WHERE YOUR CONTRIBUTION DOLLAR GOES

As a Participant in the SAG-Producers Pension and Health Plans, you want to know that the Plans have sufficient assets to pay for your health benefits when you get sick and your pension benefits when you retire. This is also a primary concern of the Trustees who continually monitor the income and expenses of the Plan. The pie charts below illustrate where each dollar of Plan income was spent in 1998 in each of the Plans.

Health Plan

The largest expense for the Health Plan is benefit payments. This includes all benefits paid by the Plan, such as, major medical, hospital, dental, mental health & chemical dependency and prescription drug benefits as well as the life insurance benefits. The amount kept in reserve is to provide for retiree health benefits, for increases in claims costs due to medical inflation and increases in the number of eligible Participants.


Pension Plan

The largest expense for the Pension Plan is for reserves-the money set aside to meet the Plan’s future pension obligations. Although the monthly pension benefits paid to current retirees makes up less than 25% of the Plan’s expenses, the Plan has a future obligation to pay pensions not just to current retirees – but also to Participants who have earned the right to a pension in the future but have not yet retired.

 

Health Plan Costs Versus Contributions

Some Participants have asked why we need to keep increasing the Health Plan eligibility requirement and why we can’t expand the benefits. Even though the Health Plan is in good financial condition, the cost to provide benefits is not always covered by the contributions received for each individual.

The following chart compares the contributions received on behalf of a Participant who earns the minimum amount required for Health Plan eligibility with the actual cost of benefits.


Plan I
Plan II
Minimum Earnings for Health Plan Eligibility
$ 15,000.00
$ 7,500.00
Producer's Contribution To Health Plan @ 7.25% of Minimum Earnings
$ 1,087.50
$ 543.75
Annual Active Per Capita Cost to Provide Health Benefits
$ 3,955.00
$1,555.00
Earnings Required to Support Health Plan Costs
$ 54,552.00
$ 21,448.00

 

 

 

For every Participant whose earnings are between $15,000 and $54,552, it costs the Health Plan more to provide a year of Plan I benefits than it receives in contributions.

For example, the current eligibility requirement for Plan I is $15,000 on which the Plan receives $1,087.50 in contributions (7.25% of earnings) for one year of coverage. The actual cost to provide an individual with Plan I benefits for one year is $3,955.00. This means a Participant would have to have $54,552.00 in earnings in order for the contributions to cover the cost of one year of benefits. And, as more individuals meet the minimum earnings requirement, the overall cost to provide Health Plan benefits increases.

The Trustees are always looking for ways to provide the best possible benefits to the greatest number of Participants. Sometimes this means that eligibility requirements must be increased and that some services cannot be covered.




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New Self-Pay Option

In an effort to give self-pay Participants more flexibility in selecting their Health Plan coverage, the Trustees have expanded the circumstances under which a Participant may change his or her self-pay coverage.

Currently, Participants in the Self-Pay Program are permitted to change their coverage if there is a change in their family status, such as marriage, divorce or the birth of a child. For example, if you marry or have a child the current rules allow you to change from the Lower Cost Plan to Plan I or Plan II (depending on your original Earned Eligibility) which provides dependent coverage. The Trustees have added one additional set of circumstances under the change in family status rules, that is, if the dependent obtains insurance on their own.

For example, you are married and covered under Plan I or Plan II self-pay and your spouse obtains health benefits from another plan which does not include dependents. The new rule allows you to convert to the Lower Cost Plan to eliminate the additional cost of your spouse’s coverage. Additionally, if your spouse later loses earned coverage in the other Plan - creating another change in family status - you would be allowed to convert from the Low Cost Plan to Plan I or Plan II to add dependents. The new option is available immediately.





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And The Survey Said...

In January of this year, the Trustees conducted a Health Plan opinion survey of all Participants living outside of California. We wanted to know what you think about the Health Plan services. Are you using PHCS providers? Do you like the PHCS network? Are your claims paid in a timely manner?

Here’s What You Said


Your satisfaction with the PHCS network

In general, 7 out of 10 Participants are clearly satisfied with PHCS and only 1 out of 10 is clearly dissatisfied. The most favorable aspects of the program included the quality of medical care in the network, the location of physicians’ offices and the service of the physicians’ office staff. The least favorable aspect was the availability of network provider directories.


Location of physicians' offices
75% 14% 11%

Quality of medical care received from network physicians
75% 18% 7%

Service of network physician office staff
72% 19% 8%

Timeliness of appointment scheduling
71%
19% 10%

PHCS telephone customer service
67% 21% 12%

Physicians in PHCS network
66% 23% 11%

Access to specialists
64% 20% 16%

Avaiability of network information
61% 21% 18%

Availability of network provider directories
57% 20% 23%

Favorable

Mixed

Unfavorable

Your use of network physicians

Two out of three Participants use a PHCS network physician every time or most times. The main reason for not using the network was that the individual’s regular physician is not in the network.

When you need to see a physician, how often do you use PHCS network physicians ?
31%
37%
16%
16%

 

Every time


Most times


Seldom


Never






If you do not use network physicians, why not ?


My regular physician is not in the network
66%
Concern about quality
29%
Location of network physicians
24%
Other
20%




 

Your satisfaction with claim payments

Most Participants are satisfied with the accuracy and timeliness of claim payments, although the comments suggest that the Explanation of Benefits form (EOB) is confusing.


Accuracy of claim payments 65% 20% 15%
Timeliness of claim payments 61% 22% 17%

 

Favorable

Mixed

Unfavorable



Your opinion about changing the network

A slight majority (54%) said they would like to see the Trustees explore other networks.



Here’s What We’re Going To Do

1. Changing the PHCS Network

1,734 Participants responded to the question about their preference regarding the PHCS network. 931 responded that they would like to see the Plan explore options and 803 said they are satisfied with the PHCS network as it is. Because changing networks can create hardship and inconvenience for Participants and because there was not a clear mandate from the Participants for a change in the network, the Trustees have decided not to make a change at this time. However, the Trustees will continue to investigate managed care plans in all areas of the country to ensure that the Plan is using the best available networks.

2. Enhancing the PHCS Network

The vast majority of Participants said that the one most important thing the Trustees could do to improve the service provided by the Health Plan would be to increase the number and quality of the network physicians. The Trustees will continue to work with PHCS to enhance their networks, especially in areas where our Participant population is growing.

3. Providing Printed Network Directories

Because so many of you requested that we provide printed provider directories, we want to explain the reasons why we do not do so. First, these directories become outdated very quickly, as new providers are added or removed weekly. This means you may not always be able to rely on the information in the directory. Second, publication of directories is very expensive. The projected cost to print and mail directories to newly eligible Participants is over $50,000 per year.

However, because of the importance of finding the best network provider for you and your family, here is what we can do to help you. The Plan Office can provide you with a customized provider list in your area. Simply call the Burbank Plan Office at the toll free number (800) 777-4013 and a printed list of providers in your area will be mailed to you on the next business day. You can also find network providers on the PHCS web site at www.PHCS.com. The web site gives you listings of providers in your area by specialty, lists each provider’s hospital affiliations and gives special information about the provider such as any board certifications. Also, the web site has maps and written directions to each provider’s office. You can also reach the PHCS web site via a link from the Plan web site - www.sagph.org.

4. Improving Claims Payments

Because of the confusion you expressed about the Plan’s Explanation of Benefits (EOB), we are preparing a flyer which provides an item-by-item explanation of this very important document.

We continually strive to process claims as quickly as possible. Because of the mail delay incurred by claims from the East Coast, we recently set up a special section to handle those claims to ensure the quickest possible turnaround time. However, we want to remind Participants that often times a delay in claims payment is caused by the need to get additional information from the provider or another health plan. Long out-of-pocket delays can be avoided by assigning the claim to the provider or using a network provider where claims are automatically assigned.

The survey was conducted by the national consulting firm of Watson Wyatt who are experts in preparing and analyzing such surveys. Of the 14,000 surveys mailed, 2,057 (15%) were completed and returned. Watson Wyatt advises that this response rate is typical for a mail survey of this nature. The responses received represented a good cross-section of respondents by type of eligibility, age, gender and geographic location.

On behalf of the Trustees, we want to thank those Participants who took the time to respond to this survey. We encourage you to continue to write to us to tell us about your satisfaction with any aspect of the Health Plan.





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Pre-Authorization Required for Some Prescriptions

If you are eligible for the PAID Prescription Drug Program, most of your prescriptions can be filled at the retail pharmacy without pre-authorization. However, some of the new drugs coming onto the market are only approved by the Food and Drug Administration (FDA) for certain diagnoses or conditions. Because the Plan does not cover drugs which are not FDA approved, you may need pre-authorization from the Health Plan.

An example of this situation is the drug called Celebrex. The FDA has approved Celebrex, but only for the treatment of osteoarthritis and rheumatoid arthritis. When you take a prescription for Celebrex to the retail pharmacy, the system will automatically review your file (age and prior drug history) to determine if Celebrex can be dispensed based on the criteria available. If there is not enough information in your file, you will have to pay the full price for the prescription at the pharmacy. You or your doctor should call the Plan Office so that we can obtain the information necessary to determine if the drug is covered by the Plan. If it is covered, your claim will be sent to PAID for reimbursement at 100% minus the prescription drug copayment and deductible. Your future claims for Celebrex will be approved at the pharmacy.

The Plan must follow this procedure for any drugs that have limited FDA approval. You may wish to alert your doctor to this restriction and have him call the Plan Office to determine if the limits apply to your situation.





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VISION PLAN UPDATE

Contact Lens Restrictions Imposed by States, Not Plan

The Health Plan’s vision care benefit which is now provided through Vision Service Plan (VSP), was expanded earlier this year to include eye exams for Plan I Participants and discounts on eye wear, lenses and contact lenses for both Plan I and Plan II Participants.

We have received inquires as to why certain VSP providers will give you a written copy of a prescription for eyeglasses but not for contact lenses which you might choose to fill through a different discount eye wear provider. The reason you may be unable to obtain a copy of your contact lens prescription is this: while federal law requires eye doctors to provide you with your eyeglass prescription at no extra cost after an eye exam, no similar federal law applies to contact lens prescriptions. When no federal law exists it is up to the states to set guidelines and regulations.

Listed below are the 24 states that require doctors to release contact lens prescriptions. If the state in which you reside is not listed, be advised that providers are not required to give you a copy of your contact lens prescription.

States That Require Doctors to Provide a Contact Lens Prescription:

Alabama
Arizona
Colorado
Delaware
Florida
Georgia
Indiana
Iowa
Louisiana
Maine
Maryland
Massachusetts
New Hampshire
New Jersey
New York
North Carolina
Ohio
Oregon
South Dakota
Texas
Vermont
Virginia
Washington
Wyoming





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Pensioners and Unemployment Benefits

Are your unemployment benefits being affected by the pension you are receiving from the SAG-Producers Pension Plan? If so, the Plan Office can help.

Sometimes the Employment Development Department (EDD) will penalize - or disqualify - you from collecting unemployment insurance benefits when you are receiving a pension from this Plan. If so, you can contact the Plan Office for our help. We can write a letter to the EDD explaining the Plan rules on how and when we recalculate your pension due to additional earnings. This may help with your claim for unemployment benefits by giving the EDD in your area an understanding of our rules and how they affect your individual situation.

Please call the Burbank Plan Office and ask for the Pension Department.

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