Health Summary Plan Description

Self-Pay Program

For the latest updates to these rules and information, please see the Fall 2015 Take 2.

When you lose Earned Eligibility because of a Qualifying Event, you and your qualified dependents may continue Health Plan coverage by enrolling in the Self-Pay Program. The length of time you are allowed to self-pay depends on several factors, including which Qualifying Event caused the loss of Earned Eligibility and how many years of previous Earned Eligibility you have in the Health Plan.

A premium is required for Self-Pay Program benefits. The premium is based on the Plan for which you qualify and the number of qualified dependents you choose to enroll for coverage. Self-pay premium rates are determined in accordance with federal COBRA law and may change once a year or more frequently if significant Plan changes occur. The premium is based on a three-tier structure: Individual, Individual plus one dependent or Individual plus two or more dependents.

Qualifying Events

Failure to pay the Health Plan premium is not a Qualifying Event. Neither is the termination of Earned Eligibility as the result of a contribution or dependent verification audit.

You and your qualified dependents may have the right to elect self-pay coverage upon the occurrence of the following Qualifying Events:

Participant: Loss of Earned Eligibility due to a reduction in your Covered Earnings or Days of Employment, or the change from Plan I to Plan II due to a reduction in your Covered Earnings.

Early Retirement Pensioner: Commencement of your Early Retirement Pension, or the loss of Earned Eligibility, if later. If you do not enroll in the Self-Pay Program when you start receiving your Early Retirement Pension or lose Earned Eligibility, you cannot enroll at a later date unless you requalify for Earned Eligibility or you meet all the postponed enrollment requirements outlined on pages 23 and 24.

Disability Pensioner: Commencement of your Disability Pension, or the loss of Earned Eligibility, if later. If you do not enroll in the Self-Pay Program when you start receiving your Disability Pension or lose Earned Eligibility, you cannot enroll at a later date unless you requalify for Earned Eligibility or you meet all the postponed enrollment equirements outlined on pages 23 and 24.

Dependent Spouse or Same-Sex Domestic Partner: Loss of Earned Eligibility due to a reduction in the participant's Covered Earnings or Days of Employment, the change from Plan I to Plan II due to a reduction in the participant's Covered Earnings, divorce from the participant, termination of a domestic partnership or civil union, or the death of the participant.

Dependent Children (as defined by the Plan): Loss of coverage due to a reduction in the participant's Covered Earnings or Days of Employment, the change from Plan I to Plan II due to a reduction in the participant's Covered Earnings, the death of the covered participant, or loss of "child" status as defined by the Plan.

Qualified dependents that are covered under the Plan when Earned Eligibility terminates may be entitled to enroll individually if the participant does not elect self-pay coverage.

Your Notification Requirements

You or your dependents, as the case may be, must notify the Plan Office, in writing, in the event of death, divorce, termination of a domestic partnership or civil union, or a child losing dependent status under the Plan. In order for the dependent to receive individual self-pay rights, 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 the Plan Office is not notified, in writing within this time frame and the appropriate documents establishing proof of dependent status are not submitted, the individual losing eligibility as a dependent will forfeit his or her right to enroll in the Self-Pay Program.

Maximum Length of Self-Pay Coverage

18 months – For participants (and their qualified dependents) with fewer than 17 years of Earned Eligibility in the Health Plan who lose eligibility or change from Plan I to Plan II due to a reduction in Covered Earnings or Days of Employment. Participants who are entitled to Medicare prior to the date they lose Earned Eligibility should call the Plan Office for information concerning their maximum self-pay period.

36 months

  • For participants (and their qualified dependents) with at least 17 years of Earned Eligibility in the Health Plan who lose eligibility or change from Plan I to Plan II due to a reduction in Covered Earnings or Days of Employment.
  • For qualified dependents who lose their dependent status due to the death of a participant, divorce from a participant, dissolution of same-sex domestic partnership or civil union, or loss of "child" status as defined by the Plan.

29 months – For participants or dependents who are determined by Social Security to be totally disabled on the date Earned Eligibility terminates or within 60 days thereafter. Non-disabled dependents of the disabled individuals are also entitled to 29 months of self-pay coverage.

Early Retirement and Disability Pensioners – Participants (and their qualified dependents) receiving an Early Retirement or Disability Pension are eligible to self-pay until the last day of the month prior to the month in which they reach age 65 provided they have at least 15 Pension Credits. Pension Credits under the Alternative Eligibility Program do not count toward this self-pay eligibility. Early Retirement and Disability pensioners with less than 15 Pension Credits who lose Earned Eligibility are eligible to self-pay for either 18 or 36 months depending on their years of Health Plan Earned Eligibility. Click here for updated rule.

Dependents who will qualify for the Extended Spousal Benefit – Qualified dependents who will be eligible for the Extended Spousal benefit as a result of a participant's death are eligible to self-pay until the participant would have reached age 65 and the Extended Spousal coverage begins. See page 9 for a description of the Extended Spousal benefit.

Special Rules for Dependents

Dependents acquired after the participant's enrollment (due to marriage, birth or adoption, for example), may be added to the participant's coverage. However, except for newborn and adopted children, they will not be entitled to self-pay for coverage on an individual basis.

If your qualified dependents lose their status as eligible dependents while you are covered under the Self-Pay Program or the Senior Performers Plan, they may also qualify for individual self-pay coverage. Additionally, individual self-pay coverage may be available if they lose their dependent status while covered under the Extended Spousal benefit. This would include situations in which a surviving spouse or same-sex domestic partner remarries or enters into a new same-sex domestic partnership or civil union.

Individual self-pay coverage for your dependents is only available if they were covered under the Health Plan on both the date dependent status was lost and the date Earned Eligibility was lost. The maximum length of the individual dependent self-pay coverage is 36 months from the date Earned Eligibility was lost, even if you are an Early Retirement or Disability pensioner.

For example, assume a participant with Earned Eligibility includes his spouse under his coverage. The participant loses Earned Eligibility and enrolls himself and his spouse in the Self-Pay Program. If he and his spouse divorce after being covered under the Self-Pay Program for 28 months, the spouse will be entitled to an additional eight months of coverage.

If you lose Earned Eligibility after you become entitled to Medicare, your qualified dependents will be entitled to self-pay coverage. The maximum period of self-pay 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.

In cases where self-pay coverage is not available, a conversion policy may be available. Please refer to "Conversion Options" on page 28.

Enrollment Options

Your enrollment options depend on your prior Earned Eligibility as outlined in the chart below. Self-pay coverage is identical to the coverage provided to participants with Earned Eligibility in each respective Plan, except that self-pay participants are not entitled to life insurance or accidental death and dismemberment benefits.

If you lose Plan I Earned Eligibility you will be offered a one-time only opportunity to enroll in either Plan I self-pay or Plan II self-pay. You may not change your self-pay plan selection after your enrollment is complete.

Note: If your Earned Eligibility changes from Plan I to Plan II, you may choose to self-pay for Plan I. However, the Health Plan does not coordinate benefits between your Plan I self-pay and Plan II Earned Eligibility. Instead, you receive Plan I benefits.

Self-Pay Enrollment Options
Prior Earned Eligibility Hospital and Medical Prescription Drugs Dental Vision
Plan I Plan I (Mental Health/ Substance Abuse Included) Included Plan I Dental Included Exam Plus Plan
Plan II (Mental Health/ Substance Abuse Not Covered) Mental Health/ Substance Abuse Drugs Not Covered Plan II Dental Included Not Included
Plan II Plan II (Mental Health/Substance Abuse Not Covered) Mental Health/Substance Abuse Drugs Not Covered Plan II Dental Included if Participant has 3 Years of Earned Eligibility Not Included

Enrollment Process

When you lose Earned Eligibility, the Plan Office will send you a termination notice describing the Self-Pay Program along with a Self-Pay Enrollment Form. This is the time during which you can choose the dependents you would like to cover and select your premium rate. You can enroll dependents that were not enrolled under your earned coverage although these dependents are not entitled to self-pay on an individual basis. If you do not enroll in the Self-Pay Program following the loss of your Earned Eligibility, the dependents that were covered under the Plan when your Earned Eligibility terminated may enroll individually, provided they enroll within the 60-day time limit.

Your Self-Pay Enrollment Form must be completed online or received by the Plan Office within 60 days of the later of:

  • The date your coverage terminated; or
  • The date on your self-pay 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. See page 23 for "Coverage Changes".

Time Limits for First Payment

Your first 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 with your Enrollment Form. However, you have 45 days from the last day of your enrollment period to make the payment. Coverage will not be granted and claims will not be considered for payment until your premium is received. Also, coverage will not be verified to any hospital or physician prior to the receipt and processing of your premium payment and providers will be advised that you are still in your 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 31st, 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 NOE containing your Health Plan ID cards will be sent to you within seven to 10 business days. You may also print temporary ID cards by visiting the Plan's website at www.sagph.org.

Premium Due Dates

After the Plan Office processes your Enrollment Form, an enrollment confirmation letter and payment coupons will be mailed. You will be sent your coupons on an annual basis. After the first premium payment, all subsequent premium payments are due on the first of each month. As mandated by federal law, there is a 30-day grace period. However you are encouraged to submit the payment by the due date. Coverage will not be granted and claims will not be considered for payment until your premium is received in full.

If you elect a change in self-pay coverage, as outlined on page 23, you will receive new payment coupons which reflect your new coverage and premium rate. If you do not receive your billing coupons within 30 days after enrollment or a change in coverage, please contact the Plan Office.

If you fail to pay your premium by the due date and you do not have an available late payment waiver, you will forfeit your rights to continued coverage under the Self-Pay Program.

Premium Payment Procedures

There are several ways to pay your monthly self-pay 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.

Auto Debit – The auto debit plan deducts your monthly premium automatically on a recurring basis 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. The Plan will continue to deduct the monthly premium as long as you remain continuously eligible for self-pay coverage, even if the Trustees make a change in the premium rate. You can sign up online or download an enrollment form on the Plan's website, www.sagph.org.

If you were previously enrolled in the auto debit plan during your Earned Eligibility your auto debit will not continue under the Self-Pay Program. You must complete a new auto debit enrollment form for the Self-Pay Program.

Pay by Web – You may pay your premium online with e-check or a credit card. Simply visit the Plan's website at www.sagph.org and enter your checking/savings account or credit card information. You will receive electronic confirmation that your payment has been received.

Pay by Phone – You may pay your premium over the telephone 24/7 with a credit card by calling the Plan Office at (818) 954-9400 or (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 and Participant Services Representatives will not be able to take your credit card information.

For your protection, Pay by Web and Pay by Phone payments are non-recurring. This means the Plan will not automatically charge your credit card or debit your account every time a payment is due.

Pay by Mail – Make your check, money order or cashier's check from a U.S. bank payable to: Screen Actors Guild – Producers Health Plan and send it to the Plan Office with your payment coupon. To ensure proper crediting you should include the account number from the payment coupon on your check. Your payment must be received by the Plan Office no later than the due date to be considered timely.

Any check or debit returned to the Health Plan for any reason will be assessed a handling fee. You may replace the premium payment and pay the fee using any of the payment options outlined above.

Late Payment Waiver

If your self-pay coverage is terminated because your payment was not received by the due date, 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 self-pay coverage period.

To use a late payment waiver, simply send your written request with your premium payment to the Plan Office. 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 your late payment waiver (if available) and your coverage will be reinstated retroactively.

Coverage Changes

Annual Open Enrollment

Under the Self-Pay Program, your Benefit Period is January 1st through December 31st and your Open Enrollment Period will generally occur from December 1st through January 15th. 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.sagph.org or by completing the Dependent Enrollment Form you receive in your Open Enrollment packet and returning it to the Plan Office.

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 qualified dependents, which results from birth, adoption, marriage, divorce, establishment or termination of a same-sex domestic partnership or civil union, 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 to the Plan Office within 60 days of the change in family status along with the documents establishing proof of dependent status (see page 7). Once the Plan Office receives your request and required documentation, your change will be processed and you will receive a new set of billing coupons and ID cards to confirm your new coverage and premium rate.

Postponed Enrollment for Individuals with Other Group Health Coverage

Self-pay coverage is offered on a continuous basis where enrollment immediately follows the termination of Earned Eligibility. However, if you meet all of the following requirements you may enroll following a break in coverage.

  • You have at least 17 years of Earned Eligibility in the Health Plan; and
  • You have other group health insurance at the time your SAG-Producers Health Plan Earned Eligibility expires, or gain other group health insurance while enrolled in the SAG-Producers Self-Pay Program; and
  • Your other group health coverage was either an employer-sponsored plan or a plan available as a result of your status as a student at an accredited school; and
  • You have not already exceeded the maximum number of months of self-pay coverage available to you under the SAG-Producers Self-Pay Program; and
  • You enroll in the SAG- Producers Self-Pay Program within 60 days following the later of (i) the termination of your other group health coverage if that plan is not required to offer self-pay coverage, or (ii) the last day of your other group health plan's self-pay period (the maximum number of months available for you to self-pay under the other plan); and
  • You provide a copy of the other group health plan's certificate of coverage, issued in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

For purposes of determining whether you qualify for postponed enrollment, a termination of your other group health coverage only occurs where you have lost that coverage due to termination of employment, reduction in hours, death, divorce or legal separation, dissolution of same-sex domestic partnership or civil union, loss of student status, or loss of your dependent child status. Failure to pay premiums under your other group health coverage is not a termination event.

Extended Self-Pay Coverage for Military Service

Your choices under USERRA with regard to immediately using your Earned Eligibility or immediately enrolling in the Self-Pay Program are outlined on page 4. Your maximum self-pay period is 24 months if you had less than 17 years of Earned Eligibility in the Health Plan or 36 months if you had at least 17 years of Earned Eligibility in the Health Plan. The applicable premium must be paid once the waiver period described on page 4 is exhausted.

Coordinating Self-Pay Benefits With Other Plans

You and your eligible dependents may enroll in the Self-Pay Program 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 Office to determine which plan will be primary and secondary.

However, if your Earned Eligibility changes from Plan I to Plan II, and you choose to self-pay for Plan I, the Plan will not coordinate benefits between your Plan I self-pay and Plan II earned coverage. Instead, you receive Plan I benefits.

If you, your spouse or your same-sex domestic partner are covered by Medicare, you may also enroll in the Self-Pay Program. Medicare will be your primary plan and this Plan will be your secondary plan. It is very important that you and your spouse or partner enroll for Medicare Part A and Part B coverage prior to your 65th birthdays. If you fail to enroll in Medicare Part A and Part B when this Plan is secondary or tertiary, your payments from this Plan will be reduced by 80% because the Plan will coordinate benefits as if you had received reimbursement from Medicare. You and your spouse or partner are not required to enroll in a Medicare Part D Prescription Drug Program, however it may be to your advantage to do so. Refer to the section on "Medicare Part D – Prescription Drugs", pages 80 and 81 for more information.

Termination of Self -Pay Coverage

Your self-pay coverage will terminate on the earlier of:

  • The first of the month for which you do not pay your premium by the due date; or
  • The first of the month after the month in which Social Security determines you are no longer totally disabled if your self-pay coverage is based on your being totally disabled; or
  • The first of the month following the expiration of the maximum self-pay coverage period for which you qualify; or
  • The first of the month for which you qualify for Earned Eligibility, unless you are self-paying for Plan I and your Earned Eligibility is for Plan II; or
  • The date on which the Trustees reduce the amount of self-pay coverage available; or
  • The date on which the Health Plan no longer provides health coverage.