When a Participant (writer) and/or their spouse have health insurance from different sources, the Health Fund determines which coverage is primary and which is secondary (or tertiary – sometimes there are three or more health insurance providers). In these situations, the Health Fund uses a process called Coordination of Benefits (COB) to determine which health insurance providers should be billed first and which will be secondary (or tertiary).
In practical terms, though there may be some exceptions, the amount the Participant will have to pay out of pocket will be the same. The real differences in the COB process have to do with what organization pays what portion of a bill. That said, there are complications that can occur, and we want to help you be aware of what is involved.
It is the responsibility of the Participant (or their business manager, should they have one) to submit billing in the correct order. Typically, this is done by providing the doctor or medical institution in question with the information provided below. The important thing is to inform whoever is handling billing about all the coverages a Participant has, from whatever source (WGA, DGA, Medicare, COBRA, etc.)
Below, you will find answers to some commonly asked questions about the COB process. Should you have any questions, please feel free to contact the Health Fund at: (818) 846-1015 and select Option 1 for Participant Services. You can also reach Participant Services by email at: [email protected]
DUAL COVERAGE
The Participant is on earned coverage with the Writers Guild of America, east/west (WGA) and also has earned coverage with another industry health plan (DGA, SAG/AFTRA/IATSE, ETC.) Which is primary?
Answer: In a situation like this, whichever Health Fund covering the Participant has the longest continuous eligibility will be primary.
Example when WGA would be primary: The Participant has health coverage with the WGA beginning March of 2025, and their health coverage with another industry health plan begins in June of the same year. In this instance, the WGA would be primary and the other industry health plan would be secondary.
Example when the other industry health plan would be primary: If a Participant was covered by the other industry health plan beginning in January of 2025 and their coverage with the WGA began in March of 2025, then the other industry health plan would be primary.
EXTENDED COVERAGE WITH WGA AND ACTIVE COVERAGE WITH ANOTHER INDUSTRY HEALTH PLAN
The Participant is using Extended Coverage Points (GAP) for WGA Health Fund coverage. The Participant also has earned coverage with another other industry health plan, but the GAP point WGA coverage precedes the other industry health plan coverage. Which coverage would be primary?
Background: For each qualified year (when a writer earns the equivalent of the going rate for a one-hour primetime story and teleplay), a writer receives a GAP point, up to a maximum of 50 points. The writer receives an additional two points for any year (four consecutive quarters) when they earn $125,000. There is an additional point for any consecutive four-quarter period in which a writer earns $250,000 or more. A writer can use 10 GAP points per year to continue their Health Fund coverage.
Answer: The other industry health plan would be primary from the time the Participant began using GAP points. GAP points are not treated with the same primacy as earned active coverage.
Example when WGA would be primary: The WGA becomes primary when coverage changes from GAP points to earned active coverage.
Example when the other industry health plan would be primary: The other industry health plan is primary when the Participant is using GAP points and the other industry health plan is earned active coverage. This would be true even if the GAP points began before the other industry health plan earned active coverage. The primary determinant is when earned active coverage begins.
CERTIFIED RETIREE WITH WGA AND INACTIVE COVERAGE WITH ANOTHER INDUSTRY HEALTH PLAN
The Participant is 65 years old and is a Certified Retiree with the WGA (note: a Certified Retiree is someone who is at least 60 years old and has 68 qualified quarters and therefore qualifies for lifetime Health Fund coverage).
The Participant is inactive (retiree/self-pay/COBRA) status with the other industry health plan and has Certified Retiree coverage with the WGA (which has an earlier effective date). Is the other industry health plan or the WGA primary?
Answer: In this circumstance, Medicare is primary, and the other industry health plan is secondary (due to the effective date).
Example when WGA would be primary: If the Participant were to earn compensation for WGA-covered writing services (including bonuses and residuals) and earned enough to qualify for active earned coverage, the WGA would be primary, the other industry health plan would be secondary, and there would be no Medicare involved because the Participant is receiving active earned coverage.
Example when the other industry health plan would be primary: If the Participant were to obtain active earned coverage under another industry health plan employment, then the other industry health plan would be primary, Medicare would be secondary, and the WGA would be tertiary.
Example when Medicare would not be primary: If the Participant were on active coverage from the WGA and the other industry health plan, then Medicare would not be primary.
PARTICIPANT IS UNDER 65, BUT A CERTIFIED RETIREE – DEPENDENT IS OVER 65
The Participant is under the age of 65 and is a Certified Retiree with the WGA and another industry health plan. The Participant’s dependent is over the age of 65? Is the other industry health plan or WGA primary?
Answer: Medicare would be primary for the dependent, and the WGA would be secondary.
Example when WGA would be primary: The WGA would be primary if the Participant is covered by earned active coverage.
Example when the other industry health plan would be primary: If the Participant were to obtain earned active coverage from the other industry health plan, then the other industry health plan would be primary.
Example when Medicare would become primary: If the Participant is inactive (Certified retiree/self-pay/COBRA) coverage for both the WGA and the other industry health plan, then Medicare would be primary.
PARTICIPANT OVER 65 AND USING GAP POINTS FOR COVERAGE
DEPENDENT IS UNDER 65 AND INACTIVE WITH THE OTHER INDUSTRY HEALTH PLAN
The Participant is over the age of 65 and eligible for coverage by the Health Fund using GAP points with the WGA. The dependent is under the age of 65 and inactive with the other industry health plan with an effective date later than WGA. Is the other industry health plan or WGA primary?
Answer: The WGA would be primary for the dependent until the dependent is eligible for Medicare coverage, and then Medicare would become primary. Medicare would be primary for the Participant because they are over 65.
Example when WGA would be primary: If the Participant were to obtain earned active coverage, then the WGA would be primary and Medicare would be secondary.
Example when the other industry health plan would be primary: If the other industry health plan member were to obtain earned active coverage and the WGA Participant is on GAP points, then the other industry health plan would be primary.
Example when Medicare would become primary: If the WGA Participant and their other industry health plan spouse were inactive (retiree/self-pay/COBRA) coverage) then Medicare would be primary.
PARTICIPANT IS OVER 65 AND GOES BACK AND FORTH BETWEEN EARNED COVERAGE AND GAP POINTS
The Participant is over the age of 65 and their coverage goes back and forth between earned eligibility and GAP points, who is primary, the WGA or Medicare?
Answer: The Participant will remain primary with WGA when on earned coverage and take on the secondary position when the eligibility changes to GAP points, making Medicare primary at that time.
Example when WGA would be primary: The Participant is on earned active coverage, so the WGA would be primary and there Medicare would be secondary.
Example when Medicare would become primary: If the Participant is on inactive coverage (GAP points/self-pay/COBRA), then Medicare would be primary and the WGA would be secondary.
PARTICIPANT HAS GAP POINTS WITH WGA AND HAS PRIVATE INSURANCE, TOO
The Participant is covered under GAP points with the WGA and has private (non-group) insurance with AETNA. Who is primary?
Answer: The WGA would remain primary as the Health Fund does not coordinate with private insurance plans.
PARTICIPANT HAS WGA AND OTHER INDUSTRY HEALTH PLAN COVERAGE – BOTH BEGAN COVERAGE AT THE SAME TIME
The Participant is covered by the WGA and the other industry health plan with the same effective date? Which organization is primary?
Answer: In this situation, each plan is responsible for 50% of the allowed charges.
PARTICIPANT HAS GAP POINTS AND THEIR SPOUSE HAS ACTIVE COVERAGE WITH AN INDUSTRY HEALTH PLAN
The Participant is covered by the WGA under GAP points and their spouse is covered by another industry health plan under earned coverage. Who is primary, the WGA or the other industry health plan?
Answer: The plan covering the person as a Participant is primary to the plan covering the person as a dependent.
PARTICIPANT HAS GAP COVERAGE WITH WGA AND IS INACTIVE WITH ANOTHER INDUSTRY HEALTH PLAN
The Participant is using GAP points with the WGA for their coverage, and they are also inactive with another industry health plan? Which organization would be primary?
Answer: The plan covering the person with the longest continuous eligibility is primary.
Example when WGA would be primary: The Participant’s GAP point coverage begins in March of 2025, while the other industry health plan coverage lapses in February, 2025. In this example, the WGA would be primary because there is no coverage with the other industry health plan.
Example when the other industry health plan would become primary: If the other industry health plan effective coverage date occurs before WGA effective coverage date, then the other industry health plan would be primary.
GLOSSARY
ACTIVE PARTICIPANT
A writer who has enough PWGA earned coverage to qualify for Health Fund coverage (The Participant must earn the current minimum for a primetime story and teleplay in a consecutive four-quarter period.
INACTIVE PARTICIPANT
This refers to a writer who is using GAP points or Extended Coverage (see below discussions of GAP points and Extended Coverage for more details) in order to qualify for Health Fund coverage.
CERTIFIED RETIREE
(Inactive Participant) A Participant who is at least 60 years old, has 68 qualified quarters, and has opted to retire, is designated as a Certified Retiree and receives lifetime Health Coverage in addition to their pension distributions. If a Participant who meets these requirements but does not opt to retire, they will not receive this benefit until such time as they formally apply for retirement. See Certified Retirees on pages 36-38 Summary Plan Description for more information.)
COBRA (Inactive Participant)
The acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985, including all subsequent amendments, which allows for the purchase of healthcare coverage after loss of eligibility due to certain qualifying events.
COORDINATION OF BENEFITS (COB)
The payment of health care benefits when a member is covered by two or more benefit plans. One of the benefit plans will be primary and the other secondary (or tertiary, etc. if there are more than two benefit plans providing coverage).
The primary benefit plan pays first, following its rules and schedule of benefits, then the payments under the secondary plan are coordinated so that combined plan payments do not exceed 100 percent of eligible expenses. The same is true if there are three or more benefit coverage plans; the combined health plan payments cannot exceed 100 percent of eligible expenses.
COVERED EARNINGS (Active Participant)
Income for writing services covered by a collective bargaining agreement that employers report and contribute to the Fund.
ELIGIBLE DEPENDENT
Any dependent of a Participant who meets the criteria for eligibility established by the Health Fund.
MEDICARE (Inactive Participant)
The Health Insurance for the Aged and Disabled provisions in Title XVIII of the U.S. Social Security Act as it is now amended – and as it may be amended in the future. Medicare is the federal government’s health insurance program for those 65 and older, individuals who are totally disabled, and those with end-stage renal disease. The different parts of Medicare include:
• Part A, which covers inpatient hospitalizations, skilled nursing facilities (SNF), hospice care, and some home health care;
• Part B, which covers outpatient care, doctor’s services, medical supplies, and preventive services; and
• Part D which covers medications.
Part A is premium-free if you or your spouse paid Medicare taxes for a certain amount of time while working and meet certain requirements. Parts B and D have a premium that you must pay, which is calculated based on your income.
SPECIAL ENROLLMENT, SPECIAL ENROLLEE, OR SPECIAL ENROLLMENT RIGHT
The right you and/or your dependents have to enroll in the Health Fund outside the period when you and/or your dependents were initially eligible to participate. There is an Open Enrollment period when certain life events occur. (Refer to the Life Events section on pages 32-34 of the Summary Plan Description for more information.)
EXTENDED COVERAGE PROGRAM (GAP) (Inactive Participant)
The Extended Coverage Program awards points to Participants who meet the minimum earning requirement to qualify for eligibility in their four-quarter earnings cycle. (See Summary of Benefits for more details).
A Participant must accumulate at least 10 points (one time during the course of their career) to qualify for Extended Coverage benefits. These benefits become available once the 10-point minimum has been met, and the Participant subsequently loses employer-paid coverage.
If a Participant retires during a quarter where they are using GAP points, then they will have to remain on GAP until the quarter concludes before Certified Retiree coverage begins.
EXCESS EARNINGS EXTENSION (Active Participant)
If a Participant earns at least $250,000 in gross covered earnings in one earnings cycle, but does not earn enough in the next personal earnings cycle to be eligible for Health Fund coverage, the Health Fund will provide coverage for another year by dividing the $250,000 covered earnings minimum equally between the two consecutive earnings cycles. If the Participant does earn enough during the second earnings cycle to qualify for regular employer-paid coverage, they won’t require the $250,000 extension. The extension cannot be held in reserve for future use. The Fund automatically provides this extension.