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Health Fund FAQs

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?

If a week falls at the end of any calendar month, but has at least one day in the next month, you have a choice. You may use the week in the month in which the week began or the month in which the week ends. If you don’t elect one or the other, we will automatically include that week in the month in which the week ends. For example, let’s say your work week runs from Monday, July 29 to Sunday, Aug. 4. You may tell us that you want this week applied to the accumulation period that ends July 31. But if you don’t state a preference, we will apply the week to the 12-month accumulation period that ends Aug. 31.

Will I receive two weeks of eligibility if I work for two different employers during the same week?

Yes, as along as the weeks completed from both employers are within the accumulation period used to determine benefit eligibility.

What happens if I make one quarterly premium payment and then stop paying?

In addition to your coverage ending, the weeks you used to qualify for coverage can never be used again. In this case, you used your work weeks when you accepted coverage and made your first quarterly payment. For example, let’s say you qualify for 12 months of coverage starting Oct. 1 and you enroll. You used all 19 of the work weeks required for 12 months of eligibility when you made your first premium payment. Those 19 weeks would never be counted toward eligibility again.

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?

Not necessarily. It is true that you may simply decline to pay the $100 quarterly premium anytime coverage is offered to you. However, unless you are certain you will accrue additional work weeks in a future period, you may lose your opportunity for coverage altogether. Anytime you forgo coverage, you run the risk of not having health coverage at a time when you may need it.

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?

We check your eligibility monthly, but we only mail notices of eligibility quarterly. However, you may check eligibility on a month-by-month basis at any time by visiting our Self-Service Portal. At the portal, you can also sign up to receive electronic notifications of eligibility monthly via text message or email.

Will I receive a bill for the $100 premium?

Yes, you will receive one invoice quarterly. This invoice will include premiums for any other types of coverage you might already be paying for, such as dental coverage. Each $100 premium will provide you with three months of health coverage (for example, Oct. 1 through Dec. 31) while you are eligible. If you have chosen to receive electronic notifications, you will be notified monthly via text message or email.

How can I pay my $100 premium?

Payments can be made online at our Self-Service Portal  via credit card, debit card or ACH payment.

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 health@equityleague.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?

Yes, you may pay for as much coverage as have qualified for and accepted. If you accept and enroll for six months of coverage, you may pay for two quarters at once ($200). If you accept 12 months of coverage, you may pay for up to four quarters at once ($400).

Will I be sent an offer to apply for extended health coverage when my health coverage through covered employment runs out?

Yes. We will mail an offer to enroll in COBRA continuation coverage – automatically and by law – to you at the address we have on file. COBRA continuation coverage is self-paid coverage.

Who should I contact if I have a problem with one of the insurers that provide the Health Fund's different Plan options?

You may contact the insurer directly. Or you may contact the Equity-League Benefit Funds Health Department at (212) 869-9380 (New York City) or (800) 344-5220 (toll-free nationwide), and we’ll be happy to help.

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?

Cigna is not profiting on the dependent and COBRA premiums. While Cigna pays our claims for us and provides the provider networks that Fund participants can use, the Health Fund is largely self-insured. This means we pay for claims directly out the Fund’s assets, instead of paying an insurance company a premium and having them profit from the difference between premiums paid and claims and administrative costs incurred for providing health insurance coverage to plan participants and their dependents (Cigna does insure our dental benefits and we do pay premiums to the HMOs that cover a relatively small number of your plan participants). Therefore, every dollar received by the Health Fund on behalf of medical benefits is used either to pay the claims generated by those covered by the plan, or to pay for administrative expenses, the latter of which we continually strive to keep to a minimum. And we take great pride in doing that. According to our auditors, our administrative expenses are among the lowest for Funds of our size and type. The dependent rates we charge are based on the actual costs we incur for providing medical benefits. These costs are many times higher per person than the $100 quarterly premium we charge for employee only coverage that is earned through employment. This is because cost of the latter is largely covered by the contributions that we receive from employers on behalf of participants who work in covered employment. For instance, the average annual cost of covering one dependent is roughly $10,000 per year. The average annual cost to the Fund of providing COBRA coverage is even higher.

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?

While this sounds like a perfectly reasonable idea, providing such additional coverage is very problematic. This is because the average annual cost of providing a single employee with medical coverage is approximately $10,000, or about $190 per week. Since that is more than the average contribution received by the Health Fund for each week worked, working 19 weeks actually pays for less than the true cos of 19 weeks of coverage, instead of for a full year.

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?

“Self-pay” or “self-paid” describes coverage that you pay the full amount of what the Fund charges for that coverage. Examples of self-paid coverage include:

• Dependent coverage

• Dental coverage

• COBRA continuation coverage, and The Health Fund’s Self-Pay Program after COBRA

How Much does “self-pay” coverage cost?

EQUITY- LEAGUE HEALTH FUND COBRA RATES – EFFECTIVE JANUARY 1, 2016
CIGNA COBRA Monthly Rate Quarterly Rate
Individual Member $878.10 $2,634.30
Member + 1 dependent $1,748.12 $5,244.36
Member + 2 or more dependents (Family Coverage) $2,286.76 $6,860.28
2 Domestic Partners $1,748.12 $5,244.36
HIP – HMO COBRA Monthly Rate Quarterly Rate
Individual Member $810.98 $2,432.94
Member + 1 dependent $1,481.58 $4,444.74
Member + 2 or more dependents (Family Coverage) $2,356.80 $7,070.40
2 Domestic Partners $1,481.58 $4,444.74
Kaiser DC – HMO COBRA Monthly Rate Quarterly Rate
Individual Member $605.94 $1,817.82
Member + 1 dependent $1,212.05 $3,636.15
Member + 2 or more dependents (Family Coverage) $1,756.48 $5,269.44
2 Domestic Partners $1,212.05 $3,636.15
Kaiser SC – HMO COBRA Monthly Rate Quarterly Rate
Individual Member $708.66 $2,125.98
Member + 1 dependent $1,417.47 $4,252.41
Member + 2 or more dependents (Family Coverage) $2,005.05 $6,015.15
2 Domestic Partners $1,417.45 $4,252.35
Kaiser NC – HMO COBRA Monthly Rate Quarterly Rate
Individual Member $713.97 $2,141.91
Member + 1 Dependent $1,428.10 $4,284.30
Member + 2 or more dependents (Family Coverage) $2,020.09 $6,060.27
2 Domestic Partners $1,428.10 $4,284.30

 

How long can self-pay coverage last?

That depends on the type of coverage: COBRA, Self-Pay After COBRA or dental-only coverage. Participants may generally remain on COBRA coverage for 18 months. Participants who have received a disability award from the Social Security Administration may remain on COBRA for 29 months. Once COBRA ends, you may be eligible for Health Fund’s Self-Pay Program After COBRA coverage. View more information about COBRA and post-COBRA benefits on this page. Dental-only coverage can continue indefinitely, as long as you continue to pay your dental premium.

Does the Fund offer Medicare Supplemental coverage?

Yes. You are eligible for the Fund’s Medicare Supplemental coverage if you are eligible for Medicare on the date your coverage earned through covered employment, COBRA, or the Self-Pay Program After COBRA, ends.

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?

No, your coverage will terminate and you will no longer be eligible. Once you lose the right to self-paid coverage, you cannot have coverage under the Health Fund – unless you again qualify under the Fund’s eligibility rules through covered employment.

The Self-Pay Program After COBRA (SPAC)

Self-Pay Program After COBRA

After your COBRA benefits end, if you have accumulated at least 10 separate years of vesting service under the Equity-League Funds Equity-League Benefit Funds Pension Plan, (the two for one rule does not apply to work reaching the required 10 years of Vesting Service that are required to qualify for this program) you may continue your benefits under the Self-Pay COBRA Extension (CE) Program for up to another 18 months.

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

10

18

15

23

20

28

25

33

30

38

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?

Even if your Marketplace passes the general viability test, you may continue coverage under the Self-Pay After COBRA Program in certain special situations. If any of the exceptions outlined below apply to you, you will not be required to exit the SPAC Program:

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?

The Fund has contracted with the Actors Fund to help you determine whether your situation meets the limited care exception or the high premium exception. The Actors Fund staff is skilled at evaluating all coverage options, and they will promptly determine if you may be eligible to continue coverage under the Self-Pay Program under these exceptions. For additional information or assistance contact the Actors Fund at (212) 221-7300 ext. 280 or email ahirc@actorsfund.org.

What if I have other questions related to COBRA?

If you have other questions about COBRA continuation coverage, view the full Notice of COBRA Continuation Rights or the Health Plan FAQs. You may also refer to the Health Fund’s Summary Plan Description (SPD) and any modifying Plan changes communicated via Now Playing newsletters. Lastly, at any time you may contact the Equity-League Benefit Funds Health Department for assistance at (212) 869-9380 (New York City) or (800) 344-5220.

Dependent coverage


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?

Yes, you can choose to add self-paid medical and/or dental coverage for your dependent if you enroll in the same coverage.

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
$2,360.61 $3,822.03 $1,425.36 $2,138.04

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
Wash. D.C. Kaiser $1,818.30 $3,451.62
NY HIP EmblemHealth $2,011.83 $4,637.49

Why is the premium for dependent coverage so much higher than my premium?

Dependent coverage offered by the Health Fund is self-paid, which describes coverage that you pay for entirely out-of-pocket. That is, the premium is not reduced or supported by benefit contributions made by employers, which you earn through covered employment.

When can I enroll my dependents?

Participants typically enroll dependents when they first become eligible for coverage, or when they regain eligibility from a prior period through covered employment. In these situations, you may enroll any eligible dependents for medical and vision coverage at the same time you enroll yourself.

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?

If you choose to add one or more dependents to your existing coverage, you must submit a completed Dependent Coverage Form (for the Cigna Plan) or a new Enrollment Application (different for each HMO Plan) . Along with the form or application, you must also provide proof of dependent status, which may include one or more of the following

• 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?

You must pay the required additional premium to add coverage for one or more dependents. Dependent coverage offered by the Health Fund is self-paid. This is why the dependent premium is considerably higher than the premium for participant coverage (which is earned through covered employment).

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?

In addition to failing to pay the required premium, some life events can cause a covered dependent to lose coverage through a loss dependent status. Events that can trigger a loss of dependent status (and therefore, coverage) include:

• 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.

HMO


What is an HMO?

An HMO (Health Maintenance Organization) is an insurer that contracts with a comprehensive network of providers to provide health care to a population. HMOs generally do not offer cover services from non-network providers.

How are the HMO Plans different from the Cigna Plan?

Most HMOs require you to choose a Primary Care Physician (PCP) who assumes responsibility for making all your referrals to specialists. Except for emergency situations, generally you can only receive coverage from network health care providers.

Where are the HMOs located?

The Equity-League Health Fund currently has contracts with HMOs only in the following locations:

• 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?

Listed below is contact information for the regional HMO Plans contracted with the Health Fund:

• 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?

You may enroll in an HMO Plan when:

◦ 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?

You may change from an HMO Plan to the Cigna Plan during the Health Fund’s Annual Open Enrollment. Send a letter with your request during the month of November (for coverage effective the following January 1) to:

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?

You may find the enrollment materials at this page. If you are newly eligible (and you reside in an HMO service area), the Health Fund will mail your enrollment information approximately two months prior to the coverage effective date.

What if I have a serious illness, and I don’t think the HMO can provide me with the care I need?

You may write a “special circumstances” letter requesting a transfer of your coverage to the Cigna Plan. Please address your letter to:

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)?

The Cigna Plan provides comprehensive medical benefits, whether you use a Cigna network physician or not. Visit this page for a full description of Cigna Plan benefits.

Is pre-admission required for inpatient hospital visits under the Cigna Plan?

Yes. For non-emergency hospital admissions, you or your physician must contact CIGNA at 1-800-244-6224 (the phone number on your CIGNA ID card).  If you don’t pre-certify you are subject to a $250 penalty and you won’t know in advance whether CIGNA will cover that admission, so please call prior to the admission.

What is the maximum reimbursable charge (MRC) under the Cigna Plan?

This is the maximum charge that will be reimbursed for a particular treatment. The MRC is determined based upon what other providers (of the same type) typically charge in a specific geographic area. The MRC is generally set at a level that approximately 80% of providers will accept as payment in full. You can find out in advance whether the charge made by your provider exceeds the MRC asking your provider the amount of a charge and then contacting Cigna.

I have Cigna Plan coverage, and I'm pregnant. Are services covered for my newborn baby under my policy?

Any child born while you are covered will become automatically insured under your policy for up to 31 days after the child’s birth. This means all expenses for your newborn may be considered for coverage for 31 days. If you wish to add dependent coverage beyond the child’s first 31 days, then you must pay the required premium for self-paid dependent coverage. For example, if the child is born Oct. 15, all expenses may be considered under your participant coverage until Nov. 15. After that date, you then have the option to pay for dependent coverage effective Nov. 1 or Dec. 1. The Health Fund’s dependent premium is determined on a monthly basis.

Prescription drug benefits under the Cigna Plan

How are my prescription drugs covered?

Prescription drugs are covered under a plan separate from the Cigna medical plan. To learn more, please visit these pages to view a summary of your prescription drug benefits or view a complete explanation of prescription drug benefits.

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?

The non-network reimbursement is based on a percentage of the maximum reimbursable charge (MRC) for that procedure. If the non-network doctor’s charge is higher than the MRC, you’d be responsible for the difference.

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?

Simply call Cigna toll-free at (800) 244-6224. This number also is on your ID card, and you can reach Cigna representatives at this number 24 hours a day, seven days a week. Or you may visit http://cigna.com.

Do Cigna Plan co-payments count toward the $5,000 annual out-of-pocket coinsurance maximum?

No. Copayments also do not count toward the $350 (individual) or $700 (family) annual deductibles for non-network care.

Can any provider belong to the Cigna Plan's OAP network?

Providers who wish to be in the Cigna network are carefully screened by CIGNA for quality.  In addition, network providers must agree to the contractual terms that Cigna negotiates with them. Each provider must then continue to meet Cigna’s contract terms and credentialing requirements going forward.

My wife and four kids are covered under the Cigna Plan. Do each of us has to meet the $350 annual deductible?

When you and at least one dependent are covered, a $700 family deductible non-network applies. At least one family member will have to meet the $350 individual deductible. After this occurs, the balance of the deductible can be a combined with other family members to meet only the family deductible. But remember, when you use Cigna network providers, there is no deductible. So you could save a considerable amount of money by using the Cigna Plan’s OAP network providers.

Once I reach the eligibility age for Medicare, can I continue to be covered under the Cigna Plan?

Yes, as long as the Cigna Plan – not Medicare – provides primary coverage. Basically, this means that must remain eligible through covered employment and continue to receive primary coverage from the Cigna Plan. In such a case, Medicare will provide your secondary coverage.

Are Cigna providers everywhere?

Essentially everywhere nationwide, yes. National access to providers was a key criteria in our decision to offer the Cigna Plan. In fact, when the Health Fund’s Trustees looked at where participants live, more than 99% live within a few minutes’ drive from a Cigna OAP network physician (within three miles in urban areas, or 12 miles in suburban areas). But remember, even if you’re one of the few participants with no Cigna network providers nearby, you will may still receive coverage from non-network doctors.

It turns out my doctor isn't in the Cigna OAP network. Can she join?

If Cigna is working to expand its network in that particular area, Cigna may choose to accept physician nominations. For more details, ask your doctor to contact Cigna’s Provider Relations Department at (800) 244-6224.

How will a Cigna OAP provider know I'm entitled to network benefits?

Providers learn this from your ID card, so be sure to have your ID card with you when you visit the doctor. In fact, your Cigna provider is required to keep a copy of your ID card on file. To facilitate this, be sure to have your doctor’s office staff make a copy of your ID card on your first visit. This way, your doctor has a permanent record of your eligibility for Cigna Plan benefits.

What if I don't get my new ID card by the start of my eligibility period?

You can contact Cigna directly 24 hours a day, seven days a week by calling toll-free at (800) 244-6224. Or you may contact the Fund Office, (212) 869-9380 from the New York City area, or toll-free nationwide at (800) 344-5220.

Are Annual Physicals Covered by the Health Fund?

The Equity League Health Fund , covers immunizations and routine tests with no copays.  And there is only a $25 copay if your annual exam is done with a network physician.

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?

In light of Cigna’s policy, the Equity-League Health Fund has chosen to override the Plan requirement to purchase maintenance medications from Cigna via mail order. This exception allows participants to continue using manufacturer coupons to save money outof-pocket, but only at retail pharmacies. For example, suppose your physician tells you that you have ulcerative colitis. She suggests the brand name drug Lialda as a treatment option. After she tells you about Lialda’s benefits and potential side effects, you mention that your prescription drug plan requires the use of generics wherever possible. Your physician responds that she generally has good results with generics, and so she prescribes a generic alternative to Lialda. After you have taken the generic for some time, you and your doctor are not satisfied with the results, so now she receives approval for coverage of Lialda in your case. If the cost of the prescription is $350, under the Cigna prescription drug plan, your copayment would be 20% of that, or $70. However, the drug’s manufacturer offers you a coupon, which can be used to offset $50 of your copay. Since Cigna will no longer accept such coupons at their mail order pharmacy, the Fund’s exception would permit you to purchase your Lialda at a retail pharmacy, using the coupon from the manufacturer. To take advantage of this exception, you must call the Equity-League Benefit Funds Health Department at (212) 869-9380 (New York City) or (800) 344-5220 (toll-free nationwide). Simply state that you want to use manufacturers’ coupons at retail pharmacies, and a representative will guide you through the steps required to do so. 

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, 2014 through May 31, 2015. 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).

Insurance Information

The plan has contracts with Kaiser Foundation Health Plan Inc., Kaiser Foundation Health Plan Inc., Emblem Health Plan Of New York, , Cigna Health And Life Insurance Company And Affiliates, Kaiser Foundation Health Plan Of The Mid-Atlantic, Berkley Life And Health Insurance Company, Cigna Health And Life Insurance Company And Affiliates and Berkley Life And Health Insurance Company 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, 2015 were $5,353,965.

Basic Financial Statement

The value of plan assets, after subtracting liabilities of the plan, was $125,655,624 as of May 31, 2015, compared to $124,912,099 as of June 01, 2014. During the plan year the plan experienced an increase in its net assets of $743,525. This increase 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 $67,732,509, including employer contributions of $47,699,902, employee contributions of $12,406,216, realized losses of ($93,774) from the sale of assets, earnings from investments of $4,395,165, and other income of $3,325,000.

Plan expenses were $66,988,984. These expenses included $3,860,814 in administrative expenses, and $63,128,170 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.

Dental coverage

When am I eligible for dental coverage?

The Fund offers self-paid dental coverage to participants who qualify for health 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?

Yes, you may choose to take self-paid dental coverage even if you do not pay the $100 premium for medical/vision coverage. However, you must continue to pay your dental premium on time to continue your 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, 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?

Participants may choose a PPO or an HMO(DHMO). You can visit this page to see your plan options or to learn more.

What are the quarterly premiums I would be responsible for under the DHMO and the PPO dental plans?

Participants may choose from one of two types of dental coverage: a PPO option and an HMO(DHMO) option. You can visit this page to choose your plan option or to learn more.

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 indefinitely. 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?

The Health Fund automatically provides vision care benefits to you while you are covered for medical benefits. There is no additional premium charged for 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?

The process varies depending on the type of claim you are appealing. An overview of the processes required for different types of claims in the bullets below. However, we suggest that you review the Appeals section on pages 59-63 of the Summary Plan Description thoroughly before submitting any appeal, so that you’ll understand the process more fully.

• 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?

Other key points to remember about Equity-League Benefit Funds health appeals are summarized below:

• 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.