from Plan I to Plan II, you may choose COBRA Plan I coverage in lieu of Plan II Earned Eligibility coverage – but not both.

If you or your spouse is covered by Medicare, you may also enroll in COBRA Continuation Coverage. Medicare will be your primary plan and this Plan will be your secondary plan. Please see the section on “Coordination of Benefits with Medicare,” for important information on how your benefits will be affected if you do not enroll in Medicare when you are eligible to do so.

Termination of COBRA 

Your COBRA will terminate on the earlier of:

  • The first of the month for which you do not pay your premium by the due date; 
  • The first of the month after the month in which Social Security determines you are no longer totally disabled if your extended COBRA is based on you being totally disabled;
  • The first of the month following the expiration of the maximum COBRA period for which you qualify;
  • The first of the month for which you qualify for Earned Eligibility, or
  • The date on which the Plan no longer provides health coverage.

Total Disability Extension

How the Plan Defines “Totally Disabled”

An adult Participant or adult Dependent is “Totally Disabled” if he or she is prevented, solely because of sickness or accidental bodily injury, from performing the material and substantial duties of his or her regular occupation. A minor Participant or minor Dependent is “Totally Disabled” if he or she 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.

If you or your enrolled Dependent is considered Totally Disabled when Earned Eligibility or COBRA ends, the disabled individual may be entitled to an extension of coverage for a maximum of 12 months beginning with the first month following the month that existing coverage ends. The disabled individual must pay the required Plan premium. If the disabled individual qualifies for Medicare, he or she must enroll in Medicare Parts A and B. The Plan will pay benefits as if Medicare was the primary coverage even if the disabled individual does not enroll in Medicare.

Coverage is available under this provision only if the disabled individual is considered Totally Disabled as defined by the Plan and is not covered by any other group health plan, with the exception of Medicare.

All requests for the total disability extension must be approved by the Plan’s medical consultant.

Total Disability Coverage Benefits

Only the disabled individual may be covered under the total disability extension. Other family members are not covered. However, family members may be entitled to coverage under COBRA.

Length of Total Disability Coverage Extension

The total disability extension is available for a maximum of 12 months and will be granted only once for the same disability. If you regain Earned Eligibility during extended disability coverage, you will be able to use any remaining months of the total disability extension when you subsequently lose Earned Eligibility, provided that you are still considered Totally Disabled from the same disability. This provision also applies to Dependents on the total disability extension.

If you recover from one disability, regain Earned Eligibility, and subsequently become Totally Disabled from a new and different disability, you will be entitled to another 12 months of total disability extension for the new disability.

If your total disability ends during the middle of the month, as commonly occurs in the case of pregnancy, you must pay the full monthly Plan premium. The amount will not be prorated.

Option to Choose COBRA or Total Disability Extension

If you or your Dependent is Totally Disabled at the time Earned Eligibility ends, you have two choices for coverage as described below:

  • Option 1Enroll in COBRA  If this option is selected, the Totally Disabled individual may continue coverage under the total disability extension when the maximum number of months of COBRA have elapsed – provided he or she is still considered Totally Disabled and is not covered under another group health plan.
  • Option 2 - Elect coverage under the total disability extension   If this option is chosen, the disabled individual may continue coverage under COBRA when the maximum number of total disability extension months have elapsed.

If you choose Option 2 and your Dependents do not enroll in COBRA  while you are covered under the total disability extension, they may be added to your COBRA  following the total disability extension.

If you choose Option 2 and you gain Dependents during the 12-month period, you may change your coverage from the disability coverage – which does not include Dependent coverage – to COBRA Continuation Coverage. However, in doing so, you will forfeit the remaining months of coverage under the total disability extension, and you will not be entitled to return to disability coverage after your COBRA Continuation Coverage ends (unless you become Totally Disabled due to a new disability).

In addition, if the disabled individual does not want to choose either of the options set forth above and if they are eligible for Medicare based on their disability, they can instead access the SAG-AFTRA Health Plan / Via Benefits program to explore options for individual Medicare plans offered through Via Benefits.

Extended Coverage for Military Service

In accordance with the Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA), the Plan provides certain benefits for Participants who have military service. Congress enacted USERRA to provide protection to individuals who are members of the uniformed services. Uniformed services are defined as:

  • The Armed Forces, Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty for training or full-time National Guard duty;
  • The Commissioned Corps of the Public Health Services; and
  • Any other category of persons designated by the president in time of war or national emergency.

You will have the choice of using your Earned Eligibility before continuing coverage under COBRA. Alternatively, you may immediately enroll in COBRA Continuation Coverage and freeze your Earned Eligibility for up to five years of uniformed service. In either case, the Earned Eligibility or COBRA premium will be waived for up to 24 months while you are in military service.

Upon your return from military service, you may use any frozen Earned Eligibility that remains, provided you notify the Plan of your intent to resume coverage and that coverage is resumed within one year of your return from uniformed service. Please contact the Plan for additional information if you are going to serve or have served in the military.