HEALTH PLAN
How do I qualify for coverage? What is the cost for the Individual Plan coverage? What is the cost for the Family Plan coverage? How do I add a dependent to my plan for health coverage? Is there a lifetime benefit maximum? What is the in-network deductible for major medical benefits? What is the non-network deductible for major medical benefits? What are my in-network major medical benefits? What are my non-network major medical benefits? What are my in-network inpatient hospital benefits? What are my non-network inpatient hospital benefits? Do I have to pre-certify if I am admitted to a hospital? How do I find out if my doctor or hospital is in the network? If I am traveling outside of the U.S., does the Plan pay for health care services that I receive? Do I need to fill out a claim form if my doctor is in the network? What happens if my spouse and I are covered under two different plans? How long are my children covered as dependents? Can I add my same-sex domestic partner as a dependent? Can I add my opposite-sex domestic partner as a dependent? What should I do if my claim is denied? What happens to my coverage under the Health Plan if I enroll in Medicare? Does the AFTRA Health Plan cover Physical Therapy? Does the Plan cover expenses for drug and alcohol rehabilitation? Is there a deductible for the prescription drug program? What are the participating pharmacy benefits? What are the non-participating pharmacy benefits? How does the mail order service work? Who administers the Dental Plan and how do I contact them? What services does the Dental Plan offered though the AFTRA Health Fund cover? What is the supplemental dental/vision plan?
Q. How do I qualify for coverage?
A. If your covered earnings in four consecutive calendar quarters or less are $10,000, but less than $30,000, you qualify for medical coverage in the Individual Plan. If your covered earnings in four consecutive calendar quarters or less are at least $30,000, you qualify for medical coverage in the Family Plan. Coverage begins on the first day of the second calendar quarter following the quarter in which the earnings requirements are met. Below is a table that shows how coverage is implemented:
Schedule of Effective Dates for Coverage
Different rules apply if you are a full-time station staff employee covered by an AFTRA agreement. For more information, call the Participant Services Department at 1-800-562-4690.
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Q. What is the cost for the Individual Plan coverage?
A. If you meet the minimum earnings requirement for Individual Plan coverage, a quarterly premium is required to maintain coverage. As of January 1, 2007, the quarterly premium is $315 for the participant plus a 'buy-up' premium if you want to cover any dependents. To find out the current cost of the buy-up, call Participant Services at 1-800-562-4690.
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Q. What is the cost for the Family Plan coverage?
A. If you meet the minimum earnings requirement for Family Plan coverage, effective January 1, 2007, you are required to pay a quarterly premium of $315 for yourself, $551 for yourself and your spouse, $551 for yourself and children, and $603 for yourself, your spouse and children.
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Q. How do I add a dependent to my plan for health coverage?
A. Send a copy of your marriage certificate to the Fund Office if you are adding your spouse to your policy, or birth certificate if you are adding a child. Please note that unmarried children are only covered to the end of the year in which they reach age 21. If they are full-time college students, they are covered up to their 23rd birthday.
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Q. Is there a lifetime benefit maximum?
A. The maximum is $1,000,000 for major medical benefits. This includes charges for mental health and chemical abuse treatment. This maximum does not include benefits provided through the hospital program. A separate $1,000,000 maximum applies for hospital and prescription drug benefits combined.
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Major Medical
Q. What is the in-network deductible for major medical benefits?
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Q. What is the non-network deductible for major medical benefits?
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Q. What are my in-network major medical benefits?
A. Once the in-network deductible has been satisfied, the Plan will pay 90% of the next $10,000 of each individual's annual covered expenses. It will pay 100% of these covered expenses over that amount for the remainder of the calendar year. Your annual out-of-pocket costs will be no more than $1,000 per year plus the deductible and any applicable copayments.
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Q. What are my non-network major medical benefits?
A. Once the non-network deductible has been satisfied, the Plan will pay 60% of the next $8,000 of the scheduled allowances for each individual's annual covered expenses. It will pay 100% of these covered expenses over that amount for the remainder of the calendar year. In general, you are responsible for any charges over the scheduled allowances plus the deductible and any applicable copayments.
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Hospital
Q. What are my in-network inpatient hospital benefits?
A. There is a $100 copayment for each inpatient stay; no deductible is required. Then, the Plan will pay 90% of the first $10,000 for covered in-network expenses in a calendar year. It will then pay 100% of remaining in-network covered expenses. This means, the maximum out-of-pocket expense for covered expenses for in-network hospitals will be $1,100 (including the copayment).
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Q. What are my non-network inpatient hospital benefits?
A. The Plan will pay 60% of the first $7,000 of covered expenses in a calendar year (excluding the $100 copayment); you will be required to pay the remaining 40% of the first $7,000. This means your annual out-of-pocket costs for the use of non-network hospitals can be as much as $2,800, plus non-covered expenses. There are two exceptions:
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Q. What services does the Dental Plan offered though the AFTRA Health Fund cover?
A. The Dental Plan offered through the AFTRA Health Fund provides only preventive services. These include office visits and examinations, diagnostic services, such as X-rays, cleaning and dental sealants (subject to age limits as described in the Health Plan summary plan description).
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Supplemental Dental/Vision Plan
Q. What is the supplemental dental/vision plan?
A. Supplemental dental/vision coverage is not provided by, administered through or endorsed by the AFTRA H&R Funds. It is provided through the Union on a completely voluntary basis and is administered by Group Benefits Associates (GBA) and The Guardian. A separate premium will apply. This supplemental coverage provides benefits in excess of those provided through the Funds. Contact your local AFTRA office for details on the supplemental coverage and the types of benefits it covers.
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Q. How do I qualify for coverage?
A. If your covered earnings in four consecutive calendar quarters or less are $10,000, but less than $30,000, you qualify for medical coverage in the Individual Plan. If your covered earnings in four consecutive calendar quarters or less are at least $30,000, you qualify for medical coverage in the Family Plan. Coverage begins on the first day of the second calendar quarter following the quarter in which the earnings requirements are met. Below is a table that shows how coverage is implemented:
Schedule of Effective Dates for Coverage
| End of quarter in which the minimum covered earnings requirements are met: | Your coverage begins on: |
| September 30 | January 1 |
| December 31 | April 1 |
| March 31 | July 1 |
| June 30 | October 1 |
Different rules apply if you are a full-time station staff employee covered by an AFTRA agreement. For more information, call the Participant Services Department at 1-800-562-4690.
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Q. What is the cost for the Individual Plan coverage?
A. If you meet the minimum earnings requirement for Individual Plan coverage, a quarterly premium is required to maintain coverage. As of January 1, 2007, the quarterly premium is $315 for the participant plus a 'buy-up' premium if you want to cover any dependents. To find out the current cost of the buy-up, call Participant Services at 1-800-562-4690.
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Q. What is the cost for the Family Plan coverage?
A. If you meet the minimum earnings requirement for Family Plan coverage, effective January 1, 2007, you are required to pay a quarterly premium of $315 for yourself, $551 for yourself and your spouse, $551 for yourself and children, and $603 for yourself, your spouse and children.
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Q. How do I add a dependent to my plan for health coverage?
A. Send a copy of your marriage certificate to the Fund Office if you are adding your spouse to your policy, or birth certificate if you are adding a child. Please note that unmarried children are only covered to the end of the year in which they reach age 21. If they are full-time college students, they are covered up to their 23rd birthday.
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Q. Is there a lifetime benefit maximum?
A. The maximum is $1,000,000 for major medical benefits. This includes charges for mental health and chemical abuse treatment. This maximum does not include benefits provided through the hospital program. A separate $1,000,000 maximum applies for hospital and prescription drug benefits combined.
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Major Medical
Q. What is the in-network deductible for major medical benefits?
| A. | $200/Individual |
| $400/Family |
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Q. What is the non-network deductible for major medical benefits?
| A. | $400/Individual |
| $800/Family |
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Q. What are my in-network major medical benefits?
A. Once the in-network deductible has been satisfied, the Plan will pay 90% of the next $10,000 of each individual's annual covered expenses. It will pay 100% of these covered expenses over that amount for the remainder of the calendar year. Your annual out-of-pocket costs will be no more than $1,000 per year plus the deductible and any applicable copayments.
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Q. What are my non-network major medical benefits?
A. Once the non-network deductible has been satisfied, the Plan will pay 60% of the next $8,000 of the scheduled allowances for each individual's annual covered expenses. It will pay 100% of these covered expenses over that amount for the remainder of the calendar year. In general, you are responsible for any charges over the scheduled allowances plus the deductible and any applicable copayments.
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Hospital
Q. What are my in-network inpatient hospital benefits?
A. There is a $100 copayment for each inpatient stay; no deductible is required. Then, the Plan will pay 90% of the first $10,000 for covered in-network expenses in a calendar year. It will then pay 100% of remaining in-network covered expenses. This means, the maximum out-of-pocket expense for covered expenses for in-network hospitals will be $1,100 (including the copayment).
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Q. What are my non-network inpatient hospital benefits?
A. The Plan will pay 60% of the first $7,000 of covered expenses in a calendar year (excluding the $100 copayment); you will be required to pay the remaining 40% of the first $7,000. This means your annual out-of-pocket costs for the use of non-network hospitals can be as much as $2,800, plus non-covered expenses. There are two exceptions:
- If the hospital is located in a part of the country in which there are no in-network hospitals, the Plan will pay 80% of the covered expenses after the copayment, and you will pay 20%; or
- If the confinement was the result of a medical emergency, which precluded the use of an in-network hospital, the Plan will pay 80% of the covered expenses after the copayment, and you will pay 20%.
After an individual's covered hospital expenses total $7,000 in a year, the plan will pay 100% of any additional covered hospital expenses for that year.
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Q. Do I have to pre-certify if I am admitted to a hospital?
A. Yes. You or your doctor must call CareAllies at 1-800-768-4695 before you are admitted to any hospital. In any confinement because of an emergency, the authorization must occur within 72 hours following admission. Otherwise benefits will be reduced.
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Q. How do I find out if my doctor or hospital is in the network?
A. For all states except California, please access the CIGNA Web site at www.cignasharedadministration.com or call 1-800-768-4695. If you live in California, please access the Blue Cross Web site by clicking here.
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Q. Do I have to pre-certify if I am admitted to a hospital?
A. Yes. You or your doctor must call CareAllies at 1-800-768-4695 before you are admitted to any hospital. In any confinement because of an emergency, the authorization must occur within 72 hours following admission. Otherwise benefits will be reduced.
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Q. How do I find out if my doctor or hospital is in the network?
A. For all states except California, please access the CIGNA Web site at www.cignasharedadministration.com or call 1-800-768-4695. If you live in California, please access the Blue Cross Web site by clicking here.
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Q. If I am traveling outside of the U.S., does the Plan pay for health care services that I receive?
A. Yes. The Plan will pay 80% of the scheduled allowance, after the deductible, and you will pay 20%. (This is the same reimbursement schedule that applies when you use a provider in an area of the U.S. in which there are no Network Providers.) Once you return to the U.S., you will be responsible for submitting the bill to the Fund office.
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A. Yes. The Plan will pay 80% of the scheduled allowance, after the deductible, and you will pay 20%. (This is the same reimbursement schedule that applies when you use a provider in an area of the U.S. in which there are no Network Providers.) Once you return to the U.S., you will be responsible for submitting the bill to the Fund office.
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Q. Do I need to fill out a claim form if my doctor is in the network?
A. In many cases, your doctor or other medical provider will send in the claim for you. If they do not, you should send in the original itemized bill to the New York Fund office. All claims should be submitted within 90 days of the date of service. Please keep in mind that claims not submitted within 15 months of the date of service will not be paid. If your doctor does not submit a claim form, it is your responsibility to make sure that you do.
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Q. What happens if my spouse and I are covered under two different plans?
A. This Plan will coordinate benefits with another health plan if you are covered by more than one plan. One plan will pay first (primary plan), and the other (secondary) will reimburse additional costs (if any) up to 100% of allowable expenses. For more information about what an allowable expense is and how this works, including how primary and secondary plans are determined, please see “Coordination of Benefits”.
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Q. How long are my children covered as dependents?
A. In general, your unmarried children are covered to the end of the calendar year in which they reach the age of 21, or age 23 if they are attending school or college as full-time students. There is a limited exception to the age limit for certain children who are mentally or physically impaired. In all cases, your children are only covered if they are chiefly dependent on you for support (unless you have a court order that meets certain requirements). For more information , please see “definition of dependent”.
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Q. Can I add my same-sex domestic partner as a dependent?
A. Yes, as long as your same-sex domestic partner meets the requirements of domestic partnership as defined by the Plan and you provide the Fund with the required documentation. You should consider the tax consequences of coverage of your domestic partner if he or she does not meet the legal definition of dependent under the tax law.
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Q. Can I add my opposite-sex domestic partner as a dependent?
A. No. The Plan’s dependent eligibility rules limit domestic partners to those of the same sex only.
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Q. What should I do if my claim is denied?
A. You may file an appeal if your initial claim for benefits is denied. Depending on what type of claim you file (e.g., the type of benefit you are seeking and whether your claim is a “pre-service,” “post-service” or “urgent care” claim), there is a different set of procedures you should follow to appeal. Keep in mind that there are time limits for filing your appeal, which you should review carefully. For more information on filing appeals, please see “Appeals Procedures”.
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Q. What happens to my coverage under the Health Plan if I enroll in Medicare?
A. If you are enrolled in the Health Plan as an active participant and you enroll in Medicare, Medicare becomes your “secondary” health plan and reimburses additional costs not covered by the Health Plan (if any), up to 100% of allowable expenses. If you are enrolled in the Senior Citizen Health Program, then Medicare becomes your “primary” health plan.
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Q. Does the AFTRA Health Plan cover Physical Therapy?
A. Yes, no pre-authorization is required. However, the services must be considered medically necessary.
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Chemical Dependency Program
Q. Does the Plan cover expenses for drug and alcohol rehabilitation?
A. The Chemical Dependency Program offers coverage for the treatment of chemical dependency, including alcohol and drugs. This program is administered by ValueOptions. Patients will be referred by ValueOptions to counselors and to other services as appropriate. In order to receive reimbursement, you must obtain a referral and pre-authorization for treatment from ValueOptions. You must also complete your treatment program to receive the full reimbursement. You can reach licensed clinicians at ValueOptions 24 hours a day, seven days a week by calling 1-800-704-1421.
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Prescription Drug Program
Q. Is there a deductible for the prescription drug program?
A. Yes. The deductible is $75 for an individual and $150 for a family. Mail order service purchases are not subject to, and do not count toward, the deductible.
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Q. What are the participating pharmacy benefits?
A. Once you have satisfied the deductible, you pay the greater of $15 or 25% of the discounted network price for a brand-name prescription drug, or the greater of $5 or 25% of the discounted network price for a generic equivalent.
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Q. What are the non-participating pharmacy benefits?
A. At a non-participating pharmacy, you pay the full retail price, and then submit a claim for reimbursement to Medco (claim forms are available at any Fund office). Once you have satisfied the deductible, you pay the greater of $15 or 30% of the discounted network price, plus the difference between the discounted price and the actual charge.
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Q. How does the mail order service work?
A. There is no deductible. You pay the greater of $30 or 20% with a $75 maximum copayment per prescription for each brand name and $10 or 20%, with a $35 maximum copayment per prescription for each generic prescription (including refills). You then receive up to a 90-day supply for that prescription. Simply send in your prescription(s) and payment in the pre-addressed mail order service envelope, available from any Fund office or Medco. You should use the mail order service for any medications you are taking on an ongoing basis. Be sure to send in the order at least two weeks in advance of when you need it.
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Dental Program
Q. Who administers the Dental Plan and how do I contact them?
A. In many cases, your doctor or other medical provider will send in the claim for you. If they do not, you should send in the original itemized bill to the New York Fund office. All claims should be submitted within 90 days of the date of service. Please keep in mind that claims not submitted within 15 months of the date of service will not be paid. If your doctor does not submit a claim form, it is your responsibility to make sure that you do.
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Q. What happens if my spouse and I are covered under two different plans?
A. This Plan will coordinate benefits with another health plan if you are covered by more than one plan. One plan will pay first (primary plan), and the other (secondary) will reimburse additional costs (if any) up to 100% of allowable expenses. For more information about what an allowable expense is and how this works, including how primary and secondary plans are determined, please see “Coordination of Benefits”.
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Q. How long are my children covered as dependents?
A. In general, your unmarried children are covered to the end of the calendar year in which they reach the age of 21, or age 23 if they are attending school or college as full-time students. There is a limited exception to the age limit for certain children who are mentally or physically impaired. In all cases, your children are only covered if they are chiefly dependent on you for support (unless you have a court order that meets certain requirements). For more information , please see “definition of dependent”.
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Q. Can I add my same-sex domestic partner as a dependent?
A. Yes, as long as your same-sex domestic partner meets the requirements of domestic partnership as defined by the Plan and you provide the Fund with the required documentation. You should consider the tax consequences of coverage of your domestic partner if he or she does not meet the legal definition of dependent under the tax law.
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Q. Can I add my opposite-sex domestic partner as a dependent?
A. No. The Plan’s dependent eligibility rules limit domestic partners to those of the same sex only.
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Q. What should I do if my claim is denied?
A. You may file an appeal if your initial claim for benefits is denied. Depending on what type of claim you file (e.g., the type of benefit you are seeking and whether your claim is a “pre-service,” “post-service” or “urgent care” claim), there is a different set of procedures you should follow to appeal. Keep in mind that there are time limits for filing your appeal, which you should review carefully. For more information on filing appeals, please see “Appeals Procedures”.
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Q. What happens to my coverage under the Health Plan if I enroll in Medicare?
A. If you are enrolled in the Health Plan as an active participant and you enroll in Medicare, Medicare becomes your “secondary” health plan and reimburses additional costs not covered by the Health Plan (if any), up to 100% of allowable expenses. If you are enrolled in the Senior Citizen Health Program, then Medicare becomes your “primary” health plan.
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Q. Does the AFTRA Health Plan cover Physical Therapy?
A. Yes, no pre-authorization is required. However, the services must be considered medically necessary.
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Chemical Dependency Program
Q. Does the Plan cover expenses for drug and alcohol rehabilitation?
A. The Chemical Dependency Program offers coverage for the treatment of chemical dependency, including alcohol and drugs. This program is administered by ValueOptions. Patients will be referred by ValueOptions to counselors and to other services as appropriate. In order to receive reimbursement, you must obtain a referral and pre-authorization for treatment from ValueOptions. You must also complete your treatment program to receive the full reimbursement. You can reach licensed clinicians at ValueOptions 24 hours a day, seven days a week by calling 1-800-704-1421.
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Prescription Drug Program
Q. Is there a deductible for the prescription drug program?
A. Yes. The deductible is $75 for an individual and $150 for a family. Mail order service purchases are not subject to, and do not count toward, the deductible.
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Q. What are the participating pharmacy benefits?
A. Once you have satisfied the deductible, you pay the greater of $15 or 25% of the discounted network price for a brand-name prescription drug, or the greater of $5 or 25% of the discounted network price for a generic equivalent.
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Q. What are the non-participating pharmacy benefits?
A. At a non-participating pharmacy, you pay the full retail price, and then submit a claim for reimbursement to Medco (claim forms are available at any Fund office). Once you have satisfied the deductible, you pay the greater of $15 or 30% of the discounted network price, plus the difference between the discounted price and the actual charge.
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Q. How does the mail order service work?
A. There is no deductible. You pay the greater of $30 or 20% with a $75 maximum copayment per prescription for each brand name and $10 or 20%, with a $35 maximum copayment per prescription for each generic prescription (including refills). You then receive up to a 90-day supply for that prescription. Simply send in your prescription(s) and payment in the pre-addressed mail order service envelope, available from any Fund office or Medco. You should use the mail order service for any medications you are taking on an ongoing basis. Be sure to send in the order at least two weeks in advance of when you need it.
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Dental Program
Q. Who administers the Dental Plan and how do I contact them?
| A. | The Guardian (DentalGuard Preferred) P.O. Box 2459 Spokane, WA 99210-2459 (800) 765-6405 |
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Q. What services does the Dental Plan offered though the AFTRA Health Fund cover?
A. The Dental Plan offered through the AFTRA Health Fund provides only preventive services. These include office visits and examinations, diagnostic services, such as X-rays, cleaning and dental sealants (subject to age limits as described in the Health Plan summary plan description).
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Supplemental Dental/Vision Plan
Q. What is the supplemental dental/vision plan?
A. Supplemental dental/vision coverage is not provided by, administered through or endorsed by the AFTRA H&R Funds. It is provided through the Union on a completely voluntary basis and is administered by Group Benefits Associates (GBA) and The Guardian. A separate premium will apply. This supplemental coverage provides benefits in excess of those provided through the Funds. Contact your local AFTRA office for details on the supplemental coverage and the types of benefits it covers.
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