Periodically the Plan discovers that reported earnings are intentionally misrepresented in order to obtain Health Plan eligibility. In essence, signatory companies are fraudulently contributing on behalf of performers who do not perform services covered by a SAG-AFTRA Collective Bargaining Agreement or misrepresenting the amount of compensation the performer received for covered services and the basis for the compensation reported. They are "buying" health coverage for participants by contributing the minimum necessary to qualify for Earned Eligibility. Companies and participants who engage in this conduct are liable to the Plan for any overpaid benefits and administrative fees mistakenly or improperly paid by the Plan.
The verification of contributions to the Health Plan is an important aspect of the Plan's integrity because fraudulently obtained benefits deplete the Plan's assets and affect the benefits available to the rest of the participants.
You should maintain and be prepared to supply, upon the Plan's request, copies of employment contracts, proof of service, proof of payments, including payroll stubs, W2 forms, income tax returns and bank records. You bear the burden of demonstrating that you provided services of the type covered by the Collective Bargaining Agreement, and the failure to provide access to such documents may be deemed by the Plan as the basis to disallow any contributions reported for your services.
You may be selected for an audit to verify the eligibility of your dependents under the Health Plan. Failure to comply with an audit request can lead to a loss of benefits for your dependents.
By participating in the Health Plan, you are agreeing to cooperate with the Plan's reasonable efforts to audit the status of any dependent. Timely providing information or documents that are required or requested is a condition of your dependent's eligibility for benefits. Therefore, if the information or documents are not provided, the Health Plan in its sole discretion may determine that your dependent does not qualify as a dependent or loses continued eligibility as a dependent. You may be held responsible for any overpayments made as a result of the failure to provide such information or documentation.
When you become eligible for benefits under the Health Plan, you must file a Performer Information Form with the Plan Office. This confidential legal document must be signed by the participant. If the participant is under the age of 18, the parent or legal guardian must sign for the child.
In order to verify dependent eligibility, the Plan performs routine audits. These audits are for your protection to assure that Plan benefits are reserved for eligible participants and their eligible dependents.
If you are selected for an audit, the Plan Office will send you an initial inquiry specifying the documents needed for dependent verification. For example, a copy of a recorded marriage certificate to verify your spouse or a recorded birth certificate for a child. If you cannot locate a requested document, contact the Plan Office which can assist you in contacting the issuing agency. If the Plan Office does not receive a response to its initial request, a follow-up notice will be sent. The failure to respond will be deemed an admission of fraudulent conduct. If there is no response to our second request you will receive a Notice of Termination of Benefits for the unverified dependents. Additionally, you will be responsible for paying back any medical expense paid out by the Health Plan on behalf of non-qualified dependents.
If you need to update your dependents, contact the Plan Office for the proper form.
The Health Plan has the right to recover any mistaken payment, overpayment, or any payment made to any individual who was not eligible for that payment. All together, these overpayments are referred to in this SPD as an "overpayment". You will receive written notification if a reimbursement to the Plan is required.
You can be held individually liable for reimbursing the Health Plan for the amount of the overpayment if your eligibility was established because of fraud or intentional misrepresentation of material fact. In addition, the Health Plan has the right to collect the overpayment from you, your eligible dependents (or any individual you have claimed to be your eligible dependent), or your employer, or to pursue each or all of you for reimbursement. The Board of Trustees can take all actions as it determines appropriate, in its sole discretion, to recover the overpayment. Such actions may include:
In addition, the Board of Trustees may in their discretion, seek payment of such amounts through filing a lawsuit or taking any other measure they deem necessary and appropriate. You, your eligible dependent(s) (or any individual you have claimed to be your eligible dependent), and your employer are also responsible for paying the Health Plan all expenses incurred collecting the overpayment, audit fees, attorneys' fees and interest calculated from the date of the initial overpayment.
Anyone who submits any false or fraudulent claim or information to the Health Plan may be subject to criminal penalties including a fine or imprisonment or both as well as damages in a civil action under California or federal law. Furthermore, the Board of Trustees reserves the right to impose such restrictions upon the payment of further benefits to any such participant or dependent as may be necessary to protect the Health Plan, including the deduction from such future benefits of amounts owed to the Health Plan because of the payment of any false or fraudulent claim. The participant, dependent or any individual you have claimed to be your eligible dependent must pay the Health Plan for all its legal and collection costs as well as benefit payments made (with interest).
If it is determined that a participant became eligible for Health Plan benefits as a result of earnings which are determined to be non-Covered Earnings, the participant's coverage could be cancelled immediately. Also, to the extent permitted by law, the participant may be obligated to refund all benefits received in excess of contributions by the participant's employer to the Health Plan on the participant's behalf. If the participant also loses Screen Actors Guild – Producers Pension Plan Pension Credit as a result, improper pension contributions may be utilized as an offset against benefits paid to the participant.
Termination of eligibility as a result of a contribution or dependent verification audit does not constitute a Qualifying Event for purposes of the Self-Pay Program.