Health Summary Plan Description

IV. GLOSSARY OF TERMS

The following definitions apply whether or not such terms are capitalized when used in this book.

Allowable Charges or Allowed Amount or Allowance. The amount established by the Board of Trustees from time to time, for the area in which they are incurred, but not to exceed the incurred charges.

Case Management. A program in which a coordinator works with the patient, his or her physician, his or her family, and the Health Plan to decide an appropriate treatment plan in the event of catastrophic or chronic sickness or injury.

Collective Bargaining Agreement. The agreement or agreements in force and effect from time to time between SAG-AFTRA and Producers with respect to the employment and services of actors in the production of motion pictures and which provide for contributions by such Producers into the Health Plan.

Contract Allowance. The amount a network provider must accept as the total charge. Network providers cannot bill you for covered charges in excess of the Contract Allowance.

Coordination of Benefits (COB). The method of dividing responsibility for payment among the health plans that cover an individual so that the total of all reasonable expenses for covered services will be paid. Special rules apply to coordination with other entertainment industry health plans (EICOB).

Copay and Coinsurance. These refer to the amounts you pay for provider services after the deductible has been satisfied. Copays are generally flat dollar amounts, such as the $15 copay for office visits to network physicians under Plan I or the $200 emergency room copay under Plan II. Coinsurance is generally a percentage of the Plan's Allowance, such as the 30% coinsurance a participant who sees non-network physicians must pay.

Cosmetic Surgery. Any surgery or procedure which is directed at improving the patient's appearance anddoes not meaningfully promote the proper function of the body or prevent or treat illness or disease. Surgery to correct birth defects of individuals under age 19, or prompt repair of accidental injury, or mammoplasty following a mastectomy shall not be considered cosmetic under the Health Plan.

Custodial Care. Treatment or services, regardless of who recommends them or where they are provided, that could be given safely and reasonably by a person not medically skilled and are designed mainly to help the patient with daily living. Examples include help with walking, bathing, dressing, and using the toilet.

Deductible. This refers to the amount of covered expenses you must pay before the Plan begins to pay. There are separate deductibles for hospital, medical, prescription drug and dental coverage. Deductibles may be higher when you use non-network providers.

Dentist. A person duly licensed to practice dentistry by the governmental authority having jurisdiction over the licensing and practice of dentistry in the locality where the service is rendered.

Durable Medical Equipment. Includes medical supplies such as bandages and surgical dressings obtained in a physician's office, surgical supplies such as appliances to replace lost physical organs or parts or to aid in their functions when impaired, oxygen and equipment for the administration of oxygen, wheelchairs or hospital-type beds, mechanical equipment for the treatment of respiratory paralysis and blood and blood plasma. Payment will be made only if the supplies and/or equipment:

  1. Are prescribed by a covered provider; and
  2. Are provided by a qualified DME supplier; and
  3. Are used by the eligible individual for whom a claim has been made; and
  4. Cannot be used where sickness or injury is not present; and
  5. Can withstand repeated use; and
  6. Are not general use items which can be used by other family members.

Entertainment Industry Coordination of Benefits (EICOB). EICOB refers to the special rules for coordinating benefits for individuals who are covered under the Screen Actors Guild – Producers Health Plan and another entertainment industry health plan(s).

Experimental or Investigative Procedures. A drug, device, medical treatment or procedure is experimental or investigative if:

  1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or
  2. The drug, device, medical treatment or procedure, or the patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review or approval; or
  3. Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, or is the research, experimental, study or investigative arm of on-going phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or
  4. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis.

Explanation of Benefits (EOB). The EOB statement is a summary of services provided and the amounts paid.

Health Plan or Plan. The Health Plan, or Plan, means the benefits provided by the Screen Actors Guild – Producers Health Plan. The Health Plan is subject to change or termination by the Board of Trustees at any time.

Hospital. An institution legally operating as a hospital which (i) is primarily engaged in providing, for compensation from its patients, inpatient medical and surgical facilities for diagnosis and treatment of sickness or injury and the care of pregnancy, and (ii) operated under the supervision of a staff of physicians and continuously provides nursing services by graduate Registered Nurses for 24 hours of every day.

The term Hospital shall not include any institution which is operated primarily as a rest, nursing or convalescent home, or any institution or part thereof which is principally devoted to the care of the aged or the treatment of drug or alcohol abuse or any institution engaged in the schooling of its patients.

Medically Necessary. The Plan determines if a service or supply is medically necessary for the diagnosis or treatment of an accidental injury, sickness, pregnancy or other medical condition. This determination is based on and consistent with standards approved by the Plan's medical consultants. These standards are developed, in part, with consideration as to whether
the service or supply meets the following:

  1. It is appropriate and required for the diagnosis or treatment of the accidental injury, sickness, pregnancy or other medical condition.
  2. It is safe and effective according to accepted clinical evidence reported by generally recognized medical professionals or publications.
  3. There is not a less intensive or more appropriate diagnostic or treatment alternative that could have been used in lieu of the service or supply given.

Network. This refers to providers in one of the Plan's provider networks which are outlined on page 31. Services from network providers give you the best value for your health dollar.

Network Level of Benefits. There are certain times the Plan pays the network level of benefits when you use non-network providers. In these cases, you are responsible for the lower network deductibles, copays and coinsurance plus the difference between the Plan's Allowance and the billed amount.

Non-Network. This refers to providers who are not in one of the Plan's networks. Your out-of-pocket expenses are usually greater using these providers.

Notice of Eligibility (NOE). Your NOE is sent to you after you pay your premium during the Open Enrollment Period. Your NOE contains your Health Plan ID cards, information regarding your benefit coverage and a list of your enrolled dependents.

Physician. A duly licensed doctor of medicine authorized to perform a particular medical or surgical service within the lawful scope of his or her practice.

Producers. A person or entity signatory to a Collective Bargaining Agreement between SAG-AFTRA and the person or entity or producer representatives requiring contributions to the Health Plan. Producer also means SAG-AFTRA, the SAG Foundation and the Screen Actors Guild – Producers Pension and Health Plans as employers required to make contributions to
the Health Plan.

Reasonable Charge. For services rendered by or on behalf of a physician, the Reasonable Charge is an amount not to exceed the amount determined by the Plan in accordance with the applicable fee schedule adopted by the Board of Trustees. For all other charges, the Reasonable Charge is an amount measured and determined by the Plan by comparing the actual
charge for the services or supply with the prevailing charges made for it. In determining the prevailing charge the Plan takes into account all pertinent factors including the complexity of the service, the range of services provided and the prevailing charge level in the geographic area where the provider is located and other geographic areas having similar medical cost experience.

While the Plan staff will do its best to answer any questions you have concerning the Reasonable Charge over the phone, you may not rely on any information obtained in that manner. Only information in writing signed on behalf of the Board of Trustees can be considered official.

Totally Disabled. With respect to an adult participant or adult dependent, a person who is prevented, solely because of sickness or accidental bodily injury, from performing the material and substantial duties of their regular occupation. With respect to a minor participant or minor dependent, Totally Disabled means a person who is presently suffering from a sickness or accidental bodily injury, the effects of which are likely to be of long or indefinite duration and which will prevent him or her from engaging in most of the normal activities of a person of like age and sex in good health.

Trust Agreement. This is the Screen Actors Guild– Producers Health Plan Trust Agreement entered into as of February 1, 1960 and any modification, amendment, extension or renewal thereof.

Trustees. The Board of Trustees (and its respective authorized agents) as established and constituted from time to time in accordance with the Health Plan Trust Agreement