Aetna Hospital Indemnity Plan Information Tier 1, 2 and Basic only
The Welfare Fund of Local No. One, I.A.T.S.E. provides MAJOR MEDICAL AND HOSPITAL BENEFITS to our participants through our insurance carrier, AETNA.
On AETNA’s website AETNA.com, you can access comprehensive information regarding your health insurance coverage, including coverage and claims information and deductible and out-of-pocket year-to-date totals. You can order a new ID card, or print one. You can research doctors, hospitals and other facilities; the provider directory will give you detailed physician profiles. But it is much more than just an information source about your health coverage. The site also features tools and resources that can help you take control of your health and wellness. One of these tools is a confidential online questionnaire called “My Health Assessment.” This confidential online questionnaire can help you monitor your health status and identify health issues. You can also find out how your family health history may affect you, learn about preventive care, and check your progress toward your health goals. Based on your responses, you’ll learn if you are at risk for conditions such as diabetes or high blood pressure, and also receive recommended next steps to help you get started on a path to better health.
Prescription Benefits
The Welfare Fund of Local No. One, I.A.T.S.E. provides PRESCRIPTION DRUG BENEFITS to our participants through our insurance carrier Express Scripts.
On Express Scripts website you have access to the Express Scripts Home Delivery service and can track your order history and order prescriptions. You can get answers to your prescription questions by following the “Manage Presciption” link, and search Express Scripts prescription drug list to learn about Express Scripts preferred brand equivalents that could save you money on your drug co-pays.
For information regarding eligibility, enrollment, self-pay premiums and other aspects of the Welfare Plan, click on the subjects listed on the left.
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Retiree Coverage
Aetna Medicare Advantage Plan
For Information click on the links below:
Welfare Plan Documents & Forms The Summary Plan Description (also called the SPD), together with the AETNA booklets for Tiers I, II or III and retiree coverage (see below), describe the key features of the Welfare Fund benefits program. Please note that the SPD was last issued in May of 2016. Plan Changes and Clarifications 05-06-2016 elimination of age 26-29 coverage 10-31-2016 change in tier III eligibility 01-01-2018 self-pay premium rates and various coverage changes 03-23-2018 tier III eligibility and various coverage changes 06-01-2018 enrollment changes, births 12-01-2018 various coverage changes 01-01-2019 self-pay premium rates changes 12-01-2019 fmla and gene therapy 01-01-2020 self-pay premium rates and various coverage changes 03-20-2020 defer self-pay 07-01-2020 recovery tier 01-01-2021 medicare advantage 02-08-2021 eligibility 07-01-2021 eligibility, self-pay rates, retiree 01-01-2022 eligibility, self-pay rates, disability 04-01-2022 eligibility changes 07-01-2022 eligibility changes 07-01-2022 gene therapy 07-01-2022 no surprise act 01-01-2024 medicare advantage 07-01-2024 eligibility changes Benefit Descriptions: Basic Tier Summary of Benefits Tier I Summary of Benefits and Coverage Tier 2 Summary of Benefits and Coverage Tier 3 Summary of Benefits and Coverage Basic Tier Schedule Benefits Booklet Tier 1 Schedule of Benefits Booklet Tier 2 Schedule of Benefits Booklet Tier 3 Schedule of Benefits Booklet Benefit Summary Chart: The following chart summarizes the benefits the Welfare Plan will provide for the all eligible participants. Summary Annual Report: This is the most recent basic financial statement sent to participants of the Welfare Funds. HIPAA Privacy Notice: This notice describes how medical information about you may be used and disclosed and how to get access to this information. Forms: Spousal Coverage Confirmation: This form only needs to be completed if you have elected medical coverage for your spouse. AETNA Claim Form: This form only needs to be completed if the provider is not submitting the claim on your behalf. Change of Address Form: Please use this form for changes of address or other contact information. |
Eligibility and Enrollment
Participant Eligibility
Welfare benefits start July 1 and ends December 31. To be eligible for Welfare benefits you must have “Covered Earnings” (earnings on which an employer pays contributions to the Welfare Fund).
Eligibility for the six-month coverage period July 1, 2024 through December 31, 2024:
You will be eligible for Welfare Fund benefits for this period, if you had at least $37,500 in Covered Earnings during the twelve-month period April 1, 2023 through March 31, 2024.
Dependent Eligibility
If you qualify and elect coverage for yourself, you may also elect coverage for your eligible dependents. Eligible dependents include:
- your spouse to whom you are legally married or your same-sex partner if your relationship is legally recognized as a marriage or civil union in the state or jurisdiction where the marriage or civil union was performed.Effective January 1, 2015, same-sex civil union coverage for partners who live in a state or jurisdiction that permits same-sex marriage will be eliminated. Thus, all Plan participants in a civil union who are currently covering a same-sex partner under the Plan that lives in a state that allows same-sex marriage will need to be married by December 31, 2014 in order to continue coverage of the same-sex partner. A copy of the certified marriage certificate must be provided to the Plan within 60 days of the date of marriage. If no marriage certificate is received by the Plan, the same-sex partner’s coverage will be terminated effective December 31, 2014. When coverage is terminated, COBRA continuation coverage will not be offered,
- unmarried dependent children (until the end of the calendar year in which they turn age 26),
Coverage for dependents is subject to various documentation requirements. Please see the Summary Plan Description or call the Fund Office for details.
Open Enrollment
During Open Enrollment you are able to enroll for the first time, make changes to your election type (Participant, Participant +1, or Family coverage). The Fund Office will send you enrollment materials if you qualify for coverage based on your “Covered Earnings” as shown above. For the self-pay premium rates see the Self-Pay Premium Chart.
Mid-Year Coverage Changes
Generally speaking, you may only make coverage elections or changes during the Open Enrollment period. This is very important because if you lose your coverage because you fail to pay your self-pay premium on time, you will not be able to elect coverage again until the next open enrollment.
However, there are some exceptions.
- If you decline coverage for yourself or any of your dependents because you have other insurance coverage, and you then lose that coverage (for reasons other than cause or failure to pay premiums), you may be eligible to enroll mid-year. However, you MUST request enrollment within 60 days of the other coverage ending.
- You may be able to do a mid-year enrollment in cases of marriage, birth and adoption. Again, you MUST request enrollment within 60 days of the marriage, birth or adoption.
In both cases, please call the Fund Office as soon as possible to check your eligibility and get the process started.
It’s also possible that your election type could change mid-year in cases of death, divorce, and children becoming ineligible for coverage. Please note that if you become divorced, your spouse’s coverage will terminate as of the end of the month in which your divorce is final. You are responsible for contacting the Fund Office if you and your spouse become divorced.
Dependent Coverage after the Death of the Participant
If you are NOT eligible to receive a pension and were covered under the Welfare Plan at the time of your death, your enrolled dependents will continue to be covered for the balance of the Plan year, and the subsequent year if you had met the earnings requirements for that year – provided that the self-pay premiums are paid on time.
If you were eligible to receive a pension and were covered under the Welfare Plan at the time of your death, your enrolled dependents will continue to be covered for 60 months with no self-pay premium required.
Retiree Medical Coverage
Aetna Medicare Advantage Plan
Effective January 1, 2024
For Information click on the links below:
Participant Eligibility
You are eligible for retiree medical coverage if:
- you were eligible for Welfare Fund benefits for three of the five Plan years immediately before your retirement; and
- (a) you have 25 years of pension credit at the time you retire, or (b) you have 20 years of pension credit at the time you retire AND had 12 years of pension credit as of January 1, 2008.
Please note that you MUST elect retiree medical coverage BEFORE you receive your first pension check. Failure to elect retiree coverage prior to receiving your first pension check is considered a rejection of the coverage, and that rejection may not be reversed. An exception to this rule may apply in a situation where you have other health insurance coverage. If this is your situation, please contact the Fund Office for more information.
Dependent Eligibility
If you qualify and elect coverage for yourself, you may also elect coverage for your dependents at the time of your retirement. Eligible dependents include:
- your spouse to whom you are legally married or your same-sex partner if your relationship is legally recognized as a marriage or civil union in the state or jurisdiction where the marriage or civil union was performed.Effective January 1, 2015, same-sex civil union coverage for partners who live in a state or jurisdiction that permits same-sex marriage will be eliminated. Thus, all Plan participants in a civil union who are currently covering a same-sex partner under the Plan that lives in a state that allows same-sex marriage will need to be married by December 31, 2014 in order to continue coverage of the same-sex partner. A copy of the certified marriage certificate must be provided to the Plan within 60 days of the date of marriage. If no marriage certificate is received by the Plan, the same-sex partner’s coverage will be terminated effective December 31, 2014. When coverage is terminated, COBRA continuation coverage will not be offered,
- dependent children (until the end of the calendar year in which they turn age 26),
Coverage for dependents is subject to various documentation requirements. Please see the Summary Plan Description or call the Fund Office for details.
Coverage Changes after your Retirement Date
Generally speaking, you may only make changes with respect to the enrollment of dependents at the time you first elect retiree medical coverage.
However, if you originally declined coverage for a dependent because the dependent had other health insurance coverage, and your dependent later loses that coverage for reasons other than failure to pay premiums or termination of coverage for cause, your dependent may be eligible for enrollment after your initial election. In such case, you MUST request enrollment within 60 days after the other coverage for your dependent ends, submit valid documentation verifying the loss of other coverage, and pay any additional premium that might be required.
If you are a retiree already enrolled in the Plan, and you acquire a new family member as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll that new eligible family member in the Plan. You must request enrollment in the Plan within sixty (60) days after the marriage, birth, adoption, or placement for adoption, submit valid documentation verifying the new family member(s), and pay any self-pay premium required by the Plan. Please see the Summary Plan Description for details.
Please note that if your coverage is terminated either voluntarily, or due to non-payment of your self-pay premium, you will not be permitted to resume coverage in the future.
Medicare Coverage
Please note that you MUST have Medicare Part B in place before you retire, and you should contact Medicare and make your application three months before your anticipated retirement date. You can start the process by calling 1-800-MEDICARE.
If you retire before you are eligible for Medicare coverage, you will be covered by Tier I, II or III “Active” coverage until you become eligible for Medicare. The Tier that you qualify for will be the highest Tier for which you had coverage in 3 of the 5 Plan years prior to retirement. (Please note that years prior to 7/1/2005 are considered to be Tier III for this purpose.) In this case, you are obligated to apply for Medicare Part B a few months before you become eligible. For those of you who took an early retirement pension, that would mean age 65. If you are receiving a disability pension you may become eligible for Medicare after you have been receiving Social Security Benefits for a period of two years. It is your responsibility to know when you become eligible, and to apply for Medicare so that it is in place on the date you become eligible for Medicare coverage.
With regard to your dependents, if you become Medicare eligible before they are eligible, they will continue to have the Fund as their primary coverage carrier. If they later become Medicare eligible, they have the same obligation to make sure that Medicare Part B coverage is in place on the date of their eligibility. Also, if you are not Medicare eligible, and your dependent is or becomes eligible before you, he/she will have Medicare as the primary coverage carrier and the Fund as secondary coverage carrier effective on the date he/she becomes Medicare eligible. You will continue to be covered by the “Active” Tier coverage until you become eligible or otherwise lose coverage under the Welfare Fund.
Dependent Coverage after the Death of the Retiree
If you die before you have received 60 monthly pension payments, your enrolled dependents will continue to be covered until they have been covered to 60 months from the time of your retirement. In this event, the self-pay premium will be waived.
Self-Pay Premiums
Effective July 1, 2024, if the payment is not received on or before the deadlines 07/01, 10/01, 01/01, and 04/01 your coverage will be terminated, and you will NOT have another opportunity to have coverage during the coverage period.
Unlike in prior years, there is no longer an option to pay your self-pay premiums late and have coverage reinstated.
In addition to the earnings requirements for coverage, to be eligible for Welfare Fund coverage, you are required to submit self-pay premium payments to the Fund Office. The rate for your self-pay depends on the coverage type you have elected (Participant, Participant + 1, or Family). Follow this link for a chart showing the current Self-Pay Premium Chart.
You will receive an invoice from the Fund Office in advance of the first day of each quarterly period. If it is more convenient, please note that you have the option to pay your self-pay premium up front for 6 months, instead of every quarter. You can remit payment to the Fund Office via:
- Credit card on our website fundoneiatse.com,or by calling (212)247-5225.
- Check made payable to “The Welfare Fund of Local No. One, I.A.T.S.E. There will be a $15.00 charge for any check returned from the bank. Post-dated checks not accepted.
Changes to Coverage Elections
There are certain circumstances that may allow you to change your coverage election (Participant, Participant +1, and Family). These include situations where a dependent loses eligibility for other insurance, or you have changes in your immediate family like marriage, divorce, birth or adoption, and death. If you experience such a qualifying change, you must request a change in coverage in writing and provide valid documentation within 60 days of the event. If you do not request the change within the 60-day window, you will have to wait until the next open enrollment to make the change. For additional information, see the “Mid-Year Coverage Changes” section above, or contact the Fund Office.
COBRA
COBRA refers to the federal law entitled the Consolidated Omnibus Budget Reconciliation Act of 1985. Under this law, the Fund is required to offer a temporary extension of health coverage at group rates in certain instances when benefits would normally terminate.
Participant Eligibility
If you are employed by a contributing employer and covered by the Welfare Plan, you may elect COBRA continuation coverage if you lose your coverage due to a reduction in your hours or termination of your employment (for reasons other than gross misconduct).
Dependent Eligibility
Your spouse and dependent children have the right to continuation coverage if they lose coverage for any of the following reasons:
- the death of the participant,
- the termination of the participant’s employment (for reasons other than gross misconduct) or reduction in the participant’s hours of employment,
- divorce or legal separation,
- the participant becomes enrolled in Medicare (Part A, B or both), or
- a child ceases to be a “dependent” (see Eligibility and Enrollment above for information on when a child is considered to be a dependent).
Duration of COBRA Coverage
The length of time that you may elect COBRA coverage is generally 18 months. Following are circumstances when COBRA coverage may extend beyond 18 months:
- If your family experiences another qualifying event while receiving the 18 months of continuation coverage, your spouse and dependent children may qualify for up to an 18-month extension (maximum of 36 months). This extension may be available to your dependents if you die, become enrolled in Medicare, have a divorce or legal separation, or if your child ceases to be a “dependent child.”
- If you or one of your qualified dependents become disabled before the 60th day of COBRA coverage, and the disability lasts through the end of the 18-month period, you may be entitled to an 11-month extension (maximum of 29 months). To be eligible for this extension, you or your family member must provide the Fund Office with a copy of your Social Security Disability Award letter within 60 days of the Social Security determination.
Please note that your COBRA coverage may be cut short if you do not pay your self-pay premium on time, become covered under another health plan (including Medicare), or are on an 11-month extension and are determined to be no longer disabled.
Cost of COBRA Coverage
The monthly cost of COBRA coverage beginning July 1, 2024 Plan year is:
| Tier I | COBRA | Disability COBRA |
| Participant | $1,058.24 | $1,556.24 |
| Participant + 1 | $2,109.89 | $3,102.79 |
| Family | $3,117.98 | $4,585.27 |
| Tier II | COBRA | Disability COBRA |
| Participant | $1,098.36 | $1,615.24 |
| Participant + 1 | $2,192.12 | $3,223.72 |
| Family | $3,240.33 | $4,765.19 |
| Tier III | COBRA | Disability COBRA |
| Participant | $1,135.46 | $1,669.81 |
| Participant + 1 | $2,267.38 | $3,334.39 |
| Family | $3,355.14 | $4,934.03 |
Please note that if you have an 11-month disability extension, your premium will be approximately 150% of the premium rates listed above.
For New York Residents Only
The New York State (NYS) 75% COBRA Subsidy Program for members in the entertainment industry is available once again. Currently, participants approved by the State will have 75% of their COBRA premium paid for by NYS.
To access the subsidy, complete and submit it directly to NYS. They will determine whether you qualify for this program. For more information on it, please visit the website
https://entertainmentcommunity.org/services-and-programs/artists-health-insurance-resource-center
Electing COBRA Coverage
When the Fund Office is notified or determines that a qualifying event has taken place, we will mail you forms that further explain your rights under COBRA and give you the opportunity to elect COBRA coverage. You have 60 days from the later of: (1) the date the coverage would normally terminate or (2) the date of the Fund Office’s notice to you of your COBRA rights, to make an election for COBRA coverage. If you do not make an election within the 60-day window, you will not be able to elect COBRA coverage.
Disability Crediting & Waivers
If you become disabled, the Welfare Plan has provisions that may help you by: (1) crediting you with earnings for the purposes of determining future medical coverage eligibility, and (2) waiving your self-pay premium payments. The lifetime maximum for disability crediting and waivers is 104 weeks.
If you are disabled and would like more information regarding these provisions, please contact the Fund Office.
Required Proof of Disability
To qualify for up to 104 weeks of disability crediting and waivers, you must submit proof of your disability to the Fund Office on a monthly basis. Proof of disability means copies of documentation that prove you are receiving benefits from:
- Social Security Disability,
- State Disability,
- Long Term Disability,
- Workers’ Compensation, or
- demonstrate that you have spent 21 or more consecutive days as an inpatient in a hospital or other facility for which the Fund provided coverage.
If you have exhausted State Disability benefits but have not yet received a Social Security Disability Award or qualified for Long Term Disability, you may be able to continue receiving disability crediting and waivers if you provide other evidence of your ongoing disability.
Disability Crediting
For every week that you are eligible for disability crediting, we credit you with “covered earnings” (the calendar year earnings amount that is used to determine your eligibility for Welfare coverage in the following Plan year) equal to 1/52nd of the amount necessary to qualify you for the applicable Tier. The applicable Tier is the Tier you would be eligible for based upon your covered earnings in the 52 weeks prior to your date of disability.
Disability Self-Pay Waivers
For any month in which you were eligible for disability crediting, you may also be eligible to have your self-pay premium waived. You must apply and be approved for a self-pay premium waiver; please contact the Fund Office for more information. Please note that if you elected to buy up to Tier III, you are still responsible for paying the applicable buy-up premium even if you are granted a self-pay premium waiver.
Please remember that the Welfare Plan currently provides for a lifetime maximum of 104 weeks of disability credits and waivers. If you do not need the disability earnings credits to qualify for Welfare benefits, you may not want to use up your weeks just to receive self-pay waivers. Disability credits are more important as a means to continue your benefits if you become disabled, than as a way to reduce your self-pay premium. Disability credits are a kind of insurance, and you should use them carefully, and only when you need them.
Exception to the 104-week Maximum Rule
You will not receive disability credits for more than one-hundred four (104) weeks of disability in your lifetime, whether for one disability or multiple disabilities, unless you fall within the following exception: If you have received 104 weeks of disability credits, but have yet to receive a Social Security Disability Award for which you have applied, and you would have sufficient pension credits to qualify for retiree medical coverage were you to later receive a disability pension from the Pension Fund of Local No. One, IATSE, you will be granted up to an additional one-hundred fifty-six (156) weeks of disability credits, provided you remain totally and permanently disabled (and submit ongoing proof of such disability to the Fund Office in the form and manner required) and continue to timely pay for coverage on the same basis as retirees receiving Plan benefits. Please contact the Fund Office for further information if you are in this situation.
Member Assistance Program
The Welfare Fund’s Member Assistance Program is administered for the Welfare Fund by The Actors Fund.
This tremendous organization, which is celebrating its 125th anniversary, has for many years provided Local 1 members with a wide range of wonderful and important services. They have helped many of us through life’s difficult times, and they continue to do so every day. Many of you may be aware of The Actors Fund fine work with members and family members that have experienced problems with alcohol or drugs at some point in their lives. Their extremely competent staff works closely with our members, the Fund Office, and AETNA to assess individual needs, develop treatment plans, and provide support throughout the recovery process to those struggling with an addiction problem.
But this is just one of the services The Actors Fund provides to our members. The Actors Fund social workers work with our members to provide short-term counseling for problems ranging from emotional difficulties, stress management, to helping members deal with financial problems. They assist members in locating in-network individual and family psychotherapists. They provide career counseling, referrals for legal services, help with locating affordable housing, and health-related services including smoking cessation and nutrition. They provide free workshops related to financial planning, housing seminars, and stress and time management. They run support groups related to addiction recovery, managing anxiety and depression, and career transition issues. They provide free screenings for cholesterol, blood pressure, skin cancer, and many other health-related issues. To see a copy of the Actors Fund Brochure, click on the link.
If you need assistance, just call the Member Assistance Program line at (212)221-7300, ext. 119. You may also want to check out their website at ActorsFund.org to get additional information about their programs, and schedule information for their workshops.