Jeffrey Wade
The SAG-AFTRA Health Insurance plan offers a wide range of services, including medical, surgical, mental health, life and AD&D insurance, maternity care, dental and vision services, and more. The cost to members is between $125 and $250 per month, or up to $2501 following unemployment. To qualify for this insurance, you must meet the “Earned Eligibility” requirements, which vary depending on occupation and earnings. If you are a retiree, you may still have access to the plan through the SAG-AFTRA Health Plan / Via Benefits program. It is important to note that you are not required to use this insurance if you meet the eligibility requirements but can choose to opt-out by not paying the premium.
Characteristics and Values of SAG-AFTRA Health Insurance
| Characteristics | Values |
|---|---|
| Services Covered | Medical, Surgical, Mental Health, Life and AD&D Insurance, Maternity Care, Hearing Aids, Therapy, Dental and Vision Services |
| Eligibility Requirements | "Earned Eligibility" based on occupation, work under specific contracts, or earnings through a contributing employer during a set period |
| Cost | $125 - $250 per month, or up to $2501 following unemployment |
| Medicare Coordination | Primary benefits paid by the plan if "Earned Eligibility" is met, with Medicare paying secondary |
| Pharmacy Coverage | Allows two 30-day fills at any network pharmacy, then covers long-term medications through CVS Caremark Mail Service or CVS Pharmacy locations |
| Dependent Coverage | Coverage available for dependents, with potential reduction or elimination if premiums are not paid |
| Medicare Part A and B Enrollment | Required when Medicare is primary coverage and SAG-AFTRA Health Plan is secondary; benefits reduced by 80% if Medicare enrollment is not maintained |
| Dental, Hearing, and Vision Coverage | Includes dental insurance, covering routine care and most procedures, as well as hearing aids and eyeglasses |
| Retiree Health Credits | Calculated based on SAG Pension Credits and AFTRA Qualifying Health Years; provides access to the SAG-AFTRA Health Plan / Via Benefits program or the Senior Performers Health Reimbursement Account (HRA) Plan |
| COBRA Program | Available for those who do not meet minimum earnings or days requirements for continued earned eligibility |
| Private Insurance | Option to seek private insurance coverage if eligibility requirements are not met |
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What You'll Learn
Eligibility requirements for SAG-AFTRA health insurance
To qualify for the SAG-AFTRA Health Plan, participants must meet eligibility requirements and pay the applicable premium. Earned active eligibility for health coverage is established through employment with producers who have signed Collective Bargaining Agreements with SAG-AFTRA. A notice of qualification is sent once eligibility is achieved, and coverage is extended upon receipt of the appropriate premium payment.
There are two main ways to qualify for the plan: by meeting the eligibility threshold for earnings and days worked or by qualifying under the Alternative Days eligibility rule. To meet the eligibility threshold, participants must earn at least $26,470 in Covered Earnings during their 12-month Base Earnings Period. Both sessional and residual earnings are included in this threshold. Participants must also meet the Eligibility Threshold for Eligibility Days (currently 102 days) worked during their 12-month Base Earnings Period under specified contracts.
If you do not satisfy the Covered Earnings requirements, you may qualify under the Alternative Days eligibility rule. To qualify under this rule, you must have at least 106 Eligibility Days during your Base Earnings Period. Eligibility Days are determined by dividing your total applicable sessional Covered Earnings by the SAG-AFTRA minimum daily rate, which is based on the type of production. It is important to note that earnings from employment under certain agreements, such as the Sound Recordings Code, the Audiobooks Agreement, and any Regional or Local AFTRA (or SAG-AFTRA) code for Television or Radio Broadcasting, cannot be used to satisfy the Eligibility Days requirement for Alternative Days eligibility.
Additionally, there are special eligibility rules for retirees, including Senior Performers, who are taking a pension from the SAG-Producers Pension Plan or the AFTRA Retirement Fund. These individuals may qualify for the SAG-AFTRA Health Plan / Via Benefits program, which allows them to shop for individual insurance policies to enhance and supplement their Medicare coverage. Senior Performers may also be eligible for the SAG-AFTRA Health Plan Senior Performers Health Reimbursement Account (HRA) Plan.
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Cost of the insurance
The cost of the SAG-AFTRA Health Insurance plan varies depending on the member's employment status. Members pay anywhere between $125 and $250 per month, with a maximum of $2501 following unemployment. The plan offers an extensive package of healthcare benefits to eligible participants and their qualified dependents.
To receive coverage, one must meet the eligibility requirements and pay the required premiums. The eligibility criteria are complex and vary depending on the occupation, with criteria relating to the performance of work under specific contracts or earnings through a contributing employer during a set period. For retirees, the eligibility threshold for covered earnings during their base earnings period is currently $25,950. Only sessional earnings are included in covered earnings unless the member becomes a retiree while covered under the Active Plan. In that case, both sessional and residual earnings are included during the first earnings evaluation, after which only sessional earnings are considered.
Retirees receiving a SAG or AFTRA pension are not eligible for Extended Career COBRA. However, they will pay a reduced premium of 20% of the COBRA rate for up to 12 months.
It is important to note that members are not required to use the insurance coverage even if they meet the eligibility requirements. If they choose not to, they can simply refrain from paying the premium and will not receive coverage.
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What the plan covers
The SAG-AFTRA Health insurance plan covers a wide range of services. The plan pays for primary benefits if you meet the earned eligibility requirements, while Medicare pays secondary benefits. The earned eligibility requirements vary depending on occupation, with criteria relating to work performed under specific contracts or earnings through a contributing employer during a set period. Retirees who do not qualify for earned eligibility will have access to the SAG-AFTRA Health Plan/Via Benefits program, where they can purchase individual insurance policies to supplement their Medicare coverage.
The plan covers medical, surgical, and mental health services, as well as life and AD&D insurance, maternity care, hearing aids, therapy, and dental and vision services. It also includes prescription drug coverage, with two 30-day fills allowed at any pharmacy in the network, and long-term medications covered when filled through CVS Caremark Mail Service Pharmacy or CVS Pharmacy locations.
Medicare Part A, or Hospital Insurance, covers inpatient care in hospitals and skilled nursing facilities, while Medicare Part B, or Medical Insurance, covers medically necessary doctor's services and outpatient care. Medicare Part B will, in rare cases, pay for certain dental services, and Medicare Part A will cover dental services received in the hospital. However, routine dental care and most dental procedures are not covered by Medicare but may be covered by the SAG-AFTRA Health Plan.
Additionally, the SAG-AFTRA Health Plan covers hearing aids and eyeglasses, which are not typically covered by Medicare. For retirees, the plan offers the Senior Performers Health Reimbursement Account (HRA) Plan, and those with disabilities may be entitled to an extension of coverage.
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Coordinating benefits with other plans
Coordination of Benefits (COB) is a set of rules that determine which health plan is responsible for payment when an individual is covered by multiple plans. If you have other health coverage or are eligible to receive it, you must inform the SAG-AFTRA Health Plan so that your benefits can be properly coordinated.
The SAG-AFTRA Health Plan coordinates benefits with all other group and private health plans, as well as Medicare. This includes situations where married couples are both eligible for coverage as participants, and for dependent children of two eligible married participants. If a parent and a child are both participants, the plan will coordinate benefits with respect to the child's coverage. However, since a parent cannot be a dependent of their child, the parent will only be treated as a participant with their own coverage.
The SAG-AFTRA Health Plan also follows the Entertainment Industry Coordination of Benefits (EICOB) rule, which maintains the correct primary and secondary positions of health plans based on the longest continuous coverage. This means that if you are entitled to primary coverage with another entertainment industry plan but fail to pay the premium, the SAG-AFTRA Health Plan will remain as the secondary coverage. Other entertainment industry plans subject to the EICOB rule include the Directors Guild of America-Producer Health Plan, the Equity-League Health Plan, the Motion Picture Industry Health Plan, and the Writers' Guild-Industry Health Fund.
If you previously received Senior Performers or Surviving Dependent benefits under the Screen Actors Guild–Producers Health Plan before January 1, 2017, the SAG-AFTRA Health Plan will coordinate benefits with Medicare. However, benefits will be reduced by 80% for Medicare beneficiaries. Additionally, if you choose not to enroll in the SAG-AFTRA Health Plan or let your coverage lapse, your coverage under other plans may be reduced or eliminated, so it is important to contact your other plan to understand how your coverage may be affected.
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Medicare and SAG-AFTRA health insurance
Medicare and the SAG-AFTRA Health Plan are two separate health insurance plans, each with its own unique features and eligibility requirements. Here is a detailed overview of how they work and interact with each other:
Medicare:
Medicare is a federal health insurance program that primarily covers individuals aged 65 and older, as well as some younger people with disabilities or specific medical conditions. It is divided into parts that cover different services:
- Medicare Part A: Covers hospital-related expenses, including inpatient care, hospital stays, and some follow-up care. It also covers certain dental services received during a hospital stay.
- Medicare Part B: Covers outpatient medical services, such as doctor visits, preventive care, and some medical equipment. In rare cases, Medicare Part B may pay for certain dental services.
- Medicare Prescription Drug Plans (PDPs): These plans are available as an add-on to Medicare and are offered by insurance companies and private companies that work with Medicare. They provide coverage for prescription medications.
SAG-AFTRA Health Plan:
The SAG-AFTRA Health Plan is a comprehensive health insurance plan offered to eligible members of the Screen Actors Guild-American Federation of Television and Radio Artists (SAG-AFTRA) union. It covers a wide range of services, including:
- Medical, surgical, and mental health services.
- Life and AD&D insurance.
- Maternity care.
- Dental and vision care, including hearing aids and eyeglasses.
- Therapy.
Interaction Between Medicare and SAG-AFTRA Health Plan:
The interaction between Medicare and the SAG-AFTRA Health Plan depends on an individual's situation:
- For Retirees: Most retirees have Medicare as their primary insurance, which pays for their primary benefits. If they do not qualify for "Earned Eligibility" under the SAG-AFTRA Health Plan, they can access the SAG-AFTRA Health Plan / Via Benefits program. This program allows them to purchase individual insurance policies to enhance and supplement their Medicare coverage.
- For Those with SAG-AFTRA Health Plan as Primary: If an individual has the SAG-AFTRA Health Plan as their primary coverage and is enrolled in Medicare, Medicare will pay secondary. This means that Medicare will cover additional expenses not covered by the primary insurance, ensuring comprehensive coverage.
- Prescription Drug Coverage: If an individual has prescription drug coverage through the SAG-AFTRA Health Plan, they do not need to enroll in a Medicare prescription drug plan. They will receive a Notice of Creditable Coverage, indicating that their current coverage is comparable to Medicare's prescription drug coverage.
Eligibility and Costs:
Both Medicare and the SAG-AFTRA Health Plan have their own eligibility requirements:
- Medicare: Eligibility is typically based on age, disability status, or specific medical conditions. For retirees, the Medicare Annual Enrollment Period is from October 1 to December 15.
- SAG-AFTRA Health Plan: This plan has Earned Eligibility requirements related to occupation and earnings. Eligibility varies depending on work under specific contracts or earnings through a contributing employer during a set period. Costs for this plan vary, ranging from $125 to $250 per month, or up to $2501 following unemployment.
In conclusion, Medicare and the SAG-AFTRA Health Plan offer distinct benefits, and individuals can have one or both of these plans, depending on their eligibility and needs. It is important to carefully review the coverage details and eligibility criteria of each plan to make an informed decision about health insurance.
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Frequently asked questions
The SAG-AFTRA Health Insurance Plan covers a wide range of services, including medical, surgical, and mental health, life and AD&D insurance, maternity care, hearing aids, therapy, and dental and vision services.
The cost to the member monthly varies between $125 and $250, or up to $2501 following unemployment.
To qualify for the plan, you must meet the “Earned Eligibility" requirements. Eligibility varies depending on occupation, with criteria relating to the performance of work under specific contracts or earnings through a contributing employer during a set period.
If you do not meet the eligibility requirements, you will receive a notice advising you of your options, including the Plan's COBRA program and conversion options. You may also be entitled to an extension of coverage if you are totally disabled.
If you have another insurance plan, the SAG-AFTRA Health Plan will coordinate benefits with your other plan. The determination of which plan pays first is based on NAIC (National Association of Insurance Commissioners) guidelines and specific plan rules.
