To help you understand how the AFTRA Health Plans work, it's important for you to know the meaning of the terms defined here. When they appear in the text they are highlighted to remind you they are defined terms.
Coinsurance is the portion you pay for most covered
expenses, in addition to the deductible and any copayment. For
example, if the Plan pays 80% of covered expenses, the 20% of covered
expenses you have to pay is your coinsurance.
Contributing employer is the AFTRA Health and Retirement Funds
and any employer who is required and permitted under the Trust
Agreement to contribute to the AFTRA Health Fund under the terms of a
collective bargaining agreement with AFTRA or a written agreement with
the Fund.
Copayment is the portion you pay before you pay your deductible and coinsurance.
Covered earnings are those payments made to you by a
contributing employer for work under a collective bargaining agreement
that provides for contributions to the AFTRA Health Fund.
Covered expenses
are the costs of services or supplies for which
the Fund will pay all or a portion. The description of each program
will set forth those expenses it covers.
Covered roster artist is an individual (whether or not part of a
group) bound by an exclusive recording agreement with the record label
(signed to the sideletter agreement) as of the last day of the
immediately preceding semi-annual Schedule C period.
Custodial care means all services and supplies, including room
and board, provided primarily to assist a covered individual in the
activities of daily living, regardless of the practitioner or provider
by whom they are prescribed, recommended or performed.
Deductible is that initial part of each year's covered expenses
under a particular program for which you are responsible and for which
you will not be reimbursed by the Fund.
Dependents are your:
- legal spouse, which for purposes of this definition includes a same sex spouse to whom you are legally married in the state of Massachusetts (for tax liability, see the definition of domestic partner, below);
- unmarried children to the end of the calendar year in which they reach the age of 21;
- unmarried children who are over age 21 and attending school or college as full‑time students. Your children will continue to be eligible until they are no longer full‑time students or until the end of the calendar year in which they reach the age of 23, whichever is earlier; and
- unmarried children of any age who would otherwise lose
coverage because of the Plans' age limitations but continue to be
dependent on you due to an inability to engage in any substantial
gainful activity by reason of a medically determinable physical or
mental impairment that can be expected to result in death or which
lasts (or can be expected to last) for a continuous period of at least
12 months. You must provide proof of your child's handicap to the Fund
office in order for coverage to continue.
For the purpose of this definition, children must be unmarried children
who are chiefly dependent upon you for support and maintenance.
They may include your biological children, legally adopted children
(including a child placed for adoption during the waiting period before
the adoption becomes final), stepchildren (including stepchildren of
same-sex spouses married in Massachusetts) and foster children.
You may be required to provide proof of dependency in a form
satisfactory to the Plan.
Children may also include your unmarried child who meets the
requirements of b, c or d above, but is not chiefly dependent on you
for support or maintenance if the child is recognized under a qualified
medical child support order (QMCSO) as having a right to enrollment
under the Plan. Participants and beneficiaries can obtain,
without charge, a copy of the Plan’s procedures governing QMCSOs from
the Plan Administrator.
Domestic partner is:
- a. is at least 18 years old;
- is unmarried;
- has shared a principal residence with the covered performer for at least six months prior to enrollment and is committed to do so indefinitely;
- shares responsibility with the covered performer for each other's living expenses;
- is not related to the other
- is the sole domestic partner of the other and neither has any other domestic partner;
- does not have a spouse or other domestic partner in the last six months who is still living; and
- is not entitled to health insurance coverage through an employer and has not declined such coverage.
With the exception of the Glossary of Terms and the sections on COBRA,
wherever the terms dependent or dependents are used, they will be
understood to include domestic partners.
After the requirements for a domestic partner relationship as outlined
above are met, coverage will begin on the first day of the month
following receipt by the Fund office of fully executed and notarized
documents, including the “Declaration of Same-Sex Domestic Partnership
for Enrollment or Eligibility”, birth certificates, the “Registration
of Domestic Partnership” and the “Affidavit of Dependency for Tax
Purposes” if your domestic partner qualifies as a dependent under the
IRS code, Section 152. However, if your domestic partner does not
qualify as a dependent under the IRS code, any federal or state taxes
due, as indicated on the invoice you will receive from the Fund office,
must be paid at the same time you pay the premium for coverage to
become effective. For additional information, contact the Fund office.
Experimental procedure means:
- any medical procedure, equipment, treatment or course of treatment, or drug or medicine that is under investigation and the use of which is limited to research;
- techniques that are restricted to use at centers which are capable of carrying out disciplined clinical efforts and scientific studies;
- procedures which are not proven in an objective way to have therapeutic value or benefit; and
- any procedure or treatment whose effectiveness is medically questionable.
