Medicare Elegibility: Equity-League Fund

Medicare Eligibility

Medicare consists of three parts: Part A, which provides hospital benefits, Part B, which provides medical benefits and Part D which provides prescription drug benefits (there is also a Part “C” alternative to Parts A and B, coverage by a Medicare approved insurer, such as an HMO or a PPO. Most of these Part C insurers offer Part D coverage as well, but if they don’t, participants in Part C plans can obtain Part D coverage from another Medicare approved Part D provider). Parts A, B and D require you to pay a deductible before they pay benefits. You are also required to pay a premium for Part B coverage and most Part D coverage (Part D coverage is available only through providers approved by Medicare it is not available directly from Medicare). You (and your dependents) may become eligible for Medicare upon turning 65, after the first 18 months of end-stage renal disease (“ESRD”), or if you have been deemed totally and permanently disabled by the Social Security Administration (“SSA”). What you’ll find here is an explanation of what happens to your medical benefits under the Fund when you become eligible for Medicare. For more information on Medicare, please refer to www.medicare.gov, or contact the Fund Office..

Coordination of Benefits with Medicare:

Here’s how your Medicare eligibility is linked to your eligibility for Fund benefits.
- If you’re still eligible for Fund benefits through employment and become eligible for Medicare as a result of turning age 65, you are eligible for Medicare even though you are still working. If you are covered by the Fund through employment, you will continue to be eligible for the same benefits as any other participant. The Fund will generally remain the primary payer of your medical benefits and Medicare (if you have signed up for it) will be secondary. This means that after the Fund pays its benefits, you can submit a claim to Medicare for amounts not covered by the Fund. (A covered spouse will be treated the same way upon turning 65.) However, you also have the option of electing to either stop participating in the Fund, in which case Medicare would be your only health insurance, or not enrolling in Medicare, in which case the Fund would provide your only health coverage. Remember that if the Fund should be primary and you do not enroll in it, and Medicare discovers this, they may try to reimburse you as if you had taken Fund coverage, that is with Medicare as the secondary payer, even if that is incorrect.
- If you’re not eligible for Fund benefits through employment and become eligible for Medicare as a result of turning age 65, and you no longer have Fund coverage through employment, Medicare will be your primary coverage, and you should sign up for it as soon as you’re eligible. However, you also may have the option (if you satisfy the Fund’s eligibility requirements, see page xx) of self-paying for secondary coverage through the Fund’s Medicare Supplemental Plan, which is provided through CIGNA. (If you are eligible for Medicare because you have been diagnosed with ESRD or are totally and permanently disabled, you would also be eligible for the Medicare Supplemental Plan.) If you sign up for the Medicare Supplemental Plan, you will be eligible for Out-of-Network medical benefits only. However, you will have both Network and Out-of-Network prescription drug and vision coverage. Once Medicare has paid its benefit, the unpaid portion of an expense can be submitted under the Medicare Supplemental Plan. (The total benefits paid under both Medicare and the Medicare Supplemental Plan cannot exceed the expense incurred.) In addition, your benefits from the Fund will be calculated as if you are enrolled for Medicare for both Part A and Part B, even if you haven’t, so be sure to sign up for Medicare as soon as you’re eligible. If you do not enroll in Medicare (either Part A or Part B), the Fund’s Medicare Supplemental Plan will not reimburse you for any amount that would have been covered by Medicare had you enrolled.
-If you’re eligible for Fund benefits through employment and become entitled to Medicare because of ESRD: If, while in coverage as a result of employment, an eligible individual under the Fund becomes entitled to Medicare because of ESRD, this Plan pays first and Medicare pays second for 30 months starting the earlier of the month in which Medicare ESRD coverage begins; or the first month in which the individual receives a kidney transplant. Then, starting with the 31st month after the individual becomes entitled to Medicare, Medicare pays first and this Plan pays second.

Rules governing the coordination of Medicare are complex, and this is only a very brief overview. You should contact the Fund Office at 1-212-869-9380 or 1-800-344-5220 (outside NYC) if you need additional information.

What Secondary Coverage does the Fund Provide for those Eligible for Medicare?

If you sign up for the Fund’s Medicare Supplemental Plan, you will be eligible for medical benefits Out-of-Network only. However, you will have both Network and Out of Network prescription drug and vision coverage. Once Medicare has paid its benefit, the unpaid portion of the expense can be submitted under the Fund’s Medicare Supplemental Plan. If Medicare benefits are exhausted the Fund will revert to paying at its standard out-of-network benefit level.

Network benefits are not available under the medical portion of Fund’s Medicare Supplemental Plan because Medicare does not allow participation in preferred provider organizations like the Open Access Plus network. (Medicare sets the fees paid to doctors and other providers under the Medicare program and will not recognize arrangements negotiated by the PPO.)

If you are enrolled in Medicare Parts A and B, you may also have the option of electing Medicare Part C (Medicare+Choice, also known as Medicare Advantage), which provides an HMO alternative to the “fee for service” coverage provided by Parts A and B. Whether Part C coverage is available in your area depends on whether an HMO offers it (not all HMOs do). Note that if you elect Part C coverage, you will not be eligible to participate in Fund’s Medicare Supplemental Plan

If you are Covered by the Fund and Enter into a Medicare Private Contract:

Under the law a Medicare participant is entitled to enter into a Medicare private contract with certain health care practitioners under which you agree that no claim will be submitted to or paid by Medicare or health care services and/or supplies furnished by that health care practitioner. If you enter into such a contract the Fund will NOT pay any benefits for any health care services and/or supplies the Medicare participant receives pursuant to such contract.

Whenever the Fund is secondary to Medicare, the Fund will assume the amount payable under:
Part A of Medicare has been paid by Medicare, even for a person who did not apply for Medicare if that person is eligible for Part A without paying a premium;
Part B of Medicare has been paid by Medicare, even for a person who is entitled to be enrolled in Part B, but is not enrolled in Part B; and/or
A person is considered eligible for Medicare on the earliest date any coverage under Medicare could become effective.

Other Health Care Resources Once you Reach Age 65:

Unfortunately, negotiating the health care system doesn’t get any easier as you get older. The resources available through the Actors’ Equity Association and the AFL-CIO can help you locate health insurance and health care once you reach age 65. Another resource for Medicare-eligible participants is American Association of Retired Persons (“AARP”). You can reach AARP through their toll-free number, 1-888-OUR-AARP (687-2277), or their website, www.aarphealthcare.com. The website has a useful tool that helps identify the key features of standard Medicare supplement plans and which of those plans are available in your state.

If you have any questions about coverage under the Fund, or need help in comparing benefits offered by the Fund and Medicare, please contact the Fund Office.