Qualification
How do I qualify for coverage?
You qualify for medical coverage under the Individual and Family Health Plans by meeting one of the minimum covered earnings requirements.
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What are covered earnings?
Covered earnings are payments you receive for work performed under a collective bargaining agreement that requires your employer to contribute to the AFTRA Health Fund.
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What are the minimum covered earnings requirements?
If your covered earnings over a maximum period of four consecutive calendar quarters are $10,000, but less than $30,000, you qualify for medical coverage in the Individual Health Plan. If your covered earnings over a maximum period of four consecutive calendar quarters are at least $30,000, you qualify for medical coverage in the Family Health Plan. The period during which AFTRA H&R tracks a performer’s covered earnings to determine qualification for medical coverage is called the earnings cycle.
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Can the minimum covered earnings requirements be satisfied in less than four consecutive calendar quarters?
Yes. It is important to note that performers who meet the $10,000 threshold for individual Health Plan coverage in a given quarter during their initial earnings cycle, but do not satisfy the $30,000 threshold for family coverage before that same calendar quarter ends, will only be allowed to pay the required premium and enroll for individual coverage for their first four-quarter Coverage Period. Most commonly, this situation occurs with freelance performers and part-time staff performers.
However, effective with Coverage Periods that began on and after July 1, 2009, AFTRA H&R allows performers who initially qualify for individual coverage to pay the higher premium and enroll instead for family coverage if they reach the $30,000 threshold required for family coverage by the end of their three-month waiting period. (The waiting period is the quarter after the end of a Performer’s Earnings Cycle and before the start of the Performers 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.
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When does coverage begin?
Coverage begins on the first day of the second calendar quarter following the quarter in which at least one of the minimum covered earnings requirement thresholds is satisfied, provided the necessary premium has been paid in full and on time. The start date establishes the beginning of your coverage period, which lasts four quarters. Below is a table that shows the calendar quarters when coverage would begin based upon various earnings cycle end dates:
| End of four quarter earnings cycle in which at least one of the minimum covered earnings requirements is met: | Your four quarter coverage period begins on: |
| September 30 | January 1 |
| December 31 | April 1 |
| March 31 | July 1 |
| June 30 | October 1 |
Different rules apply regarding 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.
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How do I add a dependent to the Health Plan?
To add a new legal spouse to the Health Plan, send written notice that includes your spouse’s name and Social Security number, or a completed Performer Enrollment Form, to AFTRA H&R requesting his or her addition as a dependent, along with your marriage certificate/license, within 30 days of the date of marriage. By meeting these requirements, your spouse will be added as a covered dependent retroactive to the date of the marriage. If you miss this 30-day window, you may submit a completed Performer Enrollment Form with your marriage certificate/license to AFTRA H&R prior to the start of your next coverage period. This will enable you to add your new spouse to the Health Plan as a dependent when that coverage period begins, provided the necessary premium is paid in full and on time.
If you’re adding a child, send written notice including the child’s name and Social Security number, or a completed Performer Enrollment Form, to AFTRA H&R requesting his or her addition as a dependent. Be sure to include either the birth certificate, adoption papers issued by a court, or a letter of placement from an adoption agency, to AFTRA H&R within 30 days of the birth or adoption. By meeting these requirements, your child will be added as a covered dependent retroactive to the date of the birth or adoption. If you miss this 30 day window, then you may submit a completed Performer Enrollment Form with the documentation described above to AFTRA H&R prior to the start of your next coverage period. This will enable you to add your child to the Health Plan as a dependent when that coverage period begins, provided the necessary premium is paid in full and on time.
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How long can my children be covered as dependents?
Unmarried children are only covered to the end of the calendar year in which they reach age 21. Full-time students may remain as a dependent in the Health Plan until the end of the calendar year in which they reach age 23, provided an official transcript or letter is received from the school or college each semester verifying that the child is both an enrolled full-time student and is attending classes. There is an 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” on pages 7-8 of the 2005 Health Plan Summary Plan Description.
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Can I add my same-sex domestic partner as a dependent?
Yes, as long as your same-sex domestic partner meets the requirements of domestic partnership as defined by the Plan and you provide AFTRA H&R with the required documentation. See page 8 of the 2005 Health Plan Summary Plan Description. It is important to note that there are tax consequences of covering your domestic partner if he or she does not qualify as a dependent under the Internal Revenue Service code.
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Can I add my opposite-sex domestic partner as a dependent?
No. The Health Plan’s dependent qualification rules limit domestic partners to those of the same sex only.
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What happens to my coverage under the Health Plan if I enroll in Medicare?
If you are an enrolled participant in either the active Individual or Family Health Plan and you also qualify for and enroll in Medicare, Medicare becomes your “secondary” plan and reimburses that portion of covered expenses not reimbursed by your AFTRA Health Plan (if any), up to 100% of the Medicare allowance.
If you are enrolled in the Senior Citizen Health Program, then Medicare is considered your “primary” plan. The Senior Citizen Health Program is your “secondary” plan with respect to Medicare, and Program reimbursement is based upon the difference between the Medicare allowances for services you receive and the amount that Medicare pays. The Senior Citizen Health Program will reimburse you based upon the Medicare benefit, whether or not you are not covered by Medicare. Participants planning to enroll in the Senior Citizen Program, therefore, are strongly encouraged to take both Medicare Part A and Part B. See page 62 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates for further details on coordination of benefits with Medicare.
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