High Concepts

Before getting into the story details, we'll set the stage by defining some frequently used terms that will describe the role you'll play in paying for your care:

Eligible Expenses
"Eligible expenses" are the services and other expenses your plan says are covered and for which benefits will be considered.

Calendar-Year Deductible
A "calendar-year deductible" is the portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits. Exceptions include prescription drug benefits, mental health and substance abuse benefits and wellness benefits, many of which require copays but no deductibles. Deductibles apply to all plans except Open Access Plan network services.

Here is the breakdown on deductibles:

• Individual deductible - Each covered person pays a specific amount each calendar year toward eligible expenses before the Fund begins paying a portion of those expenses.
• Family deductible - If you cover your dependents, any medical expense that counts toward an individual's deductible automatically counts toward the family deductible. Once three or more covered persons have met the combined deductible maximum, all enrolled family members are considered to have met their deductibles for the calendar year, and benefits will be paid accordingly.
• Multiple family member accident - If two or more covered family members are injured in the same accident, only one individual deductible for all family members involved will be applied to the eligible expenses resulting from the accident. The deductible will be applied only to those accident-related medical expenses incurred during the calendar year in which the accident occurs.
• Deductible carryover - This is a special provision that applies to every covered family member. It allows you to carry over eligible expenses that were applied to your deductible from one year to the next under certain circumstances. Any portion of your calendar-year deductible satisfied in the fourth quarter (i.e., October, November, December) of each year will be carried over and applied to the next calendar-year deductible.

Copayments
A copayment, or "copay", is a fixed-dollar amount that you pay for an eligible expense at the time the service is provided. Most network services require a copay for each visit or service. After you pay the copay and any applicable coinsurance, the Fund pays the rest of your cost of care, up to certain maximums and limitations. Copays are required for most Open Access network services, as well as for specific benefits for all plans. Copays don't count toward your out-of-pocket maximums.

Coinsurance
"Coinsurance" is the percentage of eligible expenses that you and the Fund must pay after the calendar-year deductible has been met. Coinsurance applies to all plans, except to the Open Access Plan network services.

Contracted Rates (Network Services)
"Contracted rates," or "allowed charges," are the rates that have been negotiated between the networks and their network providers. These rates apply only to network services. When you use a network provider, you're not responsible for paying any amount over the contracted rate, even if the provider bills a higher amount.

Reasonable And Customary (R&C) Limits (Non-Network Services)
"Reasonable and customary (R&C) limits" are maximums for charges considered reasonable and customary based on what 80% of providers in your geographic area charge for similar services or supplies. (A "geographic area" is an area grouped by several ZIP codes.) Any amount above the R&C limit isn't considered an eligible expense. R&C limits apply anytime you see a non-network provider or a provider in a state where a PPO isn't available. If you use a non-network provider or a provider in a state where no PPO network is available, you're responsible for paying any amount over the R&C limit.

If you're contemplating incurring a major medical expense, you may want to find out whether your non-network provider's charges fall within R&C limits for that service. Before you receive care, call the Administrative Office for assistance. Keep in mind that R&C limits can change over time.

Out-Of-Pocket Maximum
The "out-of-pocket maximum" is the total amount of coinsurance you pay for eligible expenses during the year before most plans begin paying 100% of most eligible expenses for the rest of the year. A new out-of-pocket maximum begins each calendar year. If you reach your out-of-pocket maximum, the plan begins paying 100% of eligible expenses, except for mental health/substance abuse benefits, which remain at the normal coinsurance levels.

Also keep in mind that eligible network and non-network expenses count toward the out-of-pocket maximum.

Even if you reach the out-of-pocket maximum, you must still pay copays for:

• Prescription drugs, hospital admissions, and emergency room and urgent care facility visits under the Regular Plan and Open Access Plan;
• Hospital admissions and emergency room and urgent care facility visits under the Low Option Plan; and
• The Industry Health Network.

Lifetime Maximum Benefit
The "lifetime maximum benefit" is the maximum medical benefits payable for a covered person throughout his/her lifetime. Once the lifetime maximum benefit is reached, no additional plan benefits will be paid. The lifetime maximum benefit is the same amount whether you use network providers or non-network providers.

Under certain circumstances, the Fund's lifetime maximum benefit (currently $5 million) will be coordinated with the lifetime maximums of the following industry health plans:

• Directors Guild of America-Producer Health Plan;
• Motion Picture Industry Health Plan;
• Screen Actors Guild-Producers Health Plan;
• AFTRA Health Fund; and
• Their successor plans.

"Coordination of lifetime maximums" means that if a writer or dependent is a participant in more than one industry health plan - for example, health plans offered by the WGA and SAG - the Fund will subtract payments made to the writer by the SAG health plan from the individual's Fund lifetime maximum. The coordination provision is triggered if a participant or beneficiary has accumulated more than $100,000 in payments from the Fund (including payments made before January 1, 2004). In other words, any payments that have been made (or will be made in the future) by the health plans for the four guilds listed above (or their successor plans) to such a participant or beneficiary will reduce the balance of the individual's lifetime maximum benefit with the Fund.

Dissolve To...
The heart of the matter -- your medical plan options and how they work.