Health Fund FAQs

The Fund offers two coverage levels, and eligibility is earned for six months at a time. The level of coverage for which you qualify is related to the number of weeks you work in covered employment, as shown below:

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. To help assist you in choosing the tier of coverage that best suits your needs, click on the link, "Knowing When to Choose the Correct Tier of Coverage".

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.

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.

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

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 6 months of Tier 1 coverage starting Oct. 1 and you enroll. You used all 15 of the work weeks required for the 6 months of eligibility when you made your first premium payment. Those 16 weeks would never be counted toward eligibility again.

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.

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 $300 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.

HEALTH PREMIUM PAYMENTS CAN BE MADE VIA OUR SELF-SERVICE PORTAL!

You can make your health premium payments by credit card, debit card, or Bank ACH directly on your Equity-League Self-Service Account.  You will also be able to view your work history, update mailing and email addresses, and much more.

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 Benefit Services Department at (212)869-9380 (toll free 800-344-5220 outside the NY Metro area) or health@equityleague.org. Our Benefit Services 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

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 ($600).

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.

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.

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 $300 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 $13,000 per year. The average annual cost to the Fund of providing COBRA coverage is even higher.

“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

Click here to see the Current Health and Dental Premium Rates

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.

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.

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.

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:

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).

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.

• 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.

The Fund has contracted with the Entertainment Community Fund to help you determine whether your situation meets the limited care exception or the high premium exception. The Entertainment Community 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 Entertainment Community Fund at (212) 221-7300 ext. 280 or email ahirc@actorsfund.org.

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.

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

For those eligible for Health Coverage through covered employment click here to view the Current Premium Rates.

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.

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 . 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 first have 31 days to do so. If this is not done within the initial 31 days, you will still have an additional 31 days to enroll and pay for this coverage, but only if you pay an additional $100 penalty. Coverage can begin on the first day of the month in which the Fund receives notice of the dependent, or it can begin the first day of the following month.

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.

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, Suite 812

New York, NY 10036

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.

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.

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.

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.

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)

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

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.

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.

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

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 provides comprehensive medical benefits, whether you use a Cigna network physician or not. .

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.

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.

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 drugs are covered under a plan separate from the Cigna medical plan. To learn more, visit this page.

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.

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.

No. In-network copayments also do not count toward the $500 (individual) or $1,000 (family) annual deductibles for non-network care under the Cigna Tier 1 Plan.

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.

When you and at least one dependent are covered, a $1,000 family deductible non-network applies. At least one family member will have to meet the $500 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 for Tier 1 coverage, there is no deductible. So you could save a considerable amount of money by using the Cigna Plan’s OAP network providers.

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.

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.

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.

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.

The Equity League Health Fund , covers preventative care treatments such as physicals, immunizations and routine tests, with no copays at 100% based on benefits determined under the Affordable Care Act (ACA).

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.

The Equity-League Health Fund does permit the use of Manufacturer Coupons in order to assist you with any potential high copay amounts. For example, suppose your physician tells you that you have ulcerative colitis. She suggests the brand name drug Apriso as a treatment option. After she tells you about Apriso’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 Apriso. 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 Apriso in your case. If the cost of the prescription is $360 under the Optum RX prescription drug plan, your copayment would be 25% of that, or $90. However, if the drug’s manufacturer offers you a $50 coupon to offset against your copayment of $90, the copay you would only be required to pay is $40. In addition, coupons can be used at a retain pharmacy location. For prescriptions ordered through Optum RX’s mail order pharmacy, please contact them directly to determine if a manufacture coupon can be used.

FOR EQUITY-LEAGUE HEALTH TRUST FUND

SUMMARY ANNUAL REPORT

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

Yes, you may choose to take self-paid dental coverage even if you do not pay the $300 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 (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.

Participants may choose a PPO or an HMO(DHMO). You can visit this page to see your plan options or to learn more.  In order to use the Dental HMO Plan, you must name a primary dentist prior to enrolling for this dental coverage. If you do not name one once the coverage is elected, CIGNA will automatically assign one to you in the first available dental office within a 25 mile radius from your place of residency. If you subsequently wish to change your assigned primary care dentist, you will need to inform CIGNA and wait until the 1st of the subsequent month in order to so. We therefore urge you complete a dental enrollment form located under the Health Forms section to name a primary care dentist of your choice and send it to the Health Benefits Dept. once this coverage has been paid for. Please note that under certain state law mandates, the Dental HMO Plan is not permitted, and therefore if you reside in any of these states, your only option to enroll in dental coverage will be the Dental PPO Plan:

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 the rates for each option.

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.

Visit this page to view the vision benefits provided with medical benefits.