SAG-AFTRA Health SPD

Qualifying for SAG-AFTRA Health Plan Coverage

The Plan provides an extensive package of health care benefits to eligible Participants and their qualified Dependents. To receive coverage, you must meet the Plan’s eligibility requirements and pay the required premiums.

NOTE: Effective January 1, 2021, the Plan consists of one Active Plan for Participants who qualify. Previously, there were two plan levels available — Plan I and Plan II — depending on your Covered Earnings and other requirements. Participants and Dependents who previously qualified for coverage under Plan II and were in the midst of their Benefit Period as of January 1, 2021 will continue to be covered under Plan II, with certain modifications, until their current Benefit Period runs out. No new enrollments (other than additions of family members through special enrollments triggered by a life event, see page 20) will be permitted in Plan II on or after January 1, 2021.

This section describes the Plan’s requirements for Earned Eligibility. The sections that follow describe the Plan’s premiums and payment rules, and the options that may be available to you if you lose Earned Eligibility.

The Plan does not provide any benefits for Claims for services, supplies or treatments incurred or received after eligibility for coverage under this Plan has ended, even if the condition requiring the service, supply or treatment developed when you were eligible for coverage under this Plan, unless you have elected COBRA.

Understanding Covered Earnings

Before reviewing the different ways you can become eligible for coverage, it is important to understand Covered Earnings under the Plan.

Covered Earnings are earnings paid to you and reported to the Plan on your behalf by a Contributing Employer for Covered Employment. Covered Employment is work performed under a Collective Bargaining Agreement that requires the employer to make contributions to the Plan on your behalf with respect to those earnings.

Special Rule for Work Performed Under the Non-Broadcast/Industrial Code

If you are employed by a company in which you or a family member has an ownership or controlling interest, or which you fund directly or indirectly, earnings from that company will not qualify as Covered Earnings for purposes of this Plan unless the project for which the earnings are reported was produced for one or more clients who are third parties (entities not owned, funded or controlled, directly or indirectly, by you, your spouse, parent or child, or by a trust for your benefit or your spouse, parent or child).

Earnings Not Considered for Eligibility (Non-Covered Earnings)

Contributions to the Plan are not required to be made for non-Covered Earnings. As such, non-Covered Earnings do not count toward eligibility for benefits. Examples of non-Covered Earnings include but are not limited to:

  • Payments for various penalties and allowances such as meal penalties, payments for rest period violations, traveling, lodging or living expenses, interest or liquidated damages (late fees), reimbursements for special hair or dress, payments for wardrobe damage or reimbursements for the use of a personal automobile or other equipment.
  • Payment for services not covered by a SAG-AFTRA Collective Bargaining Agreement, such as producing, directing and writing work.

Additional examples of non-Covered Earnings may be obtained by calling the Plan at (800) 777-4013 or online.

Earned Eligibility Requirements

Meeting the qualifications for Plan coverage is called Earned Eligibility. Most Participants will qualify based on Covered Earnings or Alternative Days worked; however, certain types of Participants qualify under separate rules:

  • Covered Network / Station Staff and Roster Artists qualify under separate rules (see page 23). 
  • Staff of SAG-AFTRA (the union), the SAG-AFTRA Foundation, the SAG-Producers Pension Plan, and the AFTRA Retirement Fund also qualify under separate rules (see page 23)
  • Retirees (including Senior Performers) taking a pension from the SAG-Producers Pension Plan or the AFTRA Retirement Fund qualify under separate rules (see page 24).

The minimum requirements for Earned Eligibility, including the special rules, are outlined below. In addition to satisfying one of these requirements, if you enroll in coverage, you must pay the Plan premium. Refer to www.sagaftraplans.org/health for the current premiums.

 

Qualifying for Plan Coverage — For Participants under age 65

 

Covered Earnings Eligibility Threshold

You must meet the Eligibility Threshold (currently $25,950) in Covered Earnings during your 12-month Base Earnings Period.

Both sessional and residual earnings are included toward the Eligibility Threshold.

Alternative Days Eligibility Threshold

You must meet the Eligibility Threshold for Eligibility Days (currently 100 days) worked during your 12-month Base Earnings Period under specified contracts.

Active Plan (formerly Plan I) Earnings Threshold

You must earn at least $25,950 in Covered Earnings in your Base Earnings Period to receive Earned Eligibility for Plan I health coverage.

Note: In future years, these minimum earnings requirements may increase. If so, the number of days required for Alternative Days Eligibility will be increased proportionately.

Eligibility Days are determined by dividing your total applicable sessional Covered Earnings by the SAG-AFTRA minimum daily rate for the covered Collective Bargaining Agreement, which is based on the type of production. As of January 1, 2021, Sessional Covered Earnings from employment under the following agreements may be used to satisfy the Eligibility Days requirement for Alternative Days eligibility: Codified Basic (Theatrical) Agreement, Television Programming Agreement, Television Commercials Agreement, Infomercials Agreement, New Media Agreement, Interactive Media Agreement, Corporate / Educational & Non-Broadcast Contract, Music Videos Agreement, Television Network Code and New Media Network Code (as set forth in the table).

Sessional Covered Earnings from employment under the following agreements may NOT be used to satisfy the Eligibility Days requirement for Alternative Days eligibility: Sound Recordings Code, the Audiobooks Agreement, the Commercial Radio Broadcasting Agreement, the Radio Commercials Agreement, any Regional or Local AFTRA (or SAG-AFTRA) code for Television or Radio Broadcasting or any other AFTRA or SAG-AFTRA Collective Bargaining Agreement side letter or other agreement requiring contributions to be made to the AFTRA Health Plan or to this Plan (with the exception of those identified as counting toward Alternative Days eligibility in the table).

In addition, Alternative Days eligibility is NOT available to employees of a radio or television station or network or to Staff Employees.

SAG-AFTRA Agreements

Codified Basic (Theatrical)

Yes

Television Programming (Network, Cable, Public, Made for Video, Animation, Exhibit A)

Yes

Television Commercials

Yes

Infomercials

Yes

New Media

Yes

Interactive Media

Yes

Corporate/Educational

Yes

Music Videos

Yes

Television Network Code (Front-of-the-book)

Yes

New Media Network Code (Front-of-the-book)

Yes

Sound Recordings Code

No

Audiobooks

No

Commercial Radio Broadcasting

No

Radio Commercials

No

Regional or Local Code for Television or Radio Broadcasting

No

Network/Station Staff

No

Important Note: The Plan’s prior Age and Service rules for qualifying for any Plan coverage are eliminated effective on or after January 1, 2021. The Plan is offering a new option that may apply to individuals who previously qualified under Age and Service, called Extended Career COBRA, which is described on page 31.

How You First Qualify for Earned Eligibility

Base Earnings Period

The Plan establishes your Base Earnings Period based on the first four consecutive Calendar Quarter periods during which you meet one of the thresholds for Earned Eligibility. In future years, your Covered Earnings during this same four-quarter period will determine if you continue to qualify for Plan benefits.

You become eligible for 12 months of health coverage.
Subsequent Covered Earnings or Eligibility Days are not considered until your next Base Earnings Period, which will then be used to determine your continuing eligibility status.

Benefit Period

Once you qualify for Earned Eligibility, you are eligible for 12 months of coverage once the Plan reviews your Covered Earnings and Eligibility Days, provided that you pay the required Plan premium. This 12-month period of coverage is referred to as your Benefit Period. The Benefit Period begins on the first day of the Calendar Quarter after the Plan determines you are eligible for coverage, as outlined below.

 

Base Earnings Period/Benefit Period

January 1 – December 31

February 15

April 1 – March 31

April 1 – March 31

May 15

July 1 – June 30

July 1 – June 30

August 15

October 1 – September 30

October 1 – September 30

November 15

January 1 – December 31

*You can expect to receive your enrollment packet approximately a week after we determine eligibility. You can also check Benefits Manager to see your progress toward earning eligibility.

Generally, the review and determination of your eligibility occurs approximately six (6) weeks after the end of your Base Earnings Period. This six-week period is needed for the Plan’s participating employers to submit reports of your earnings and for the Plan to process these reports.

Here's an example of how this works:

December 31 $0
March 31 $4,000
June 30 $10,000
September 30 $19,000
Total Covered Earnings $17,340

In This Example:

The Participant begins Covered Employment in January. By the end of the third Calendar Quarter (September 30), the Participant satisfies the Plan’s Covered Earnings requirement. To determine eligibility, the Plan looks back at the four-quarter period ending September 30 (since that is when the earnings requirement was met). As such, the Participant’s Base Earnings Period becomes October 1 through September 30. The Participant’s Benefit Period begins January 1. 

 

how timing works

Network / Station Staff Eligibility

The qualification rules for Plan coverage are different if you are a full-time employee of a radio or TV station or a network that is a Contributing Employer and you have Covered Earnings in that capacity.

You will qualify to enroll for coverage on the first day of the month after you complete 30 days of full-time employment with a Contributing Employer if your scheduled annual Covered Earnings meet either of the earnings thresholds described earlier in this section.

In addition, if you are a network or station staff employee transferring into the Plan as part of a group from a Contributing Employer’s group health plan, you will qualify for coverage immediately (with no 30-day waiting period) upon termination of that employer’s coverage if:

  • Your scheduled annual Covered Earnings meet either of the earnings thresholds and you were enrolled in the employer’s plan for at least 30 days immediately preceding the transfer; and
  • The transfer was made according to the terms of a Collective Bargaining Agreement with SAG-AFTRA.

Benefit Period

If your coverage starts at the beginning of a Calendar Quarter, your Benefit Period will be the 12-month period beginning on the date your coverage starts. If your coverage start date is not on the first day of a Calendar Quarter, your Benefit Period will be the 12-month period that starts on the Calendar Quarter which follows your coverage start date. The one or two months prior to the start of your initial Benefit Period is called interim eligibility.

Network/Station Staff Eligibility

February 1, March 1 or April 1 April 1 – March 31
May 1, June 1 or July 1 July 1 – June 30
August 1, September 1 or October 1 October 1 – September 30
November 1, December 1 or January 1 January 1 – December 31

Covered Roster Artist Eligibility

A special qualification rule applies to certain roster artists, including newly signed roster artists, signed to an exclusive recording agreement with a signatory record label that is party to the Covered Roster Artists side letter agreement to the current SAG-AFTRA National Code of Fair Practice for Sound Recordings (Sound Code). The Sound Code requires the signatory record label to make an annual special payment to the Plan on the roster artist’s behalf to provide one year of coverage under Plan II.

Under this alternate eligibility rule, if your royalty earnings from the label over the current and immediately preceding six-month reporting period are insufficient for you to meet the Plan’s earnings requirements, you will be eligible to enroll in Plan II coverage for one year provided that you pay the premium and the label makes the annual special payment required under the Sound Code. You may also enroll in one year of Plan II coverage if you are a new artist who recently signed a royalty agreement with a signatory label and you do not yet have sufficient earnings to qualify under the earnings requirements, provided that you pay the premium and the label makes the required annual special payment to the Plan.

Note that the record label is required to make the special payment on your behalf only if you enroll in the Plan and pay the required premium in full by the due date.

Benefit Period

The special employer payment will provide one year of coverage beginning as described below.

Covered Roster Artist Eligibility

January – June 30

October 1

October 1 – September 30

July 1 – December 31

April 1

April 1 – March 31

Retirees (Including Senior Performers)

If Medicare currently pays your primary benefits, which is the case for most Retirees, you will have access to the SAG-AFTRA Health Plan / Via Benefits program as of January 1, 2021, unless you qualify for Earned Eligibility for Plan coverage, as set forth below.

Retirees can qualify for Earned Eligibility by meeting one of the following requirements. 

Covered Earnings Eligibility Threshold    

Retirees must meet the Eligibility Threshold (currently $25,950) in Covered Earnings during their Base Earnings Period. Only sessional earnings are included in Covered Earnings, except if you become a Retiree while covered under the Active Plan. In that case, the Plan will include both sessional and residual earnings in Covered Earnings during your first earnings evaluation as a Retiree; afterwards, the Plan will include sessional earnings only in subsequent evaluations. 

Alternative Days Eligibility Threshold
Retirees must meet the Eligibility Threshold for Eligibility Days (currently 100 days) worked under specified contracts during their Base Earnings Period. For a list of contracts.
Eligibility Days are determined by dividing total applicable sessional Covered Earnings by the SAG-AFTRA minimum daily rate, which is based on the type of production.

If you meet the Earned Eligibility requirements, the Plan pays your primary benefits, and Medicare (if you are enrolled) pays secondary.

Retirees who do not qualify for Earned Eligibility under the Plan will have access to the SAG-AFTRA Health Plan / Via Benefits program, where you can shop with Via Benefits for a range of individual insurance policies that you may purchase to enhance and supplement your Medicare coverage. In addition, Senior Performers may be eligible for the SAG-AFTRA Health Plan Senior Performers Health Reimbursement Account (HRA) Plan. 

How You Qualify for Earned Eligibility as a Retiree

Benefit Period

Retirees can also qualify for Earned Eligibility under the Plan if they meet the Earned Eligibility requirements set forth on page 11. Beginning in 2021, the Plan is transitioning those Retirees to a calendar-year Benefit Period for all Retirees in order to align the Plan with Medicare’s annual calendar, making it easier for Retirees to work with Medicare. The Medicare Annual Enrollment Period is October 1 to December 15.

To determine whether a Retiree is eligible for Active Plan coverage or has access to the SAG-AFTRA Health Plan / Via Benefits program, the Plan will evaluate earnings from October 1 to September 30. This will determine Earned Eligibility for the next calendar year — January 1 to December 31.

Retirees will transition to the calendar-year Benefit Period as follows:

Retiree Scenario

Retirees with Medicare primary as of October 1, 2020, and Retirees with Plan primary coverage and a current Benefit Period ending on December 31, 2020.

Alignment to Calendar-Year Benefit Period

The Plan evaluated earnings from October 1, 2019 to September 30, 2020.

  • If the individual was not a Retiree as of October 1, 2019, both sessional and residual earnings are used in its evaluation.
  • If the individual was a Retiree as of October 1, 2019, only sessional earnings are used in its evaluation. If the Retiree met the Earned Eligibility requirements, Active Plan coverage runs from January 1, 2021 to December 31, 2021.

If the Earned Eligibility requirements were not met, the Retiree will have access to the SAG-AFTRA Health Plan / Via Benefits program effective January 1, 2021, with Senior Performers eligible for the HRA Plan.

The Retiree’s next earnings evaluation is in October 2021. The Plan will evaluate earnings from October 1, 2020 to September 30, 2021, to determine Earned Eligibility offered for calendar year 2022.

  • If the Retiree meets the Earned Eligibility requirements, coverage under this Plan is offered for January 1 through December 31.
  • However, if the requirements are not met, the Retiree will have access to the SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan. Their earnings will be evaluated again for the next October 1 through September 30 Base Earnings Period to see if they requalify for Earned Eligibility beginning January 1 of the following year.

This practice will apply in subsequent years.

 

Retiree Scenario

Retirees with Plan primary coverage and a Benefit Period ending March 31, 2021, June 30, 2021 or September 30, 2021.

Alignment to Calendar-Year Benefit Period

The Plan reviewed earnings from October 1, 2019 to September 30, 2020, and if the Retiree satisfied the Earned Eligibility requirements, their Plan primary coverage is extended through December 31, 2021.

  • If the individual was not a Retiree as of October 1, 2019, both sessional and residual earnings are used in its evaluation. 
  • If the individual was a Retiree as of October 1, 2019, only sessional earnings are used in its evaluation. 

If the requirements were not met, the individual’s current coverage runs out at the end of their 2021 Benefit Period (March 31, 2021, June 30, 2021 or September 30, 2021). At that point, the individual will be offered access to the SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan.

The Retiree’s next earnings evaluation is in October 2021. The Plan will review earnings from October 1, 2020 to September 30, 2021, to determine the coverage offered for calendar year 2022. The Plan will include sessional earnings only in this evaluation. 

  • If the Retiree meets the Earned Eligibility requirements, Plan coverage is offered for January 1 through December 31.
  • However, if the requirements are not met, the Retiree will be offered access to the SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan. Their earnings will be evaluated again for the next October 1 through September 30 Base Earnings Period to see if they requalify for Earned Eligibility January 1 of the following year.

This practice will apply in subsequent years.

 

Retiree Scenario

Participants reaching Retiree status in 2021 or after, while covered under the Plan.

Alignment to Calendar-Year Benefit Period

The Participant can run out their current coverage. The Plan will evaluate earnings before coverage ends to determine continued Earned Eligibility. The Plan will include residual and sessional earnings for Participants who were not Retirees at the start of their current Base Earnings Period.

  • If the Participant meets the Earned Eligibility requirements, they can enroll in Active Plan coverage for their next Benefit Period. 
  • However, if the requirements are not met, the Participant will be offered access to the SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan.

The Plan will evaluate earnings again in October of the same year for the Base Earnings Period October 1 through September 30, to determine Earned Eligibility for the next calendar year. The Plan will include sessional earnings only in this evaluation. 

  • If the Participant meets the Earned Eligibility requirements, Plan coverage is offered for January 1 through December 31.
  • However, if the requirements are not met, the Participant will be offered access to SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan. Their earnings will be evaluated again for the next October 1 through September 30 Base Earnings Period to see if they have Earned Eligibility for the Benefit Period starting January 1 of the following year.

This practice will apply in subsequent years. Example:

  • A Participant has Plan primary coverage from July 2021 through June 2022. They become a Retiree in February 2022.
  • The Participant’s current coverage runs out on June 30, 2022.
  • In May of 2022, the Plan evaluates the Participant’s earnings during their Base Earnings Period (April 1, 2021 to March 31, 2022).
  • The Participant meets the requirements for Earned Eligibility and can enroll in the Plan beginning July 1, 2022.
  • The Plan evaluates the Participant’s earnings again in October 2022, for the Base Earnings Period October 1, 2021 to September 30, 2022. The Participant meets the Earned Eligibility requirements, and can continue coverage through December 31, 2023.
  • The Plan evaluates the Participant’s earnings in October 2023, for the Base Earnings Period October 1, 2022 through September 30, 2023. This time, the Participant does not meet the Earned Eligibility requirements. The Participant is given access through the SAG-AFTRA Health Plan / Via Benefits program. Also, the Participant meets the criteria for Senior Performer status, so the Participant is eligible for the SAG-AFTRA Health Plan Senior Performers Health Reimbursement Account Plan (HRA).
  • The Participant may enroll in the program and HRA for coverage beginning January 1, 2024 to December 1, 2024.

 

Retiree Scenario

Individuals reaching Retiree status in 2021 or after, while NOT covered by the SAG-AFTRA Health Plan.

Alignment to Calendar-Year Benefit Period

Individuals who retire while not covered by the SAG-AFTRA Health Plan will be evaluated for Earned Eligibility for the calendar year following their retirement date. For example, if an individual becomes a Retiree in April 2024, they may be eligible for coverage beginning January 1, 2025.

The Plan will evaluate the individual’s earnings in October, for the Base Earnings Period October 1 through September 30, to determine the coverage offered for the next calendar year. The Plan will include residual and sessional earnings for an individual who was not a Retiree at the start of that earnings period; otherwise, only sessional earnings will be included.

  • If the Participant meets the Earned Eligibility requirements, coverage is offered for January 1 through December 31.
  • However, if the requirements are not met, the Participant will be given access to the SAG-AFTRA Health Plan / Via Benefits program, with Senior Performers eligible for the HRA Plan. Their earnings will be evaluated again for the next October 1 through September 30 Base Earnings Period to see if they requalify for Earned Eligibility January 1 of the following year.

This practice will apply in subsequent years.