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FAQ

The answers to frequently asked questions below are general in nature and do not modify the terms of their respective Plans. You should refer to the related Summary Plan Description for more specific information regarding each Fund's Plan.

Top Frequently Asked Questions

Can a participant choose C4 later into 2015, or thereafter, if they want to downgrade their coverage?

Yes, each quarter the Fund Office sends a statement showing a participant’s available CAPP balance in advance of the prospective coverage quarter.  Downgrading to a lower level coverage in Plan C is always permissible for a future coverage quarter.  However, a participant cannot switch to a higher level of coverage except at each annual open enrollment unless there is a life event such as the birth of a child, adoption of a child, and marriage.  Pages 37 and 38 of the Plan’s Summary Plan Description booklet further describe such life events.  

What are some of the highlights of C4?

  • C4 provides coverage for in-network providers only.
  • C4 is a high deductible plan with an annual deductible of $3,000 per individual and $7,500 per family.  Once the deductible has been met (the participant has paid the first $3,000 per person, or $7,500 for the family, of covered in-network services) then the Plan will pay 50% of covered expenses.  (Plan pays 50%, patient pays 50% for covered expenses).
  • Covered in-network benefits for hospital, medical (doctor visits, laboratory, and radiology), , surgery, etc. will be provided by Empire BlueCross BlueShield.  Prescription benefits will be provided by CVS/Caremark.  Certain services have a co-payment (a flat dollar payment that the patient pays to the provider at the time of the service) and are not subject to the co-insurance (50% cost sharing) such as emergency room visits.
  • Annually, the first three (3) primary care visits per family member are reimbursable at 100% for an in-network provider.  The deductible and co-insurance will apply at the fourth (4th) visit in that calendar year.
  • There is an overall out-of-pocket limit per person of $6,450 and $12,900 for a family for 2015.  Once this limit has been reached the Plan will reimburse all covered in-network services for the balance of that calendar year at 100%.  This limit takes into account all monies paid by a participant or a family member out of his/her pocket for the following:                                                       
    •      The annual deductible (for C4 it is $3,000 per individual/$7,500 per family – this is the amount that must be paid before the Plan makes any reimbursement).                                                           
    •      All co-payments (the flat dollar amount paid at the time of a service; e.g. $250 for an emergency room visit under Plan C4).                                                      
    •      All co-insurance payments – the 50% cost sharing for in-network services provided by physicians, laboratories, diagnostic tests, surgical services, prescription drugs, etc.  
  • Are there any items not subject to the out-of-pocket limit?                                                           
    • Yes, a participant or a covered family member will be wholly responsible for full payment of any out-of-network services or provider charges and for any item not covered under the Plan, and these payments will not count toward the out-of-pocket limit.  

Why is there an Out-of-Pocket Limit now on Plans A, C1, C2, C3, and C4?

The ACA places an annual limit on how much a person is required to pay out-of-pocket for covered services under a health plan.  Once a person has met that annual limit, the health plan must cover all covered services at 100% for the rest of the year. While Plans C2 and C3 already contained an out-of-pocket limit, Plans A and C1 did not.   And, the limits under Plans C2 and C3 did not include prescription drugs, which now count toward the annual limit starting January 1, 2015.  The annual limit includes amounts paid by a participant for all essential benefits: hospital, medical, diagnostic, laboratory, mental health services, covered therapies, prescriptions, etc.   (Services not covered by the Plan, such as out of network services under Plans C3 and C4, do not count toward the annual limit).  As briefly described above, deductibles, copayments, and co-insurance (percentage) payments are all added together as out-of-pocket monies a participant is spending/cost sharing with the Plan.  Once a participant’s spending reaches a certain dollar amount, then all further covered services in that same calendar year are paid at 100%.  This means that, after that point, no more out-of-pocket expenses have to be paid by the participant except for non-covered services and out-of-network provider charges that exceed the reasonable and customary dollar amount determined by BlueCross BlueShield (or all out-of-network provider charges if the participant is covered under an in-network-only option).

 The out-of-pocket limits under Plans A, C1, C2, and C3 are more generous than required by the ACA, that is, the Plans are reimbursing more than is required by law.

Plans C2 and C3 had Out-of-Pocket Limits before. Why have they increased?

The out-of-pocket limit that previously existed only took into account co-insurance percentages for hospital, medical, and surgical services.  Co-payments and deductibles for medical services and prescription drug co-payments and/or co-insurance percentage payments were not included in the limit.  Under the ACA, all essential benefits must be wrapped into an overall out-of-pocket limit (dental and vision benefits are not included as they are not essential benefits).   The existing limits were increased slightly to account for the added prescription utilization and the inclusion of co-payments and deductibles.  Once you have met the out-of-pocket limit, whether because you incurred expenses for different types of services, or just one (such as a hospitalization with or without surgical services or high prescription usage), the Plan will pay all remaining covered services at 100% for the remainder of the year in which you met the limit. 

Will the Plans’ 2015 Out-of-Pocket Limits change in future years?

As limits increase under the ACA the Trustees will re-visit the Plans’ limits annually and decide if the limits need to be adjusted.

Why has the CAPP account forfeiture process changed?

Because Plan C runs on a quarterly basis, the Trustees decided that forfeitures should also be run quarterly instead of annually to better comport with the Plan.  We will look at the prior eight (8) coverage quarters, or 24 coverage months, (before statements for the prospective coverage quarter are generated) to determine if there was ‘activity’ in the CAPP account.  The definition of ‘activity’ is not changing; ‘activity’ means coverage in an active option (A, C1, C2, C3, or C4), submission of a covered claim for medical reimbursement, or an employer contribution to the Plan.  If there was ‘activity’ in any of the 8 prior coverage quarters then the account balance remains.  The absence of any one of the three types of activity will cause a forfeiture of the CAPP account balance to general Plan assets. 

Why has the active test for those on Medicare changed from one quarter of C3 single coverage to one quarter of C4 single coverage in employer contributions?

Under Medicare’s secondary payor rules a person who is enrolled in Medicare but continues to work (is no longer considered retired and is considered active, as defined by Medicare) and who has group coverage available to them may not use Medicare as their primary coverage and use the group coverage (such as Plan C-MRP) as secondary to Medicare.  (As explained below, you can waive Plan C coverage and stay on Medicare).  The Fund’s definition of ‘active’ for such participants is if they work and have employer contributions received in a contribution test quarter that equal or exceed the Plan’s lowest cost coverage.  Since C4 will be the lowest cost coverage as of January 1, 2015, the cost of C4 individual coverage will be used to determine who is active.  A participant who meets the active test must enroll in active coverage and freeze any retiree medical reimbursement monies they may have, or the Fund will enroll them in C4 coverage absent an active election for any other coverage option.  They will be given the right to waive their active Plan C account so they do not have to give up Medicare as their primary coverage for the prospective quarter but their retiree medical reimbursement account will continue to be frozen for the prospective coverage quarter since they met the active test.

Why will the Fund Office discontinue issuing revised CAPP account statements?

With the launch of our new ‘real time’ website and its available mobile app, CAPP Account balance information is now more readily available, especially for those participants who are on the road.    CAPP balances, primarily for those enrolled in the Stand-Alone MRP option of Plan C, can change often, as claims for reimbursements are paid.  It is confusing to our participants to discern which balance on the various statements should be used to make prospective coverage quarter decisions.  By using our website, or our interactive phone response system, or our newly improved service center dedicated e-mail address, up to the minute information is at their fingertips.  Multiple statements via US mail can get delayed, lost, or ignored.  So, the Fund Office will issue a statement as it normally does and we strongly encourage you to to check on-line or with the Fund Office before they make a change or issue a co-payment based on their statement balance.  Using our on-line credit card payment system can help assure you that you are making a co-payment with your most updated balance

Who is the Annuity Fund Plan Administrator?

The Annuity Fund is administered jointly by a 14 person Board of Trustees made up of an equal number of Union and Employer appointees. The Trustees are not compensated for the performance of their duties and have the full power and authority to administer the Plan, construe the terms and provisions and to establish all Plan rules and regulations. The Trustees employ an Executive Director to perform all day to day administrative functions of the Plan.

When was the Annuity Fund established?

The IATSE National Annuity Fund was initially established on January 1, 1973.


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