Base Year is a 12-month period from December 1 - November 30. 

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 employers are the AFTRA Health & 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 AFTRA H&R.

Copayment is the portion you pay before you pay your deductible and coinsurance.

Coverage period is the four calendar quarters during which a qualified performer is eligible for health coverage under the Plan. Qualified performers may or may not choose to enroll in coverage.

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 AFTRA H&R will pay all or a portion. The description of each program will set forth those expenses it covers.

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 AFTRA Health Fund.

Dependents are your:

a. legal spouse, which for purposes of this definition includes a same-sex spouse to whom you are legally married in the states of Massachusetts or Connecticut (for tax liability, see the definition of domestic partner, below);

b. unmarried children to the end of the calendar year in which they reach the age of 21;

c. 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

d. unmarried children of any age who would otherwise lose coverage because of the Health 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 AFTRA H&R 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 or Connecticut) and foster children. You may be required to provide proof of dependency in a form satisfactory to the AFTRA Health 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 AFTRA Health Plan. Participants and beneficiaries can obtain, without charge, a copy of the AFTRA Health Plan’s procedures governing QMCSOs from the AFTRA Health Plan Administrator.

Domestic partner is:
A person of the same sex who has an exclusive relationship with an unmarried covered Performer over the age of 18 and who:

a. is at least 18 years old;

b. is unmarried;

c. has shared a principal residence with the covered performer for at least six months prior to enrollment and is committed to do so indefinitely;

d. shares responsibility with the covered performer for each other's living expenses;

e. is not related to the other

f. is the sole domestic partner of the other and neither has any other domestic partner;

g. does not have a spouse or other domestic partner in the last six months who is still living; and

h. 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 under the Consolidated Omnibus Budget Reconciliation Act (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 AFTRA H&R 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 AFTRA H&R office, must be paid at the same time you pay the premium for coverage to become effective. For additional information, contact the AFTRA H&R office.

Earnings cycle is the four consecutive calendar quarters that a registered performer meets the earnings requirement to qualify to enroll in the AFTRA Health Plan. Performers who meet the $10,000 threshold for Individual Health Plan qualification in a given quarter during their initial earnings cycle, but do not satisfy the $30,000 threshold for Family Health Plan qualification before that same calendar quarter ends, will only be allowed to pay the required premium and enroll in the Individual Health Plan for their first four quarter coverage period. Different rules apply regarding the initial qualification of full-time staff performers, related employees and covered roster artists. For more information call Participant Services at 1-800-562-4690 or see pages 14-16 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

Enrolled participant is a qualified performer who pays his or her health premium on time and submits a completed enrollment form.

Experimental procedure means:

a. 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;

b. techniques that are restricted to use at centers which are capable of carrying out disciplined clinical efforts and scientific studies;

c. procedures which are not proven in an objective way to have therapeutic value or benefit; and

d. any procedure or treatment whose effectiveness is medically questionable.

Family qualifying year refers to qualification for coverage under the Senior Citizen or Early Retiree Program. A qualifying year is a year during which an individual had covered earnings at least equal to the greater of $2,000 or the amount required as of the last day of such Base Year to qualify for a year of eligibility under the AFTRA Family Health Plan.