The Plan has implemented the Working Spouse Rule effective January 1, 2021.
The Plan’s Working Spouse Rule states that, if your spouse is working for an employer who offers a health plan, the Plan requires them to enroll in that employer-sponsored coverage to be eligible for Plan coverage. Your spouse must confirm whether they have access to and are enrolled in their employer’s health plan.
The Plan has partnered with Cotiviti to collect details related to your spouse's other health coverage (if any).
If you intend to enroll your spouse for coverage in the SAG-AFTRA Health Plan and you are within open enrollment for your next benefit period, we will need additional information to ensure that there is no delay in their coverage.
Once your enrollment has been completed you will receive a mailing from our partner Cotiviti. For your convenience and during the collection period, you may update your record by calling (877)-795-4611 or access their website at sagaftrahp.coverageupdatecenter.com.*
*When adding or removing dependents, you’ll need to wait two business days to access your Cotiviti account.
Who is Cotiviti?
SAG-AFTRA Health Plan has partnered with Cotiviti to process the verification of other health plan coverage for your spouse and eligible dependent children. We will use this information to determine how the Plan coordinates benefits with the other health plans in which you’re enrolled.
What is the working spouse rule?
If your spouse’s employer offers a health plan, they need to enroll in that plan. If enrolled with their employer, you can choose to cover them under the SAG-AFTRA Health Plan as well. The employer’s plan will pay benefits first; then, our Plan’s cost-sharing may apply for remaining eligible expenses. If they don’t enroll in their employer’s plan, you cannot cover them with us — our Plan will not pay benefits for their healthcare.
If your spouse is not working, or their employer does not offer a health plan, you can enroll your spouse with the SAG-AFTRA Health Plan.
What is coordination of benefits (COB)?
Coordination of benefits (COB) is the method of dividing responsibility for payment among multiple health plans that cover an individual so that the amount paid by all plans will never exceed 100% of the allowable expenses.
What happens if my spouse loses their employer coverage during the benefit period?
You can enroll your spouse with the SAG-AFTRA Health Plan. Your spouse will need to provide a copy of the coverage termination letter to the Plan.
Does my spouse have to take the secondary coverage under SAG-AFTRA Health Plan?
Remember, if you decide to enroll your eligible working spouse in Plan coverage, you will pay a premium. Thus, you are not required to enroll your working spouse in Plan coverage – the choice is yours, and if you do so, the Plan pays secondary benefits for their healthcare services.
Can my dependent children be covered under SAG-AFTRA Health Plan instead of my spouse’s employer coverage?
Yes, your dependent children can be covered under the Plan.
Will married participants who are both offered SAG-AFTRA Health Plan coverage but currently choose to be covered as a dependent under one spouse’s SAG-AFTRA Health Plan be required to enroll in their own Plan coverage?
No. The choice to cover both spouses under one participant or for each spouse to have their own coverage will remain unchanged.
When do I call Cotiviti?
If you have questions regarding the verification forms you need to return for your spouse and eligible dependent children.
When do I call SAG-AFTRA Health Plan?
You may call the Plan any time you have questions regarding participant coverage verification forms.
How often do I have to submit coverage verification forms?
Once a benefit period, or if you have a life event that changes your or your dependents’ eligibility for Plan coverage. If you have a change, you must submit updated coverage verification forms within 30 days.
When is the deadline?
Please submit the forms by your premium payment due date.
Why do we have to fill out coverage verification forms?
As of January 1, 2021, the working spouse rule requires enrolled working spouses to take their employer's health plan coverage. The Plan also needs information about any other coverage that you or your dependents are enrolled in.
What happens if I don’t submit coverage verification forms?
If the Plan does not receive forms for your enrolled spouse, coverage for your spouse will be terminated and any premium refund due will be credited towards future premium payments.
What happens if my spouse does not take their employer's coverage?
Your spouse will not be eligible to be covered under the Plan.
What about my eligible dependent children?
Eligible dependent children can be covered under the Plan and are not required to be enrolled under your spouse’s employer's plan.
Does my spouse have to take the dental coverage offered by their employer?
If there is an additional cost for dental coverage, your spouse does not need to enroll in their employer’s dental plan. Your spouse (if enrolled) can be covered under the Plan for dental coverage.
Does my spouse have to take the vision coverage offered by their employer?
If there is an additional cost for vision coverage, your spouse does not need to enroll in their employer’s vision plan. Your spouse (if enrolled) can be covered under the Plan for vision coverage.
Where do I send my premium payments?
Premium payments are due to the Plan. Please log in to Benefits Manager at my.sagaftraplans.org/health or call (800) 777-4013 to make a payment over the phone. You can also pay by mail.
Is the premium less for secondary coverage for my spouse?
No, premium amounts are the same regardless if the Plan pays primary or secondary benefits for your spouse.
What if I need another copy of the forms to fill out?
Please call Cotiviti toll free at 1-877-795-4611 and they can complete your information over the phone or they can make arrangements to send you another packet.
Do I need to inform the Plan if I have Medicare coverage?
No, you do not need to indicate whether you have Medicare.
How long does it take to process the forms?
It is important to that all of the information requested on your forms is completed in full to ensure the quickest processing time. Once Cotiviti receives your completed information, the information is returned to SAG-AFTRA Health Plan within two business days. If information is missing, the Cotiviti team will reach out to obtain the additional information, but this will impact the length of the time to complete the process of your response.
When will my coverage be effective?
Your coverage will be effective as of the first day of your benefit period, assuming your spouse and eligible dependent children have completed the coverage verification process with Cotiviti, and you pay the Plan premium. You will receive a Notice of Coverage from the Plan.
How can I appeal decisions about my spouse and dependents’ eligibility and Plan coverage?
You can file your appeal with the Plan by email to [email protected] or by mail to:
SAG-AFTRA Health Plan
c/o Appeals Department
P.O. Box 7830
Burbank, CA 91510
Where can I file a complaint or grievance?
You can file a complaint or grievance by email to [email protected] or by mail to:
SAG-AFTRA Health Plan
c/o Appeals Department
P.O. Box 7830
Burbank, CA 91510