Health Plan Claims FAQs

  1. Can I make SAG my primary insurance carrier?

    You cannot elect which plan you want as your primary plan. The determination of which plan pays first is based on NAIC (National Association of Insurance Commissioners) guidelines and specific plan rules (See here).
  2. Why is the deductible a calendar year deductible when my eligibility begins April, July or October?

    It would be too costly for the Plan to maintain four separate deductible periods so the deductible is a calendar year deductible.
  3. How are my claims paid if I have other coverage (e.g. with AFTRA or Equity)?

    The SAG Plan will coordinate benefits with other plans with whom you have coverage. If you are entitled to primary coverage with another entertainment industry health plan but choose not to pay the premium required for that coverage, the SAG-Producers Health Plan will continue to consider your claims as secondary. This means the Plan will pay up to 20% of the allowed amount and the balance of the claim is your responsibility. See here for detailed information.
  4. Why am I asked for information about my coverage with other plans?

    Because the SAG Plan will coordinate benefits with other plans with whom you have coverage. Before we can process your claim, we must determine which plan should pay first and which plan should pay second. This is based on specific plan rules. See here for detailed information regarding coordination of benefits with other entertainment industry health plans.
  5. My family and I have primary coverage through an HMO but don't like our choice of doctors. Can we just use the doctors under our SAG Plan?

    It is extremely important that you use your HMO when it is your primary plan. If you do not, your benefits under the SAG Health Plan are reduced by 80% and you will have much higher out-of-pocket expenses.
  6. I don't want to enroll in Medicare because I already have such great coverage under the SAG Health Plan and I can't afford the Medicare Part B premiums. Do I have to enroll in Medicare Parts A and B?

    Yes. You are required to enroll in Medicare Parts A and B when the SAG Health Plan is secondary. If you fail to enroll in Medicare, the Plan's benefits are reduced by 80%.
  7. Will the Plan cover 100% of all my bills?

    The Board of Trustees has designed a comprehensive program of Health Plan benefits for you and your eligible dependents. However, not all services you receive are covered by the Plan. For covered services, you will be responsible for deductibles, co-payments and co-insurance amounts. You may also be responsible for amounts above the Plan's allowance. If your doctor performs services that the Plan does not cover, you are responsible for the entire bill. It is not the intent of the Health Plan to dictate what type of treatment is appropriate for a patient, nor do we wish to imply that a specific treatment is not beneficial to your condition, but rather that, benefits can only be extended within the provisions and limitations of the Plan.
  8. Why am I asked for accidental injury information on certain claims?

    If a claim has an accident or injury diagnosis, there may be another plan or entity which should provide benefits. If the injury occurred at work, Workers' Compensation would cover the benefits. If a third party is liable for the accident, they would be responsible for the benefits. In all of these cases, we need information from you to determine how your medical expenses should be paid.
  9. If I am injured on the set, will the Plan pay for my medical expenses?

    Occupational injuries or illnesses are normally covered under Workers' Compensation Insurance. On-the-job injuries or illnesses are not covered by the Health Plan. If you work for a loan-out company, you should make sure that your employer covers you under their Workers' Compensation policy.
  10. Am I covered by the SAG Health Plan when I travel to another country?

    Yes. Claims incurred in foreign countries are covered. If possible, call (800) 810-BLUE or (804) 673-1177 (collect) to find out what providers are in the BlueCard network and then show the provider your Health Plan ID Card. The provider may or may not file the claim for you. If you have to pay for services upfront, submit itemized bills to the Plan Office. You should send any dental claims to Delta Dental.
  11. If I am eligible for Plan II but do not qualify for dental coverage because I have less than 3 years of prior Health Plan eligibility, can I pay for the dental coverage?

  12. Does the Plan pay for eyeglasses?

    The Plan will only pay for the initial pair of eyeglasses or contact lenses following a covered eye surgery (i.e., cataract surgery). Otherwise glasses are not covered except for the discounts available under the vision plan with Vision Service Plan (VSP).
  13. I really don't like wearing glasses and I can't wear contacts. Will the Plan pay for surgery to correct my vision?

    No. Any surgery performed to correct a refractive error, such as LASIK, is not covered under the Plan. However, Vision Service Plan (VSP), the Plan's vision program provider offers discounts on laser vision surgery to Plan I participants. Contact the Plan Office or VSP for details.
  14. My doctor recommended that I see a nutritionist. Will the Plan cover this service?

    The Plan will cover nutritional counseling for certain chronic illnesses. Benefits are limited to one initial and two follow-up visits and are only covered if the provider is a Registered Dietitian (R.D.). There is no coverage for weight loss programs.
  15. My doctor has recommended that I go on a weight loss program since I have a heart condition. Will the Plan pay for this program?

    No. There is no Plan benefit for weight loss programs, regardless of the reason for which they may be recommended or prescribed. This is a Plan exclusion.
  16. My doctor prescribed an exercise bike. Will the Plan pay for this?

    No. Although the Plan will cover durable medical equipment (DME) when prescribed by a doctor, general use items such as an exercise bike are not covered. An item is not considered to be DME if it can be used by other members of the family or used in the absence of illness.
  17. Does the Plan cover birth control pills?

    Yes. Birth control pills are covered under the prescription drug plan. In addition, diaphragms, Norplant, IUD's and Depo-Provera are also covered.
  18. When do I need a pre-authorization for any of the Health Plan benefits?

    Pre-authorizations are required for eyelid, breast and nasal surgeries because these procedures often fall under the cosmetic exclusion. Pre-authorizations are also required for all transplant surgeries. Pre-authorizations are not required for most non-elective surgeries. However, it is always best to contact the Plan Office at least two weeks prior to your proposed surgery.

    Pre-authorizations are also required for outpatient private duty nursing and extended physical therapy.

    Pre-authorizations are also required for sleep studies.

  19. Are benefits paid to my doctor directly?

    When you use a network provider, benefits are automatically paid directly to the provider of service. This is called an "assignment of benefits". If you use a non-network provider, the Plan must have your written authorization to pay the provider directly.
  20. I think you should have paid more money on my claim. How do I appeal this claim?

    You must request reconsideration of a fully or partially denied claim within 180 days of the denial of the claim. The request must be in writing, submitted to the Administrative Director and accompanied by a statement giving the reasons the denial is believed to be incorrect.