Frequently Asked Questions
Please see the Eligibility section of our website for current eligibility requirements.
Once you have met the earnings or days worked requirement for eligibility, the Plan will send you a Notice of Qualification. You will receive your Notice of Coverage, which will include your health care ID cards and a copy of the Summary Plan Description, after the Plan receives your premium payment. The notice outlines your eligibility period, type of eligibility and benefit coverage. If you believe you have met the eligibility requirement but do not receive a Notice of Qualification, please call us at (800) 777-4013.
The Notice of Qualification packet is sent to participants who have met eligibility requirements and qualify for benefits. This packet contains the dependent enrollment form and billing statement, if applicable, as well as certain forms we need you to complete in order for us to administer your benefits.
Under the SAG-AFTRA Health Plan, you automatically qualify for family coverage when you qualify for either Plan I or Plan II coverage. To cover your family, you only need to pay a slightly higher premium than you would pay for individual coverage.
Yes, provided you supply the proper legal documentation.
Your health care ID (HCID) cards are mailed approximately 7-10 days after your premium payment is received.
Yes, once you've made your payment, your health care ID (HCID) cards are typically available in your Benefits Manager by the first day of your benefit period.
No, you are not required to use the insurance coverage. If you meet the requirements for earned eligibility but do not want to use the insurance, simply don’t pay the premium and you will not receive coverage.
If your coverage in this Plan is terminated because you did not pay your premium and this coverage would have been primary to another entertainment health plan, coverage for you and/or your dependents under the other plan may be reduced or eliminated. You should contact your other plan for further information about how your coverage may be affected should you choose to let your coverage under the SAG-AFTRA Health Plan lapse or choose not to enroll your dependents.
Please allow 5-7 business days to process your dis-enrollment. You will receive a confirmation letter in the mail once your form has been processed. For faster service, log in to your Benefits Manager to make changes to your dependents and submit your premium payment. However, note that changes to your dependent enrollment can only be made during your open enrollment period.
If you do not meet the minimum earnings or days requirement for continued earned eligibility, you will receive a notice advising you of your options, including the Plan's COBRA program, and conversion options. If you are totally disabled, you may be entitled to an extension of coverage. You can also seek private insurance coverage.
What is the reason for the three-month waiting period between the base earnings period and the benefit period?
The three-month waiting period is needed for employers to submit reports of earnings and for the Plan to process these reports. This allows the Plan to be sure that we have recorded all of your earnings and can calculate eligibility for coverage.
No. Contributions to the Plan and eligibility for benefits are made on an individual basis.
Can I pay the difference of what I need to qualify for benefits? For example, if I'm $40 short of meeting the earnings requirement, can I pay $40 to the Plan?
No. The earnings or days of employment requirements are based solely on your earnings or days of employment covered by the collective bargaining agreement. You cannot pay for any shortfall. The premium you pay for coverage does not count as earnings for eligibility.
Yes. Under federal law, Trustees have the authority to change the eligibility requirements and benefits provided under the Plan.
Yes. The minimum payment is for one quarter (3 months). You can pay in advance for up to four quarters of your current eligibility period.
Like all Plan rules, premium amounts are subject to review by the Trustees on an ongoing basis. However, unlike COBRA premiums, which are required under federal law to be adjusted every year, the amount of premium for the earned coverage is determined solely by the Trustees, based on the financial condition of the Plan.
Your premium is due by the 1st day of each calendar quarter for Earned Eligibility coverage, or by the 1st day of the month for Senior Performers or Surviving Dependent benefits. For example, the payment for the 1st quarter of the calendar year (January through March) is due on January 1. There is a 15-day grace period. Plan coverage will not be extended until your payment is processed. You are encouraged to submit your premium prior to the due date to allow processing time and avoid any interruption in your coverage. The due date applies even when traveling. The grace period is for unforeseen circumstances.
In some cases, your dependents may be entitled to enroll in the program even if you do not elect coverage. Call us at (800) 777-4013 for more information.
You can make multiple changes during your Open Enrollment Period regardless of whether the payment is made or not. The only restriction is that once payment is made you can no longer make changes online. Additional changes must be made using the New Dependent Form. You can also add dependents by logging in to your Benefits Manager.
Please see Premiums section for current premium rates.
You can pay your premium in any of the following ways:
- Automatic payments. Sign up in your Benefits Manager, and your premium will be deducted from the checking or savings account you designate.
- One-time payment using your credit/debit card or check. You can do this in your Benefits Manager, or simply visit the premium payments page.
- Pay by phone at (800) 777‐4013 using a credit/debit card.
- Send your check, money order or cashier’s check from a U.S. bank payable to SAG-AFTRA Health Plan, P.O. Box 30110, Los Angeles, CA 90030-0110. Your payment must be received by the due date.
If you are eligible and do not receive payment information in the mail by the 15th of the month before the start of the calendar quarter (for example, by December 15 for the first calendar quarter the following January), you should contact us at (800) 777-4013. You can also pay your premium online by logging in to your Benefits Manager or making a one-time payment. Please note, you will not receive quarterly payment coupons if you are enrolled in automatic payments.
To ensure that you receive all quarterly billing statements and other important Plan information, be sure to keep your contact information, including your mailing address and email address, current.
Enrolled dependent(s) are qualified family members the participant has chosen to cover for a specific eligibility period. Once the premium is received the participant and their dependent(s) will have health coverage. Dis-enrolled dependent(s) are individuals the participant chose not to cover for a specific eligibility period. Dis-enrolled dependents are not eligible for health coverage or COBRA. Dependents may only be enrolled or dis-enrolled during the participant's open enrollment period or a life event occurs.
Log in to your Benefits Manager to enroll new dependents or submit a New Dependent Form and all required documents to consider your dependent(s) as qualified. Examples are a recorded marriage certificate for a spouse or a recorded birth certificate for your dependent child. If adding the dependent changes your tier rate, we will send you a new billing statement for the difference in the new premiums.
Yes. You may make dependent enrollment changes outside of the Open Enrollment Period if you experience a life event that results in a change in family status.
If one of these events should occur, you will be permitted to change your dependent's enrollment status and change your premium tier (if applicable) based on the addition or loss of that dependent. A written request must be submitted to the Plan within 60 days from the date that the life event occurred.
Yes. If you are dis-enrolling a dependent due to divorce or death, you are required to submit a copy of the final judgment of divorce, or recorded death certificate to the Plan. In the event of divorce, you must notify the Plan within 60 days of the date of your divorce in order for the dependent to receive individual COBRA rights.
If I dis-enroll my dependents while on earned coverage, what will happen if I qualify for the senior performers benefit?
You will have the opportunity to make changes to your enrolled dependents if and when you qualify for the senior performers benefit.
If I have coverage with another entertainment industry plan, will the special coordination of benefits rules still apply?
Yes. The current entertainment industry coordination of benefits rules apply to all tier levels. If you qualify for coverage in the SAG-AFTRA Health Plan and another entertainment industry plan, you should contact us and your other carrier for their coordination of benefits rules.
If your coverage in the SAG-AFTRA Health Plan is terminated because you did not pay your premium and this coverage would have been primary to another entertainment plan, coverage for you and/or your dependents under the other plan may be reduced or eliminated. You should contact your other plan for further information about how your coverage may be affected should you choose to let your coverage under this Plan lapse or choose not to enroll your dependents.
If your payment is not received by the due date, your earned coverage will be terminated and you will not be eligible for coverage until your next benefit period, provided you re-qualify and meet the minimum earnings requirement. You cannot enroll in the COBRA Program.
The Plan allows one late payment waiver per Benefit Period with a maximum of two late payment waivers per lifetime for earned eligibility. If your coverage is terminated because your payment was not received by the due date you can reinstate your coverage by using a late payment waiver. Senior performers and dependents covered under the surviving dependent benefit are eligible for one late payment waiver per benefit period. Participants may use a late payment waiver up to the last day of the quarter for which a payment is due.
No. The benefits and coverage provided under the Plan are not contractual benefits. The benefits may be reduced, modified or discontinued by action of the Trustees at any time. Your health plan benefits will never vest.
You must request reconsideration of a fully or partially denied claim within 180 days of the denial of the claim. The request must be in writing, submitted to the Chief Executive Officer and accompanied by a statement giving the reasons the denial is believed to be incorrect.
When you use a network provider, benefits are automatically paid directly to the provider of service. If you use a non-network provider, the Plan must have your written authorization to pay the provider directly.
Yes. Birth control pills are covered under the prescription drug plan. In addition, diaphragms, Norplant, IUD's and Depo-Provera are also covered.
The Plan will cover nutritional counseling for certain chronic illnesses. Benefits are limited to one initial and two follow-up visits and are only covered if the provider is a Registered Dietitian (R.D.). There is no coverage for weight loss programs.
I really don't like wearing glasses and I can't wear contacts. Will the Plan pay for surgery to correct my vision?
No. Any surgery performed to correct a refractive error, such as LASIK, is not covered under the Plan. However, Vision Service Plan (VSP), the Plan's vision program provider offers discounts on laser vision surgery to Plan I participants.
You cannot elect which plan you want as your primary plan. The determination of which plan pays first is based on NAIC (National Association of Insurance Commissioners) guidelines and specific plan rules.
Pre-authorizations are required for eyelid, nasal and certain breast surgeries because these procedures often fall under the cosmetic exclusion.
Pre-authorizations are also required for back surgery, bariatric surgery, gender reassignment surgery, neuro-psychological testing, organ transplants, outpatient private duty nursing and sleep studies.
Please have your Physician submit a request of the proposed procedure, including the procedure codes, along with a copy of the history and physical report, clinical notes and test results. For eyelid, nasal and breast surgeries your Physician must also include diagnostic quality preoperative photographs. Physicians may fax their request to the Pre-Authorization department at (818) 973-4473.
Yes. Claims incurred in foreign countries are covered. If possible, call (800) 810-BLUE to find out what providers are in the BlueCard network and show the provider your health care ID Card. The provider may or may not file the claim for you. If you have to pay for services upfront, submit itemized bills to the Plan in English, if possible. Dental claims should be sent to Delta Dental. Pharmacy claims should be sent to Express Scripts.
Occupational injuries or illnesses are normally covered under Workers Compensation Insurance. On-the-job injuries or illnesses are not covered by the Plan. If you work for a loan-out company, you should make sure that your employer covers you under their Workers Compensation policy.
The SAG-AFTRA Health Plan will coordinate benefits with other plans in which you have coverage. If you are entitled to primary coverage with another entertainment industry health plan but choose not to pay the premium required for that coverage, the SAG-AFTRA Health Plan will continue to consider your claims as secondary.
The SAG-AFTRA Health Plan will coordinate benefits with other plans in which you have coverage. Before we can process your claim, Plan rules specify that we must determine which plan should pay first and which plan should pay second.
My family and I have primary coverage through an HMO but don't like our choice of doctors. Can we just use the doctors under the SAG-AFTRA Health Plan?
It is extremely important that you use your HMO when it is your primary plan. If you do not, your benefits under the SAG-AFTRA Health Plan are reduced by 80% and you will have much higher out-of-pocket expenses.
The Board of Trustees has designed a comprehensive program of Plan benefits for you and your eligible dependents. However, not all services you receive are covered by the Plan. For covered services, you will be responsible for deductibles, co-payments and co-insurance amounts. You may also be responsible for amounts that exceed the Plan's allowance. If your doctor performs services that the Plan does not cover, you are responsible for the entire bill. It is not the intent of the Plan to dictate what type of treatment is appropriate for a patient, nor do we wish to imply that a specific treatment is not beneficial to your condition, but rather that, benefits can only be extended within the provisions and limitations of the Plan.
If a claim has an accident or injury diagnosis, there may be another plan or entity which should provide benefits. If the injury occurred at work, Workers Compensation would cover the benefits. If a third party is liable for the accident, they would be responsible for the benefits. In all of these cases, we need information from you to determine how your medical expenses should be paid.
The Plan will only pay for the initial pair of eyeglasses or contact lenses of Plan I participants following a covered eye surgery (i.e., cataract surgery). Otherwise glasses are not covered except for the discounts available under the vision plan with Vision Service Plan (VSP).
- By fax from your doctor – Give your ID number to your doctor and have your doctor call (888) 327-9791 to obtain fax instructions.
- Online – Visit www.express-scripts.com and follow the instructions to register for Express Scripts Pharmacy’s home delivery services. Once you've registered, click “Manage prescriptions” and follow the instructions. Express Scripts will contact your doctor to transfer your current prescriptions to the home delivery pharmacy.
- By mail – Log in to your Express Scripts online account. If you don’t have an account, register here. Once you are logged in, go to “Health and Benefits Information,” select “Print and Request Forms and Cards,” locate the mail order form and mail the form with your prescriptions to the address on the form. If you need help, contact Express Scripts. You can also request Express Scripts to mail you a form; this takes 7-10 days.
Any medication that requires more than two refills of a 30-day supply is considered long-term and must be ordered through Express Scripts home delivery or a participating Smart90 Walgreens Network pharmacy. Please see the prescription drugs page for more information.
The SAG-AFTRA Health Plan also requires that all specialty medications be obtained by mail through Express Scripts’ specialty pharmacy, Accredo beginning with the first fill.
You save money by using an in-network dentist because dentists in the Delta Dental network have agreed to charge lower fees for services. If you use a Delta Dental PPO dentist, your diagnostic and preventive services are covered at 100% with no deductible. In-network dentists file the claim forms for you and you are not required to pay the entire bill in advance. You may, however, be required to pay your portion of the covered services at the time of initial service and the dentist will bill Delta Dental for the balance.
If you use an out-of-network dentist, you may be required to pay the entire bill in advance. You must file a claim form and submit it to Delta Dental. If your dentist's fees exceed the Plan's allowance, you are also responsible for the difference between the Plan's payment and the dentist's actual charges.
All dental claim forms, including claims for services performed outside the United States, should be sent to:
Delta Dental Plan of California
P.O. Box 997330
Sacramento, CA 95899-7330
Download a claim form here.
Please note, if you use a Delta Dental in-network dentist, you do not need to submit a claim form.
Contact your current dentist's office and ask them if the dentist is already a part of the Delta Dental PPO network. To find a new dentist, call Delta Dental at (800) 427-3237 or visit the SAG-AFTRA Health Plan Delta Dental website.
Three out of four dentists in the U.S. are Delta Dental dentists, and have an agreement with Delta Dental which means their fees are preapproved, they handle claims paperwork free of charge and they call Delta Dental directly with any inquiries. Because Delta Dental pays these dentists directly, you do not need to pay the entire bill and wait for reimbursement. Instead, you pay only the patient portion of the bill.
Delta Dental PPO dentists are a select group of Delta dentists who, in addition to the above conveniences, also charge lower fees. And, when you visit a Delta Dental PPO dentist, you maximize your benefits. There are approximately 50,000 Delta Dental PPO dental offices around the U.S.
To see a list of Delta Dental PPO or DeltaPremier (Delta) dentists or to check if your current dentist is in network, visit the SAG-AFTRA Health Plan Delta Dental website.
You may also request a list of Delta Dental PPO or Delta Premier dentists in your area by calling Delta Dental at (800) 427-3237. Please allow 7 to 10 business days for delivery.
Yes. You may nominate your dentist for Delta Dental in-network membership by filling out a Dentist Nomination form. You may request a nomination form by calling Delta Dental at (800) 427-3237.
The nomination process takes about 90 days. Please note, not all dentists will choose to participate. Admittance is not automatic and until your dentist is accepted into the Delta Dental network, he or she is considered an out-of-network dentist.
Dental implants are covered under the Major Services portion of the Plan's dental benefits (which are payable at 50% and are subject to the Plan’s annual maximums and deductibles). Any additional surgical procedure or special imaging performed in connection with the placement of the implant is not covered under the dental or medical plan. The Plan strongly suggests that you ask your dentist to request a pre-treatment estimate from Delta Dental, so you know upfront what the Plan will pay and the amount for which you will be responsible.
The Plan allows one oral examination every six months and two cleanings per calendar year. When services are provided by a Delta Dental PPO dentist, there is no deductible and 100% of the dentist's fee is covered. To help avoid an increased risk of periodontal complications due to hormonal changes, the Plan added an additional oral exam and cleaning for women while they are pregnant. To take advantage of this added benefit, the dentist will need to note on the claim that the patient is pregnant. Individuals receiving post-periodontal surgery maintenance from an in-network dentist are eligible for cleanings and scalings up to four times per year.
I would like to cancel pension deduction and change my payment method. Can I cancel pension deduction online?
No. A completed Payment Election Change Request form or written request must be received and processed by the Plan before you can use a different payment option.
No, there is no paperwork to submit. Your premium will automatically be adjusted to the lower premium rate effective the first of the month in which your spouse turns age 65. For example, if you are paying $120 per month and your spouse turns age 65 on May 15th, your premium will be $60 per month effective May 1st.
If you are on pension deduction or automatic payment, the rate will automatically adjust effective the first of the month in which your spouse turns age 65.
Will I receive Retiree Health Credits under the SAG-AFTRA Health Plan for years of service I earned toward retiree health eligibility under SAG Plan and/or AFTRA Plan?
Yes. You will receive credit for the greater number of retiree health years of service (i.e., SAG Pension Credits or AFTRA Qualifying Health Years) that you already earned towards retiree health coverage under either the SAG Health Plan prior to January 1, 2017 or the AFTRA Health Plan prior to December 1, 2016.
If you have credits/years in both Plans, the higher number transfers to the SAG-AFTRA Health Plan.
However, you will receive additional credits for any retiree health years of service earned under the Plan with the lower number of credits/years if:
They are SAG Pension Credits earned from January 1, 2009 through December 31, 2016
They are AFTRA Qualifying Health Years earned from December 1, 2008 through November 30, 2016.
The 12-month period in which you earned the retiree health year of service does not overlap by more than one month with any 12-month period for which you received a year of retiree health eligibility under the Plan in which you have the higher number of credits/years.
EXAMPLE: If you have 13 AFTRA Qualifying Health Years and 10 SAG Pension Credits, you would receive 13 Retiree Health Credits in the SAG-AFTRA Health Plan.
But if 3 of your 10 SAG Pension Credits were earned between January 1, 2009 and December 31, 2016 and you have no overlapping AFTRA Qualifying Health Years earned during the same period, you would receive 3 additional Retiree Health Credits in the SAG-AFTRA Plan.
So in this example, you would begin 2017 with 16 Retiree Health Credits.
Please see Premiums for current rates.
Currently the Plan is paying as the primary plan for spouses under the age of 65 because they are not yet eligible for Medicare. Costs are much higher for these spouses than for Medicare-eligible spouses.
Effective January 1, 2017, a participant who has covered earnings of at least $22,000 in a calendar year will earn a Retiree Health Credit for that year. The covered earnings threshold to earn a Credit will increase by $1,000 each year through January 1, 2022.
No. COBRA coverage must be continuous from the first day following the last day of earned coverage.
Yes, your former spouse is entitled to COBRA coverage. You must notify the Plan of your divorce within 60 days from the date of divorce.
I previously dis-enrolled my spouse from coverage and am now getting a divorce. Is my former spouse entitled to COBRA coverage of his/her own?
Your former spouse may be entitled to COBRA coverage. To see if your former spouse is eligible to receive COBRA coverage, contact the Plan for more information.
Your completed enrollment form is due within 60 days of the later of: the date coverage terminated or the date on your COBRA enrollment offer.
Notice of Coverage packets that include your health care ID cards will be mailed once your enrollment is completed and your premium payment is received.
Please allow up to 2 business days to process your enrollment form. You will receive a confirmation letter in the mail once your enrollment has been processed. For faster service, log in to your Benefits Manager to make changes to your dependents and make your premium payment online.
Yes, once you've made your payment, your health care ID (HCID) cards are typically available in your Benefits Manager on the start of your coverage period.
Premiums are due the first of the month. However, we accept payments with a postmark through the last day of the month. Remember, COBRA coverage will only be extended when your enrollment is completed and payment is received in full.
If your COBRA coverage ends and you are not eligible for Medicare, you have the opportunity to purchase coverage through the Health Insurance Marketplace established by the Affordable Care Act at www.healthcare.gov. In California or New York, you can access the Marketplace through state-run websites at www.coveredca.com or www.healthbenefitexchange.ny.gov. You can compare coverage, provider networks, premiums, deductibles and out-of-pocket costs before you make a decision to enroll. In the Marketplace you also may be eligible for a tax credit that lowers your monthly premiums.
If you are totally disabled, you may qualify for an extension of coverage. Please contact the Plan for more information.
No. We do not accept cash payments.
You will receive 4 payment coupons after you initially enroll in COBRA . After we receive your payment, we will send you monthly coupons on a quarterly basis.
Can I change my coverage when I add or drop dependents? For example, if I am single when I start COBRA but then get married, can I add my new spouse?
Yes, if a qualifying life event occurs, you can add or drop dependents. You must notify the Plan within 60 days from the date of the event (e.g., birth, marriage, divorce, death, adoption, etc.). You must provide documentation of the event and submit a completed New Dependent Form.
In some cases, your dependents may be entitled to enroll in the program even if you do not elect coverage. Contact the Plan for more information.
The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit the Social Security Administration website.
Medicare is not offered as a family or dependent benefit. This means all people must qualify on an individual basis.
Be sure to show the provider both your Medicare and SAG-AFTRA health care ID cards when services are rendered. Once the provider submits the claim to Medicare and they consider for benefits they will send the claim on to the SAG-AFTRA plan on your behalf through the Medicare Crossover process in order to consider for secondary benefits.
Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals and skilled nursing facilities (not custodial or long-term care). Medicare Part B (Medical Insurance) helps cover medically necessary doctor’s services and outpatient care.
I don't want to enroll in Medicare because I already have such great coverage under the SAG-AFTRA Health Plan and I can't afford the Medicare Part B premiums. Do I have to enroll in Medicare Parts A and B?
Yes. You are required to enroll in Medicare Parts A and B when Medicare is your primary coverage and the SAG-AFTRA Health Plan is secondary. If you fail to enroll in Medicare, the Plan's benefits are reduced by 80%. See the Medicare Parts A, B & D Notice for more information.
Medicare does not cover either routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. In rare cases, Medicare Part B will pay for certain dental services. In addition, Medicare Part A will pay for certain dental services that you get when you are in the hospital. However, if you are enrolled in the SAG-AFTRA Health Plan, you have dental insurance through the Plan.
Medicare does not cover hearing aids or eyeglasses, but you may have coverage through the SAG-AFTRA Health Plan for those items.
Beginning January 1, 2006, Medicare prescription drug plans (PDPs) are available to people with Medicare. Insurance companies and other private companies work with Medicare to offer these drug plans.
If you have prescription drug coverage through the SAG-AFTRA Health Plan, you will receive a Notice of Creditable Coverage from us advising you that you already have prescription drug coverage that is comparable to Medicare coverage; therefore you do not need to enroll in a Medicare prescription drug plan.
If you are covered by the SAG-AFTRA Health Plan, you will not need to pay the penalty as long as you stay in the Plan.
Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).