Listed below are FAQs for eligibility rules and benefits provided by the Health Fund, divided into categories. If you have additional questions or need assistance, contact the Equity-League Benefit Funds Health Department at (212) 869-9380 (New York City) or (800) 344-5220 (toll-free nationwide), and a representative will assist you.
How do I qualify for coverage and how long will it last?
In most cases, you qualify for health coverage by performing work under Actors’ Equity contracts. If you work in covered employment for at least 11 weeks in a 12 consecutive calendar month period (Accumulation Period), you become eligible for coverage as follows:
- If you work in covered employment for at least 11 weeks (but fewer than 19)in an accumulation period, you qualify for six months of coverage.
- If you work for 19 or more weeksin an accumulation period, you qualify for a full 12 months of coverage.
After you meet these qualification requirements, there is a two-month waiting period (after the end of your accumulation period). After the waiting period, your medical and vision coverage will begin. For instance, if you worked 11 weeks between January and December of a given year, your coverage would begin on March 1 of the following year.
You can enroll using the Self-Service Portal. If you choose to enroll in the Cigna Plan, there are no forms to complete – simply indicate your choice and pay the premium to enroll. If you choose an HMO Plan, you must complete the enrollment application for your HMO. Enrollment materials may be found at this page.
How are work weeks that span two months (“split weeks”) handled?
Will I receive two weeks of eligibility if I work for two different employers during the same week?
What happens if I make one quarterly premium payment and then stop paying?
Let's say I earned more than 11 benefit credits but fewer than 19 during the current 12-month accumulation period. But I expect to accumulate 19 credits in a future period. Should I wait to enroll in coverage?
If I qualify for coverage, but I don’t pay the premium when I first become eligible, when will the Fund next check my eligibility?
Will I receive a bill for the $100 premium?
How can I pay my $100 premium?
If you already registered, just click on here or the ‘Login’ on any of the side bars.
If you have not yet registered as a user, you will need to register before you can begin to make your health premium payments. During the registration process, you will need to set up a user name and password. For the registration process to be successful, you will need to enter in the following information, outside of the ID and password requirements, that will be marked with a red ‘*’
- User Type – Select Member from the pull down menu.
- Actors’ Equity Membership Identification Number – leave off any leading zero’s
- Last Name Only (this needs to match with the name Equity League has on file)
- Date of Birth
- Email Address
If you have any questions about registration, you can contact the Health Department at (212)869-9380 (toll free 800-344-5220 outside the NY Metro area) or firstname.lastname@example.org. Our Health Department staff will be able to walk you through the registration process on the spot.
Once you have completed the registration process, you will receive a separate email from the Equity-League Health Trust Fund confirming that your registration has been completed, at which point you can log on and pay your health premiums by selecting the Health Payment tab.
You may also pay your premium by a check payable to the Equity-League Health Trust fund. If you pay be check, please mail your check in the return address envelope enclosed with your invoice.
Can I pay more than $100 in advance?
Will I be sent an offer to apply for extended health coverage when my health coverage through covered employment runs out?
Who should I contact if I have a problem with one of the insurers that provide the Health Fund's different Plan options?
The $100 per quarter for health insurance is a great deal, but why are the Health Fund’s Dependent and COBRA premiums so high – is Cigna profiting on us?
I worked more than 19 weeks last year. Why can’t I use the extra weeks above 19 to earn more than 12 months of coverage?
If that is the case, how can the Fund provide members who work 19 weeks in a year with a year’s worth of coverage? It is possible because the cost of coverage for those who work only 19 weeks (or 11 weeks for 6 months of coverage) is partially paid for by those who work more than 19 weeks, those who work fewer than 11 weeks (and so do not earn coverage) and those who work more than 11 weeks but fewer than 19 weeks. It is the combination of these weeks worked that do not earn coverage, and the weeks that do earn coverage, that enables those who work 19 weeks to obtain coverage for 12 months, and those who work 11 weeks to obtain 6 months of coverage. It also permits those who have had a significant number of years of work but who are now are unable to work, sometimes because of disability, to be covered for a limited period through the Fund’s Self-Pay After COBRA coverage.
Currently, the contributions to the Health Fund received from employers and participants are slightly lower than costs. Therefore, if the Health Fund changed its eligibility rules to provide more coverage for the same number of weeks worked, extended the accumulation period, or took other steps to increase eligibility, such changes would have to be paid for through increases in contributions (from employers or members), or decreases in the benefits provided.
Moreover, if the Fund covered only those whose contributions were sufficient to actually pay the full cost for their coverage, everyone would only have about as many weeks of coverage as they worked in a given year. This would cause a massive change in who is covered by the Fund and when.
Self-pay health coverage through COBRA continuation and post-COBRA coverage
What is “self-pay” coverage?
• Dependent coverage
• Dental coverage
• COBRA continuation coverage, and The Health Fund’s Self-Pay Program after COBRA
How Much does “self-pay” coverage cost?
How long can self-pay coverage last?
Does the Fund offer Medicare Supplemental coverage?
If you choose this coverage, the Fund will coordinate your benefits with Medicare. Unless you are covered through employment, Medicare will provide your primary coverage, and the Fund will be secondary. The premium for this coverage is lower than our standard COBRA premium.
If I fail to pay the required premium for any type of self-paid coverage, can I reinstate coverage at any time?
The Self-Pay Program After COBRA (SPAC)
Self-Pay Program After COBRA
Under the CE program, the Fund establishes an extended health coverage “bank” if you accumulate at least 10 separate years of Vesting Service under the Pension Fund across your career. In such a case you will have 18 months of extended self-pay health coverage eligibility placed in your “bank” account. In addition, for each additional year of Vesting Service you accumulate across your career, beyond the 10 years required to qualify for the initial 18-month extension, you will have one additional month of extended self-pay health coverage eligibility added to your “bank” account. These eligibility months can be used as of the first of the month following the completion of an 18-month COBRA coverage period, but no more than 18 of the bank’s months can be used after any single period of COBRA coverage ends (unused months can be used to extend any subsequent periods of COBRA coverage). Months placed in an account can be used only one time, and of course the coverage must be paid for on a timely basis. Once the total number of additional months is exhausted, there are no additional months beyond the 18-month COBRA coverage period.
The table below provides examples of bank account accumulations based on years of service:
Years of Vesting Service
Extended Coverage Months
If you were participant in the Fund’s old SPAC program and your SPAC benefits commenced before July 1, 2015, you may continue the SPAC benefits beyond 18 months if the Marketplace for your state (or your county within the state) does not meet each of the criteria listed below:
• A. There are three or more participating insurers available on the Marketplace
• B. There are two or more silver and two or more bronze plans available
• C. Your State has not expanded Medicaid eligibility as per the standards established by ACA.
Rules applicable to states only:
• D. The Marketplace in your state is not operating efficiently (e.g., it is very difficult to enroll in that Marketplace as compared with Marketplaces in other areas).
Are there any other exceptions that would allow me to continue SPAC coverage?
However, in many cases, coverages available through the Health Insurance Marketplaces may be more affordable than SPAC coverage, and they may be subsidized as well. Therefore, we recommend that you consider your options outside of Equity-League Benefit Funds health coverage, especially with guidance from the Actors Fund.
Can I continue SPAC benefits beyond 18 months?
• 1. Limited care exception -You only have access to plans with very narrow networks or some other feature that limits access to needed care for a current medical condition. The Actors Fund can help you determine if you meet the limited care exception.
• 2. The out-of-area work exception – Your SPAC coverage can be extended for an additional calendar year if you can demonstrate that you will have covered employment in that coming year and you could not reasonably commute to the job location from your permanent residence.
Alternatively, if in either of the two prior calendar years you worked at least one week in covered employment that you could not reasonably have commuted to your permanent residence, you can qualify for this exception.
• 3. The high-premium exception – The premium for the silver plan with the second lowest premium in your area exceeds the premium for the Fund’s after-COBRA coverage.
• 4. You will reach age 65 in a year in which you would otherwise not qualified to remain in the SPAC program. In such a case you may continue in the program until the first date on which you qualify for Medicare Coverage.
I think the limited care exception or high premium exception applies to me. What should I do?
What if I have other questions related to COBRA?
The Equity-League Health Fund offers self-paid coverage for your dependents, including your spouse, or domestic partner, and children. Even if you have no plans to add others to your coverage (but especially if you do), take the time to understand the eligibility rules that affect dependents. Life events can affect your benefits – even those you don’t expect.
What kind of coverage can I get coverage for my dependents?
What does dependent coverage cost?
For those eligible for Health Coverage through covered employment, the following is a listing of quarterly premium rates in order to enroll your dependent(s) under the Health Plan.
QUARTERLY RATES FOR DEPENDENT MEDICAL AND VISION COVERAGE EFFECTIVE JANUARY 2016 (POS) ADMINISTERED BY CIGNA OPEN ACCESS NETWORK AVAILABLE THROUGHOUT THE U.S.
|One Dependent||Two or More Dependents||2 Participants Covered by Employment -1 Dependent||2 Participants Covered by Employment -2 or more Dependents|
HMO AVAILABILITY AND RATES AS OF January 2016
|AREA||HMO||One Dependent Only||Family Only|
|CA – Southern||Kaiser||$2,126.46||$3,889.20|
|CA – Northern||Kaiser||$2,142.39||$3,918.36|
Why is the premium for dependent coverage so much higher than my premium?
When can I enroll my dependents?
Additionally, you can add dependents in certain special enrollment situations, as outlined in the Health Summary Plan Description. Since these situations are triggered by life events, such as a marriage or birth, you may add dependents any time these situations occur. Just remember that following a life event that allows you to add a dependent, you only have 60 days to do so.
You also have an opportunity to add dependents to your coverage during the Health Fund’s Annual Open Enrollment each November. In these cases, the effective date of coverage will be the following January 1.
How do I add a dependent?
• Marriage certificate (if adding a new spouse and/or his or her children)
• Birth certificate (if adding a newborn)
• Proof of residence
• Proof of financial dependency
Please mail the competed form or application and proof of dependent status to:
Equity League Health Trust Fund
165 West 46 St, 14th Floor
New York, NY 10036
What about dependent premiums?
Checks for the additional dependent premium must be payable to the Equity-League Health Trust Fund. Or, to pay by credit card, use our Self-Service Portal.
After your dependent is enrolled, remember that he or she will lose coverage if you fail to pay the additional premium on time.
What could cause a dependent to lose coverage?
• When a dependent adult child reaches age 26
• When there is a divorce
• When there is a dissolution of a domestic partnership, and
• When a dependent dies
It is your responsibility to notify the Health Fund within 60 days of any life event that could cause a loss of coverage. In such cases, the dependent’s coverage will end after the end of the month dependent status is lost.
Dependents who lose coverage will have an opportunity to enroll in COBRA continuation coverage and keep that coverage for up to 36 months. Please note this only applies if the dependent had coverage as a result of a participant’s covered employment.
Adult children and dependent coverage under the Affordable Care Act
The Affordable Care Act requires plans that offer dependent coverage for children to make such coverage available to participants’ adult children up to age 26. This is true even if the adult child no longer lives with the parents, is not a dependent on a parent’s tax return or is no longer a student. However, this extended eligibility does not apply to the adult child’s spouse or children.
What is an HMO?
How are the HMO Plans different from the Cigna Plan?
Where are the HMOs located?
• Southern California (Kaiser Permanente)
• Northern California (Kaiser Permanente)
• New York City area (HIP, an Emblem Health Company)
• Washington, DC (Kaiser Permanente)
How do I contact my HMO, and where do I find provider directories, forms and other resources specific to my HMO Plan?
• Kaiser (800) 464-4000 www.kaiserpermanente.org/health/care/consumer/locate-our-services (Southern CA) Group # 000109137-0000
• Kaiser (800) 464-4000 www.kaiserpermanente.org/health/care/consumer/locate-our-services (Northern CA) Group # 000002861-0000
• Kaiser (800) 777-7902 www.kaiserpermanente.org/health/care/consumer/locate-our-services (Mid Atlantic) Group # 2863-00
• HIP 800-HIP-TALK http://www.emblemhealth.com/ (New York) Group # 92NY
When can I enroll in an HMO?
◦ When you first become eligible for Equity-League Benefit Funds health coverage ◦ If you move permanently into a new area served by one of the HMOs under contract with the Fund (a move in which you plan to live in the new location for nine or more continuous months.)
◦ Thereafter, during the Fund’s Annual Open Enrollment in November of each year.
I'm covered by an HMO Plan now. When can I switch to the Cigna Plan?
HMO Coordinator Equity-League Health Trust Fund 165 West 46th Street New York, NY 10036
If you move out of your HMO service area permanently or have an extended tour, you may change to the Cigna Plan effective the first day of the next month. To do so, notify us in writing of the permanent move at the HMO Coordinator address provided above.
A permanent move is a move in which you plan to live in the new location for nine or more continuous months. An extended tour is a tour which lasts nine months or more.
If you are on an extended tour, we strongly advise that you transfer your benefits to the Cigna Plan, since the Cigna Plan will allow you to seek medical care with any doctor in the country.
You do have the option to remain on the HMO and be covered by the HMO only for emergency treatment, though this is not advised. Each HMO has coverage for emergency care if you are away from your service area. Generally the care is covered by the HMO if the HMO defines your condition as an emergency, you have notified the HMO of your condition within the HMO’s required time frame, and you have received approval by the HMO.
Important: You cannot expect the HMO to cover follow-up care, or care for a condition that the HMO does not consider to be an emergency. Any charges not covered by the HMO as an emergency benefit, you must pay out-of-pocket.
Where do I get the HMO enrollment materials?
What if I have a serious illness, and I don’t think the HMO can provide me with the care I need?
Mr. Arthur Drechsler Executive Director Equity-League Health Trust Fund 165 West 46th Street New York, NY 10036
The Cigna Plan, or Open Access Plus Plan (OAP)
What is the Cigna Plan or Open Access Plus Plan (OAP)?
Is pre-admission required for inpatient hospital visits under the Cigna Plan?
What is the maximum reimbursable charge (MRC) under the Cigna Plan?
I have Cigna Plan coverage, and I'm pregnant. Are services covered for my newborn baby under my policy?
Prescription drug benefits under the Cigna Plan
How are my prescription drugs covered?
Other questions about medical benefits
When I take my daughter to her pediatrician for check-ups, it's covered at 100% under major medical benefit. What is my incentive to switch to a Cigna Plan network doctor?
I’m on the road a lot. Let’s say I get the flu and need to see a doctor. How do I find local Cigna Plan network providers?
Do Cigna Plan co-payments count toward the $5,000 annual out-of-pocket coinsurance maximum?
Can any provider belong to the Cigna Plan's OAP network?
My wife and four kids are covered under the Cigna Plan. Do each of us has to meet the $350 annual deductible?
Once I reach the eligibility age for Medicare, can I continue to be covered under the Cigna Plan?
Are Cigna providers everywhere?
It turns out my doctor isn't in the Cigna OAP network. Can she join?
How will a Cigna OAP provider know I'm entitled to network benefits?
What if I don't get my new ID card by the start of my eligibility period?
Are Annual Physicals Covered by the Health Fund?
Does the Fund Cover Reassignment Treatments?
Coverage for gender reassignment surgery and related services is available to those enrolled in the Cigna Health Plan.
Covered services available to Cigna participants 18 and older include:
• Medically necessary gender reassignment surgeries, including both female-to-male and male-to-female reassignment procedures
• Pre- and post-surgical hormone therapies
However, the following Services are not covered, including:
• Procedures associated with gender reassignment surgery performed solely for the purpose of improving or altering appearance or self-esteem related to one’s appearance are considered cosmetic and not medically necessary.
• Procurement, cryopreservation or storage of embryos, sperm, or oocytes (egg cells) to preserve fertility are not covered.
Gender reassignment are considered by CIGNA to be medically necessary for participants with confirmed gender dysphoria and who participate in a recognized gender identity treatment program. For more complete information about the new benefit, please click “Cigna Medical Coverage Policy for Gender Reassignment Surgery.” If you have other questions about this new benefit, please call the Equity-League Benefit Funds Health Department at (212) 869-9380 (New York City) or (800) 344-5220 (toll-free nationwide), and we will be happy to help you.
If you are covered under one of the Funds HMO Plans, you can review that HMO’s benefits at “Health Benefit Explained” and then contact the HMO directly to confirm any benefits that may be available for gender reassignment treatments.
Can I Use Manufacturer Coupons for Brand name Medications?
Summary Annual Report
SUMMARY ANNUAL REPORT
FOR EQUITY-LEAGUE HEALTH TRUST FUND
This is a summary of the annual report of the EQUITY-LEAGUE HEALTH TRUST FUND, EIN 13-6092981, Plan No. 501, for period June 01, 2015 through May 31, 2016. The annual report has been filed with the Employee Benefits Security Administration, U.S. Department of Labor, as required under the Employee Retirement Income Security Act of 1974 (ERISA).
The plan has contracts with Berkley Life And Health Insurance Company, Cigna Health And Life Insurance Company And Affiliates, Hip Health Plan Of New York, Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan Inc. and Kaiser Foundation Health Plan Of The Mid-Atlantic to pay health, dental, prescription drug, stop loss, HMO, indemnity and NON-HMO claims incurred under the terms of the plan. The total premiums paid for the plan year ending May 31, 2016 were $4,034,760.
Basic Financial Statement
The value of plan assets, after subtracting liabilities of the plan, was $120,933,118 as of May 31, 2016, compared to $125,655,624 as of June 01, 2015. During the plan year the plan experienced a decrease in its net assets of $4,722,506. This decrease includes unrealized appreciation and depreciation in the value of plan assets; that is, the difference between the value of the plan’s assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. During the plan year, the plan had total income of $64,399,119, including employer contributions of $47,718,753, employee contributions of $10,936,368, realized losses of ($446,647) from the sale of assets, earnings from investments of ($51,022), and other income of $6,241,667.
Plan expenses were $69,121,625. These expenses included $4,107,716 in administrative expenses, and $65,013,909 in benefits paid to participants and beneficiaries.
Your Rights To Additional Information
You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report:
• an accountant’s report;
• financial information;
• information on payments to service providers;
• assets held for investment;
• transactions in excess of 5% of the plan assets;
• insurance information, including sales commissions paid by insurance carriers;
• information regarding any common or collective trusts, pooled separate accounts, master trusts or 103-12 investment entities in which the plan participates;
To obtain a copy of the full annual report, or any part thereof, write or call the office of BOARD OF TRUSTEES OF THE EQUITY-LEAGUE HEALTH TRUST FUND at 165 WEST 46TH STREET 14TH FLOOR, NEW YORK, NY 10036-2501, or by telephone at (212) 869-9380. The charge to cover copying costs will be $0.00 for the full annual report, or $0.00 per page for any part thereof.
You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge.
You also have the legally protected right to examine the annual report at the main office of the plan (BOARD OF TRUSTEES OF THE EQUITY-LEAGUE HEALTH TRUST FUND, 165 WEST 46TH STREET 14TH FLOOR, NEW YORK, NY 10036-2501) and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, Room N1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
When am I eligible for dental coverage?
If I qualify for health coverage through covered employment, but I do not pay the $100 premium, can I still choose to self-pay for dental coverage?
If you do not continue to pay the required premium for dental coverage, you will not be eligible for dental coverage again until you:
- re-qualify for health benefits through covered employment, or
- enroll during the Plan’s Annual Open Enrollment period, in November of each year (for coverage effective Jan. 1 of the following year).
However, if you stopped paying for dental coverage during the year (other than if you dropped it the same time that you lost medical coverage through covered employment), you’ll be required to pay the missing premiums for that year before you can enroll again the following year.
What type of plan options are available with Cigna's dental coverage?
|Alaska||Montana||North Dakota||South Dakota||Wyoming|
|Hawaii||New Hampshire||Puerto Rico||Vermont|
|Maine||New Mexico||Rhode Island||West Virginia|
What are the quarterly premiums I would be responsible for under the DHMO and the PPO dental plans?
Can I continue self-paying for dental coverage after my health coverage runs out?
Yes. You may continue to pay for and retain dental coverage. As long as you pay your required premiums on time, your dental coverage continues – even if your eligibility for health benefits does not. If you decide to stop paying for dental coverage, the next time you will become eligible is when you earn health coverage through covered employment again.
Vision Benefits through Vision Works
When am I eligible for the vision coverage?
What are the benefits provided by vision coverage?
Your appeal rights under the Health Fund
If a claim is wholly or partially denied, or if you disagree with another health benefit determination, you may appeal the decision.
What is the appeal process?
• A one-level appeals process is provided for disputes involving vision, Supplemental Workers’ Compensation (SWC) and eligibility claims. These appeals are reviewed by Health Fund Trustees.
• A two-level appeal process is provided for all Cigna and HMO claims. Both levels of appeal are handled by Cigna or your HMO.
• A voluntary third-level appeal is available if levels one and two appeals are denied by Cigna or your HMO. Third-level appeals are reviewed by Health Fund Trustees.
What else should I know about appeals?
• You have the right to review documents relevant to your claim when you submit an appeal.
• To the extent possible, we protect your privacy throughout the appeals process. Personal information is redacted from appeals decided by Trustees.
• The time we are required to notify you of an appeal decision varies depending on the type of appeal.
• Equity-League Benefit Funds will not impose fees or costs on you (or your representative) if you choose to pursue the appeals process.
For complete details about the Health Fund’s appeals processes, refer to the SPD. If you have further questions about appeals, call the Health Department at the Equity-League Benefit Funds office at (212) 869-9380 (New York City) or (800) 344-5220, and a representative will assist you.