• Intro

    Self-pay coverage is an option available under certain circumstances that allows participants to continue their health coverage at their own expense, similar to the federal COBRA program. You and your qualified dependents may enroll in the Self-Pay Program even if covered by another health plan, including Medicare, on the date Earned Eligibility is lost. In some cases your dependents may be entitled to enroll in the Program even if you do not elect this coverage for yourself.

    This summary describes your rights and responsibilities for enrollment and participation in the Self-Pay Program, and contains information about other health coverage alternatives that may be available to you, including coverage through the Health Insurance Marketplace created by the Affordable Care Act (ACA). For a more detailed explanation of the Self-Pay Program, refer to your Health Plan Summary Plan Description book or visit our website at www.sagph.org.

     
  • Enrollment Opportunities:

    At the time Earned Eligibility is lost you have 60 days to enroll in the Self-Pay Program at www.sagph.org or by returning your enrollment form to the Health Plan. This is also the time during which you can choose to cover your qualified dependents and select your premium rate. You can enroll dependents that were not enrolled under your earned coverage although these dependents are not entitled to self-pay for coverage on an individual basis. The Self-Pay Enrollment Form includes your qualified dependents and premium rates.

    Your enrollment in the Self-Pay Program must be received by the Health Plan within 60 days of the later of:

    1. The date your coverage terminated; or
    2. The date on your self-pay enrollment offer.

    New dependents can only be added by completing a New Dependent Form and submitting all required documents that verify your dependent(s) as qualified. Examples are a recorded marriage certificate for a spouse or a recorded birth certificate for your dependent child. Coverage will be extended to your dependents following acceptance of your legal documents, enrollment form and premium payment. A new dependent is not entitled to self-pay for coverage on an individual basis unless he or she is a newborn or newly adopted child.

    During the annual Open Enrollment Period, you will have an opportunity to make changes to your qualified dependents, which you can also do if you experience a qualifying life event. Please refer to the following rules:

    • Annual Open Enrollment: For the duration of your self-pay period, you will have an annual opportunity to change your dependent enrollment only. You can make changes to your enrolled dependents by visiting our website at www.sagph.org or by checking the appropriate box next to their name and returning the enrollment form to the Health Plan. Enrollment materials will be mailed in October and must be received by the deadline in order to be effective January 1 st of the following year

    • Life Event Enrollment Changes: You may make dependent enrollment changes if you have 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, dissolution of a qualified same-sex domestic partnership, death or loss of dependent "child" status as defined by the Plan, or your dependent obtains or loses insurance coverage on their own.

    If one of these events should occur you will be permitted to change your dependent's enrollment status and change your premium tier (if applicable) based on the addition or loss of that dependent. A written request must be submitted to the Health Plan within 60 days of the change in family status along with the appropriate proof documents. Contact us immediately if you are not able to provide the required proof documents within the time limits specified in the Health Plan Summary Plan Description. Verbal requests will not be accepted.

     
  • Coverage Options:

    Self-pay coverage is identical to the coverage provided to participants with Earned Eligibility under each respective Plan, except that self-pay participants are not entitled to life insurance or accidental death and dismemberment benefits. Please refer to page 5 for life insurance conversion information.

    The chart below illustrates the self-pay coverage options and rates effective as of January 1, 2016. Your self-pay enrollment offer includes the specific rates and options available to you. Participants losing Earned Eligibility under Plan I may choose to enroll in either Plan I or Plan II with dental. Please refer to the Benefits Summary included in your packet for a comparison of benefits under each plan.

    Options

    Plan I

    Plan II
    (with 3 or more
    Health Years)

    Plan II
    (with less than 3
    Health Years)

    Benefits

    Hospital, Medical,
    Prescriptions, Dental, Vision,
    Mental Health/Substance Abuse

    Hospital, Medical, Prescriptions*, Dental

    Hospital, Medical, Prescriptions*

    Individual only

    $624/monthly

    $539/monthly

    $508/monthly

    Individual plus 1 dependent

    $1,225/monthly

    $1,058/monthly

    $999/monthly

    Individual plus
    2+ dependents

    $1,705/monthly

    $1,472/monthly

    $1,391/monthly

    *Does not include prescription drugs for mental health and substance abuse treatment.

    Important Note: If your Earned Eligibility changes from Plan I to Plan II, you may choose to self-pay for Plan I. However, the Health Plan does not coordinate benefits between your Plan I self-pay and your Plan II Earned Eligibility. Instead, you receive Plan I benefits. Please refer to the enclosed Benefits Summary, which outlines the benefit differences between the two Plans.

     
  • Length of Coverage:

    The maximum length of self-pay coverage is as follows:

    18 months: for participants (and their qualified dependents) with fewer 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 earnings. Participants who are entitled to Medicare prior to the date they lose Earned Eligibility should call the Health Plan for information concerning their maximum self-pay period.

    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 earnings.

    36 months: for qualified dependents who lose their dependent status due to the death of a participant, divorce from a participant, dissolution of a domestic partner relationship with a participant, or loss of "child" status as defined by the Plan.

    29 months: for participants or dependents who are determined by Social Security to be totally disabled on the date Earned Eligibility ends or within 60 days thereafter. Non-disabled dependents of a disabled participant are also entitled to 29 months of self-pay coverage

     
  • Time Limits for First Payment:

    Your first payment is due by the 1st day of the month immediately following the date on which your Earned Eligibility terminates. You must pay your first premium within 45 days from the end of your enrollment period. Coverage will not be granted and claims will not be considered for payment until your enrollment and premium payment are processed.

    Your first payment must include all of the premiums to keep your coverage continuous from the date you lost Earned Eligibility. For example, if your Earned Eligibility ended on December 31 st , and you make your first premium payment in February, you must pay both January and February.

     
  • Monthly Billing Procedure and Payment Options:

    After your enrollment is processed, an enrollment confirmation letter and payment coupons will be mailed to you. Please include a coupon for each monthly payment. If you do not receive your payment coupons within 30 days after enrollment, contact the Health Plan immediately. Payment is due by the 1st day of each calendar month, although there is a 30-day grace period as mandated by federal law. Coverage will not be granted and claims will not be considered for payment until your premium is processed. To ensure that there is no interruption to your coverage, we encourage you to submit your premium payment prior to the due date which will reduce the likelihood of services being denied at your provider's office or at the pharmacy. If you do not pay your monthly premium on time, you will forfeit your rights to coverage under this program. The Health Plan provides several convenient methods for submitting your premium:

    • Auto Debit: The Auto Debit Plan deducts your premium automatically on a recurring basis from a U.S. checking or savings account. Payments are deducted monthly on the 25 th of the month prior to the due date so you have the security of knowing your premium is paid on time. The Health Plan will continue to deduct your premium as long as you remain continuously eligible for self-pay coverage, even if there is a change in the premium rate. You can sign up online or download an enrollment form by visiting our website at www.sagph.org.

    • Pay by Web: Pay your premium online with a credit card or bank account by visiting our secure website at www.sagph.org. You will receive electronic confirmation that your payment has been received.

    • Pay by Phone:Pay your premium over the telephone with a credit card by calling (818) 954-9400 or (800) 777-4013 before the due date and following the prompts. You will receive a confirmation number indicating that your payment has been received. For your security, this is an automated system. A Participant Service Representative will not be able to take your credit card information over the phone.

      For your protection, pay by web and pay by phone payments are non-recurring. This means the Health Plan will not automatically charge your credit card or debit your account every time a payment is due.

    • Pay by Mail: A billing statement and monthly payment coupons will be sent to you on a quarterly basis, typically a few weeks before the due date. Make your check, money order or cashier's check from a U.S. bank payable to: Screen Actors Guild – Producers Health Plan and send it to the Payment Center with your coupon. To ensure proper crediting you should include the account number from the billing statement on your check. Your payment must be received by the Payment Center at P.O. Box 30110, Los Angeles, CA 90030-0110 by the due date to be considered timely. DO NOT SEND YOUR PAYMENT TO THE HEALTH PLAN OR THE SAG-AFTRA UNION OFFICE.
     
  • SAG Foundation Grant Program For Catastrophic Illnesses and Injuries:

    The SAG Foundation offers financial grants to participants or qualified legal dependents of participants who have a catastrophic illness or injury and who, due to financial need, cannot afford the Health Plan's Self-Pay Program. Contact the Health Plan for more details.

     
  • Coordination of Benefits (COB):

    The Health Plan will coordinate benefits with other plans. Contact us when coordinating benefits with your (or your spouse's) other insurance. If you have Medicare, Medicare is primary and the Health Plan's self-pay coverage is secondary.

     
  • 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.
    • 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).
    • The first of the month following the expiration of the maximum self-pay coverage period for which you qualify (see Length of Coverage section on page 3).
    • The first of the month for which you qualify for Earned Eligibility, unless you are self-paying for Plan I and your Earned Eligibility is for Plan II.
    • The date on which the Health Plan no longer provides health coverage.
    • The date on which the Trustees reduce the amount of self-pay coverage available.
     
  • Other Coverage Options:

    Other Group Health Coverage: You may qualify for a special enrollment opportunity for another group health plan for which you are eligible, such as a spouse's plan, even if the plan generally does not accept late enrollees. You must request enrollment within 30 days after your Earned Eligibility with this Health Plan terminates.

    Health Insurance Marketplace: Under the Affordable Care Act (ACA) you have the opportunity to purchase coverage through the Health Insurance Marketplace at www.healthcare.gov. In California and New York, you may want to access the Marketplace directly through the State websites: www.coveredca.com or www.healthbenefitexchange.ny.gov. The Marketplace allows you to shop and compare coverage, provider networks, premiums, deductibles and out-of-pocket costs before you make a decision to enroll. In the Marketplace, you may be eligible for a tax credit that lowers your monthly premiums. Being eligible for the Health Plan's Self-Pay Program does not limit your eligibility for coverage with a tax credit through the Marketplace. As with the Health Plan's Self-Pay Program, you have 60 days to enroll for coverage in the Marketplace.

    Other Private Insurance: You may also look for private insurance outside of the Marketplace. Please visit the Health Plan's website at www.sagph.org for a copy of a resource guide which can help you locate the private insurers in your area, as well as government programs. Several health insurance websites are provided below which can provide quotes for other insurance.

    www.insure.com
    www.ehealthinsurance.com
    www.quickquote.com

    The U.S. Department of Health and Human Services, of which Medicaid is a part, also offers health programs that protect and assist needy families. Their national toll-free number is (877) 696-6775 and their website is www.hhs.gov.

    Life Insurance Conversion: Life insurance is not included in the Self-Pay Program. However, life insurance conversion policies are available only to the participant (not dependents) immediately following the termination of Plan I Earned Eligibility due to loss of earnings. To request a conversion application, please contact MetLife at (877) 275-6387 or email solutions@metlife.com. Advise the agent that your $10,000 life insurance benefit with the group life policy number 1113312 has terminated. Life insurance conversion must be completed within 31 days of the date your Plan I coverage terminated.

    Additionally, you may qualify for a waiver of the life insurance premium if you are totally disabled. Please contact the Health Plan at (818) 954-9400 or (800) 777-4013 for more information.