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The Plan’s Working Spouse Rule states that, if your spouse is working for an employer who offers a health plan, the Plan requires them to enroll in that employer-sponsored coverage to be eligible for Plan coverage. Your spouse must confirm whether they have access to and are enrolled in their employer’s health plan.
If you intend to enroll your spouse for coverage in the SAG-AFTRA Health Plan and you are within open enrollment for your next benefit period, we will need additional information to ensure that there is no delay in their coverage.
Visit Benefits Manager to complete the Working Spouse Rule Verification. You can do this at the same time you enroll and pay your premium. If your spouse is employed, just make sure to have their employer's name and address and, if the employer offers health coverage, the name of that plan and your spouse's ID for that plan.
FAQs
What is the working spouse rule?
If your spouse’s employer offers a health plan, they need to enroll in that plan. If enrolled with their employer, you can choose to cover them under the SAG-AFTRA Health Plan as well. The employer’s plan will pay benefits first; then, our Plan’s cost-sharing may apply for remaining eligible expenses. If they don’t enroll in their employer’s plan, you cannot cover them with us — our Plan will not pay benefits for their healthcare.
If your spouse is not working, or their employer does not offer a health plan, you can enroll your spouse with the SAG-AFTRA Health Plan.
What is coordination of benefits (COB)?
Coordination of benefits (COB) is the method of dividing responsibility for payment among multiple health plans that cover an individual so that the amount paid by all plans will never exceed 100% of the allowable expenses.
What happens if my spouse loses their employer coverage during the benefit period?
You can enroll your spouse with the SAG-AFTRA Health Plan. Your spouse will need to provide a copy of the coverage termination letter to the Plan.
Does my spouse have to take the secondary coverage under SAG-AFTRA Health Plan?
Remember, if you decide to enroll your eligible working spouse in Plan coverage, you will pay a premium. Thus, you are not required to enroll your working spouse in Plan coverage – the choice is yours, and if you do so, the Plan pays secondary benefits for their healthcare services.
Can my dependent children be covered under SAG-AFTRA Health Plan instead of my spouse’s employer coverage?
Yes, your dependent children can be covered under the Plan.
Will married participants who are both offered SAG-AFTRA Health Plan coverage but currently choose to be covered as a dependent under one spouse’s SAG-AFTRA Health Plan be required to enroll in their own Plan coverage?
No. The choice to cover both spouses under one participant or for each spouse to have their own coverage will remain unchanged.
How often do I have to complete this process?
Once a benefit period, or if you have a life event that changes your or your Dependents’ eligibility for Plan coverage. If you have a change, you must update your spouse's information in Benefits Manager within 30 days of the change.
When is the deadline?
Please complete the process prior to the start of your benefit period.
Why do I have to complete the Working Spouse Rule process every year?
The Working Spouse Rule requires enrolled working spouses to take their employer's health plan coverage.
What happens if I don't complete the Working Spouse Rule verification process?
If you do not complete the verification process, coverage for your spouse will be terminated and any premium refund due will be credited towards future premium payments.
What about my eligible dependent children?
Eligible dependent children can be covered under the Plan and are not required to be enrolled under your spouse’s employer's plan.
Does my spouse have to take the dental coverage offered by their employer?
If there is an additional cost for dental coverage, your spouse does not need to enroll in their employer’s dental plan. Your spouse (if enrolled) can be covered under the Plan for dental coverage.
Does my spouse have to take the vision coverage offered by their employer?
If there is an additional cost for vision coverage, your spouse does not need to enroll in their employer’s vision plan. Your spouse (if enrolled) can be covered under the Plan for vision coverage.
Where do I send my premium payments?
Premium payments are due to the Plan. Please log in to Benefits Manager at my.sagaftraplans.org/health or call (800) 777-4013 to make a payment over the phone. You can also pay by mail.
Is the premium less for secondary coverage for my spouse?
No, premium amounts are the same regardless if the Plan pays primary or secondary benefits for your spouse.
Do I need to inform the Plan if I have Medicare coverage?
No, you do not need to indicate whether you have Medicare.
When will my coverage be effective?
Your coverage will be effective as of the first day of your benefit period, assuming your spouse has completed the coverage verification process, and you pay the Plan premium. You will receive a Notice of Coverage from the Plan.
How can I appeal decisions about my spouse and dependents’ eligibility and Plan coverage?
You can file your appeal with the Plan by email to [email protected] or by mail to:
SAG-AFTRA Health Plan
c/o Appeals Department
P.O. Box 7830
Burbank, CA 91510
Where can I file a complaint or grievance?
You can file a complaint or grievance by email to [email protected] or by mail to:
SAG-AFTRA Health Plan
c/o Appeals Department
P.O. Box 7830
Burbank, CA 91510