SELF-PAY PROGRAM

When you lose Earned Eligibility, you and your qualified dependents may continue Health Plan coverage by enrolling in the Self-Pay Program. The length of time you are allowed to self-pay depends on several factors, including which “qualifying event” caused the loss of Earned Eligibility and how many years of previous Earned Eligibility you have in the Health Plan. Asame-sex domestic partner and his or her children may only enroll in the Self-Pay Program if the participant enrolls. Self-Pay premium rates are determined in accordance with federal COBRA law and may change once a year, or more frequently if significant Plan changes occur. The following summarizes the key provisions of the Self-Pay Program, including its restrictions and deadlines.

Qualifying Events
You and your qualified dependents may have the right to elect Self-Pay coverage upon the occurrence of the following qualifying events:

Participant: Loss of Earned Eligibility due to a reduction in your Covered Earnings or Days of Employment, or the change from Plan I to Plan II due to a reduction in your Covered Earnings. Failure to pay the Health Plan premium is not a qualifying event.

Early Retirement Pensioner: Commencement of your Early Retirement Pension, or the loss of Earned Eligibility, if later.

Disability Pensioner: Commencement of your Disability Pension, or the loss of Earned Eligibility, if later.

Dependent Spouse: Loss of Earned Eligibility due to a reduction in the participant’s Covered Earnings or Days of Employment, the change from Plan I to Plan II due to a reduction in the participant’s Covered Earnings, divorce from the participant, or the death of the participant.

Dependent Children (as defined by the Plan): Loss of coverage due to a reduction in the participant’s Covered Earnings or Days of Employment, the change from Plan I to Plan II due to a reduction in the participant’s Covered Earnings, the death of the participant, or loss of “child” status as defined by the Plan.

In some cases, a qualified dependent may be entitled to enroll individually if the participant does not elect Self-Pay coverage.

Your Notification Requirements
You or your dependents must notify the Plan Office, in writing, in the event of divorce or a child losing dependent status under the Plan in order for the dependent to receive individual self-pay rights. Notification must be made within 60 days of the later of:

• The date the event occurred; or
• The date coverage terminates as a result of the qualifying event.

If the Plan Office is not notified in writing within this time frame, the individual losing eligibility as a dependent will forfeit his or her right to enroll in the Self-Pay Program.

Maximum Length of Self-Pay Coverage

18 months - for participants (and their qualified dependents) with less than 17 years of Earned Eligibility in the Health Plan who lose eligibility or change from Plan I to Plan II due to a reduction in Covered Earnings or Days of Employment.

36 months
- for participants (and their qualified dependents) with at least 17 years of Earned Eligibility in the Health Plan who lose eligibility or change from Plan I to Plan II due to a reduction in Covered Earnings or Days of Employment.

- for qualified dependents who lose their dependent status due to the death of a participant and who will not be eligible for the Extended Spousal benefit. The 36 months begins on the first of the month following the date dependent status is lost.

- for qualified dependents who lose their dependent status due to divorce from a participant or loss of “child” status as
defined by the Plan. The 36 months begins on the first of the month following the date dependent status is lost.

29 months - for participants or dependents who are determined by Social Security to be totally disabled on the date Earned Eligibility terminates or within 60 days thereafter. Nondisabled dependents of the disabled individuals are also entitled to 29 months of Self-Pay coverage.

Early Retirement Pensioners - Participants (and their qualified dependents) receiving an Early Retirement Pension are eligible to selfpay until age 65.

Disability Pensioners - Participants (and their qualified dependents) receiving a Disability Pension are eligible to self-pay until age 65.

Dependents who will qualify for the Extended Spousal Benefit - Qualified dependents who will be eligible for the
Extended Spousal benefit as a result of a participant’s death are eligible to self-pay until the participant would have reached age 65 and the Extended Spousal coverage begins. See page 13 for a description of the Extended Spousal benefit.

Special Rules for Dependents

Participants may include their qualified dependents under the Basic Self-Pay coverage at no additional cost. One premium covers you and all of your eligible dependents. If you do not enroll in the Self-Pay Program following the loss of your Earned Eligibility, your qualified dependents may enroll individually, provided they enroll within the 60-day time limit.

If you lose Earned Eligibility and you have a same-sex domestic partner, your partner and your partner’s children may be covered under the Self-Pay Program only if you elect such coverage. Same-sex domestic partners are not entitled to self-pay on an individual basis.

Dependents acquired after the participant’s enrollment (due to marriage, birth or adoption, for example), may be added to the participant’s coverage. However, except for newborn and adopted children, they will not be entitled to self-pay for coverage on an individual basis.

If you lose Earned Eligibility and are entitled to 36 months of coverage, you may include your dependents for the extended Self-Pay period. However, dependents are not eligible for longer than 18 months of coverage on an individual basis unless they subsequently lose their status as eligible dependents.

If your qualified dependents lose their status as eligible dependents while you are covered under the Self-Pay Program or the Senior Performers Plan, they may also qualify for individual Self-Pay coverage. Additionally, individual Self-Pay coverage may be available if they lose their dependent status while covered under the Extended Spousal benefit. Self-Pay coverage for your dependents is only available if they have been continuously covered under the Health Plan since the loss of your Earned Eligibility. The maximum length of the Self-Pay coverage is 36 months from the date Earned Eligibility was lost.

For example, assume a participant loses Earned Eligibility and enrolls in the Self-Pay Program. If he and his spouse divorce after being covered under the Self-Pay Program for 10 months, the spouse will be entitled to an additional 26 months of coverage.

Your dependent is not entitled to this additional coverage if he or she is your same-sex domestic partner or the child of your samesex domestic partner.

If you lose Earned Eligibility after you become entitled to Medicare, your qualified dependents will be entitled to Self-Pay coverage. The maximum period of Self-Pay coverage available will end on the later of:

• 18 months from the loss of your Earned Eligibility; or
• 36 months from your Medicare entitlement date.

In cases where Self-Pay coverage is not available, a conversion policy may be available. Please refer to “Conversion Options” on page 24.

Enrollment Options
Your enrollment options depend on your prior Earned Eligibility as outlined in the chart below.

Basic Coverage - Plan I or Plan II
Basic Self-Pay coverage is identical to the coverage provided to the Earned Eligible participants in each respective Plan, except that Self-Pay participants are not entitled to life insurance or accidental death and dismemberment benefits. One premium covers the participant and all eligible dependents.

Lower Cost Option Coverage
The Lower Cost Option offers coverage for individuals only. There is no coverage for dependent spouses or children. There is also no ValueOptions or vision coverage.

NOTE: If your Earned Eligibility changes from Plan I to Plan II, you may choose to self-pay for Plan I Basic. However, the Health Plan does not coordinate benefits between your Plan I Self-Pay and Plan II Earned coverage. Instead, you receive Plan I benefits.

Enrollment Process
When you lose Earned Eligibility, the Plan Office will send you a termination notice along with a Self-Pay Enrollment Form. Your completed Self-Pay Enrollment Form must be postmarked within 60 days of the later of:

• The date your coverage terminated; or,
• The date on the termination notice.

Once enrolled, you cannot change your election unless you have a change in family status as described on page 18.

You will not be permitted to elect Self-Pay coverage at a later date except under the Postponed Enrollment Program outlined on page 19.

Time Limits for First Payment
Your first Self-Pay premium payment is due on the first day of the month immediately following the date on which your Earned Eligibility terminates. You are encouraged to submit your first payment with your Enrollment Form. However, you have 45 days from the last day of your enrollment period to make the payment. Claims will not be considered for payment until your premium is received. Also, coverage will not be verified to any hospital or physician prior to the receipt and processing of your premium payment and providers will be advised that you are still in your enrollment or grace period.

Your first payment must include all premiums required to keep your coverage continuous from the date you lost Earned Eligibility. For example, if you lost Earned Eligibility on December 31st and you make your first premium payment in February, your payment must include the premium for both January and February. No premium payments can be skipped.

Premium Due Dates
After the Plan Office receives and processes your Enrollment Form, you will be mailed payment coupons. You will not be billed on a monthly basis. After the first premium payment, all subsequent premium payments are due on the first of each month. As mandated by federal law, there is a 30-day grace period, however you are encouraged to submit the payment by the due date. Claims will not be considered for payment until your premium is received.

If you elect a change in Self-Pay coverage, as outlined on page 18, you will receive new payment coupons which reflect your new coverage and premium rate. If you do not receive your billing coupons within 30 days after enrollment or change in coverage, please contact the Managed Care Department at the Plan Office.

If you fail to pay your premium by the due date, you will forfeit your rights to continued coverage under the Self-Pay Program.

Premium Payment Procedures
There are several ways to pay your Self-Pay premium.

Pay by Mail – Send your check, money order or cashiers check, along with the payment coupon to the Plan Office. You should not use an overnight delivery service because many of these services will not deliver to a P.O. Box. Checks should be made payable to“Screen Actors Guild – Producers Health Plan” and must be made from a U.S. bank in U.S. dollars. Please include your account number from the billing statement on your check to ensure proper crediting.

If you wish to pay for more than one month at a time, you should send a check for the total monthly payments, along with the corresponding monthly coupons.

(Registration no longer required).
Pay by Web – This option allows you to pay online with a credit card – Visa, MasterCard, American Express or Discover. It requires that you first register on our Web site, www.sagph.org, to obtain a user name and a password. For more information on the Plan’s interactive Web site, please refer to page 66. You should register well in advance of your premium payment due date because your password is mailed to you from the Plan Office and may take several days to arrive. Payments made through the Web are nonrecurring, which means that the Plan does not store your credit card information and will not automatically charge your credit card every time a payment is due.

If you choose to pay online, simply log in to the secure site and enter your credit card information. You can pay for up to 12 months at one time and you will get instant confirmation that your payment has been received.

Pay by Phone – This option allows you to pay over the telephone with a credit card – Visa, MasterCard, American Express or Discover. Simply call the Plan Office, access the Automated Information Center (AIC) and follow the prompts. The phone numbers are (818) 954-9400 or (800) 777-4013, outside the Los Angeles area. Pay by phone payments are non-recurring, which means the Plan does not store your credit card information and will not automatically charge your credit card every time a payment is due. Plan Office staff are not available to take your credit card information.

If you choose to pay by phone, simply call the AIC before the due date and provide the necessary information. You can pay for up to 12 months at one time and you will get instant confirmation that your payment has been received.

Checking and Savings Auto Debit Plan – This option allows you to pay through an automatic recurring deduction from a checking or savings account on a monthly basis. To set up these payments, you must complete an application and return it to the Plan Office at least 10 days prior to the premium due date. Applications may be obtained by speaking with a Self-Pay Analyst in the Managed Care Department at the Plan Office or by visiting our Web site, www.sagph.org. Payments are deducted on the 25th of the month before the monthly premium due date. For example, a payment due on July 1st is deducted on June 25th. You will not receive monthly coupons in advance once you have enrolled in the auto debit plan.

Any check or debit returned to the Health Plan for any reason will be assessed a handling fee. A cashiers check or money order will be required to replace the premium payment. If you have two or more returned payments during your Self-Pay coverage, you will be required to make all your future premium payments with a cashiers check or money order.

Coverage Changes
After enrollment, coverage may be changed immediately following a change in family status. A change in family status is defined as an increase or decrease in the number of your qualified dependents, which results from birth, adoption, marriage, divorce, commencement or termination of a same-sex domestic partnership, death or loss of dependent “child” status as defined by the Plan.

If you gain or lose a dependent, you will be permitted to change your coverage from Basic to Lower Cost or from Lower Cost back to Basic as the condition warrants. A coverage change will also be allowed if your dependent obtains his or her own insurance. For example, you are married, covered under Plan I Self-Pay and your spouse obtains health benefits from another plan that does not include dependents. You may change to Lower Cost to eliminate the additional cost of your spouse’s coverage. A request to change your coverage must be made to the Plan Office in writing within 60 days of the change in family status. No verbal requests will be accepted.

Once your change has been processed, you will receive a new set of billing coupons and identification cards to confirm your new coverage and premium rate.

If your request is received on or before the 10th of the month, the change will become effective on the first of the month following the date of receipt. If your request is received after the 10th of the month, the change will become effective the first of the second month following the date of receipt. The Health Plan does not retroactively change Self-Pay coverage.

For example:

Postponed Enrollment Programs
Individuals with Other Group Health Coverage

Self-Pay coverage is offered on a continuous basis where enrollment immediately follows the termination of Earned Eligibility. However, if you meet all of the following requirements you may enroll following a break in coverage.

• You have at least 17 years of Earned Eligibility in the Health Plan; and
• You have other group health insurance at the time your SAG-Producers Health Plan Earned Eligibility expires, or gain other group health insurance while enrolled in the SAG-Producers Self-Pay Program; and
• You have not already exceeded the maximum number of months of Self-Pay coverage available to you under the SAG-Producers Self-Pay Program; and
• You enroll in the SAG-Producers Self-Pay Program within 60 days following the later of (i) the termination of your other group health coverage if that plan is not required to offer self-pay coverage, or (ii) the last day of your other group health plan’s selfpay period (the maximum number of months available for you to self-pay under the other plan); and
• You provide a copy of the other group health plan’s certificate of coverage, issued in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Individuals with Other Group Dental Coverage
An additional Postponed Enrollment option is available to participants who have been enrolled in the Self-Pay Program since prior to January 1, 2002 and who have declined the Plan’s Self-Pay dental coverage because they had dental coverage in another group health plan. If your other dental coverage terminates, you may be eligible to enroll in the Plan’s Self-Pay dental if you do the following:

• Enroll in the SAG-Producers Health Plan dental coverage within 30 days following the termination of your other group dental coverage; and
• Provide a copy of the other group health plan’s certificate of coverage, issued in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

The Postponed Enrollment Program is also available if your other group health or dental coverage is your spouse’s or same-sex domestic partner’s SAG-Producers Health Plan coverage.

Extended Self-Pay Coverage for Military Service
Your choices under USERRA with regard to immediately using your Earned Eligibility or immediately enrolling the Self-Pay Program are outlined on page 6. Your maximum selfpay period is 24 months if you had less than 17 years of Earned Eligibility in the Health Plan or 36 months if you had at least 17 years of Earned Eligibility in the Health Plan. The applicable premium must be paid once the waiver period described on page 6 is exhausted.

Coordinating Self-Pay Benefits With Other Plans
You and your eligible dependents may enroll in the Self-Pay Program even if you or your dependents are covered by another group health plan on the date Earned Eligibility is terminated in this Plan. You should contact the Plan Office to determine which plan will be primary and secondary.

However, if your Earned Eligibility changes from Plan I to Plan II, and you choose to selfpay for Plan I Basic, the Plan will not coordinate benefits between your Plan I Self-Pay and Plan II Earned coverage. Instead, you receive Plan I benefits.

If you or your spouse are covered by Medicare, you may also enroll in the Self-Pay Program. Medicare will be your primary plan and this Plan will be your secondary plan. It is very important that you and your spouse enroll for Medicare Part A and Part B coverage prior to your 65th birthdays. If you fail to enroll in Medicare Part A and Part B when this Plan is secondary or tertiary, your payments from this Plan will be reduced by 80% because the Plan will coordinate benefits as if you had received reimbursement from Medicare. You and your spouse are not required to enroll in a Medicare Part D Prescription Drug Program, however it may be to your advantage to do so. Refer to the section on Medicare, page 71 for more information.

Termination of Self-Pay Coverage
Your Self-Pay coverage will terminate on the earlier of:

• The first of the month for which you do not pay your premium by the due date; or
• The first of the month after the month in which Social Security determines you are no longer totally disabled if your Self-Pay coverage is based on your being totally disabled; or
• The first of the month following the expiration of the maximum Self-Pay coverage period for which you qualify; or
• The first of the month for which you qualify for Earned Eligibility, unless you are self-paying for Basic Plan I and your
  Earned Eligibility is for Plan II; or
• The date on which the Trustees reduce the amount of Self-Pay coverage available; or
• The date on which the Health Plan no longer provides health coverage.