July 2012 1
Promoting Health and Quality Care
Your New Medical Plan for 2013
The new Health Account Plan (HAP)
does more
than protect you when you’re under the weather—
it’s your ticket to better health. The HAP helps
ensure you can be there in the years to come to
enjoy life’s important events with your friends
and family.
The new plan will be offered through both Anthem and Kaiser, and it covers all conditions and services the current plans cover—
plus, it offers lots of free preventive and primary care so you can be sure you’re getting the right care, right away. It also comes with built-in financial incentives for making healthy choices—the
PG&E-paid Health Account.
Let’s walk through how it works.
Every January 1, PG&E credits your Health Account just for being enrolled in the HAP. You can earn even more by taking a health screening, testing tobacco-free, or completing PG&E’s tobacco cessation program.
The amount you get depends whether you have single or family coverage. To get you started, you’ll have more credits in 2013 than in later years.
Best of all? Any credits you don’t use will roll over into the next year
as long as you’re enrolled in a PG&E medical plan. You can continue to accrue credits and even use them for retiree medical expenses, or for a variety of other services, like vision and dental expenses— Lasik surgery or braces for your kids.
The credits are notional, which means they have no cash value, earn no interest, and aren’t taxed. You can use them for any eligible health care expense, including medical, dental, and vision.
New Health
Account
PG&E credits your
account and gives
you the opportunity
to earn even more.
You can use your
credits to cover your
health care costs.
1.
Health
Account
Credits
The HAP covers the same services the current plans cover, but in a different way. Under the HAP, most preventive and primary care services are free. We’ll tell you more about that a little later. For the services that aren’t free, you’re responsible for the first portion of medical costs before the plan will pay benefits. This is called the annual deductible.
Your health plan deductible works the same as your car
insurance deductible. You’re responsible for paying a set amount of the cost before the plan pays.
If you have single coverage, the annual deductible is $1,000. If you have family coverage, the annual deductible is $1,000 per person but no more than $2,000 for your entire family.
Amounts that have accumulated toward the annual deductible reset to zero every January 1.
Remember, you start the year with Health Account credits from PG&E and you have the opportunity to earn even more. You can use your Health Account credits to cover your annual deductible.
Single Coverage Family Coverage
Your Maximum 2013 Health Account Credits: $1,250 $2,500
Your Annual Deductible: – $1,000 – $2,000 at the most
Your 2013 Costs: $0 You have $250 rollover credits $0 You have $500 rollover credits
After you meet the annual deductible, you’ll be responsible for either 10% or 20% of the covered cost and the HAP will pay the other 90% or 80% respectively. That’s called coinsurance.
There are no copayments under the HAP, so instead of paying $10 or $20 at the time of service (a copayment), you won’t have to pay anything until later, when you get a bill for your portion of the coinsurance.
For some services, you don’t have to meet the annual deductible before coinsurance kicks in, like for extra primary care visits past your four free visits.
2.
Annual
Deductible
Bottom Line?
By participating in the
annual health
screenings and the
tobacco-free program,
you can earn enough
Health Account credits
to reduce your annual
deductible to zero
every year.
July 2012 3 Here’s the last piece of the puzzle.
We just talked about coinsurance—the percentage you’re responsible for paying toward covered charges. You may be thinking:
“Coinsurance?! What if I fall off a cliff, rupture my spleen
and end up in a full-body cast? I’ll go bankrupt!”
Don’t panic.
The HAP protects you by limiting how much you’re responsible for paying out of pocket every year. This limit is called the annual out-of-pocket maximum.
If you have single coverage, the annual out-of-pocket maximum is $2,400.
If you have family coverage, the annual out-of-pocket maximum is $2,400 per person but no more than $4,800 for your entire family.
Amounts you pay toward the annual deductible—whether with Health Account credits or your own cash—count toward your annual out-of-pocket maximum. The HAP pays 100% of your covered costs for the rest of the year after you meet the annual out-of-pocket maximum.
Yes, you read that right.
Not many people have enough expenses to meet the annual out-of-pocket maximum.
Like the annual deductible, amounts that have accumulated toward the annual out-of-pocket maximum reset to zero every January 1. And let’s not forget about the credits in your Health Account:
Single Coverage Family Coverage
Your Maximum 2013 Health Account Credits: $1,250 $2,500 Your Annual Out-of-Pocket Maximum:
(includes annual deductible)
– $2,400 – $4,800 at the most
Your 2013 Effective Out-of-Pocket Maximum: <$1,150> <$2,300 at the most>
4.
Annual
Out-of-Pocket
Maximum
The HAP pays 100% of your covered costs for the rest of the year after you meet the annual out-of-pocket maximum.
Tip
To save money, you
can enroll in the
Health Care Flexible
Spending Account
(FSA) if you think
you’ll spend more out
of pocket than you
have in your Health
Account.
Here’s how all the pieces of the puzzle fit together with the
Health Account:
How the New Health Account Plan Works Single Coverage
Family Coverage
2013
Extra credits to get you started
You automatically get: $ 750 $1,500
If you take a health screening: $ 250 $ 500
If you test tobacco-free or complete PG&E’s tobacco cessation program:
$ 250 $ 500
Yearly total: $1,250 $2,500
2014 and Beyond You automatically get: $ 500 $1,000
If you take a health screening: $ 250 $ 500
If you test tobacco-free or complete PG&E’s tobacco cessation program:
$ 250 $ 500
Yearly total: $1,000 $2,000
Annual Deductible (includes prescription drugs) $1,000 $1,000 / person $2,000 / family
Annual Out-of-Pocket Maximum
(includes annual deductible)
$2,400 $2,400 / person $4,800 / family
Plan pays 100% for most preventive and primary care (no annual deductible required) Coinsurance Additional Primary Care
(beyond 4 free visits)
10% (no annual deductible) 10% (no annual deductible) Specialty / Hospital Care/Other
Coinsurance costs will never exceed annual out-of-pocket maximums 20% after annual deductible 20% after annual deductible Effective Annual Deductible
(if you earn all incentives) 2013 2014 and beyond $0 You have $250 rollover credits $0 $0 You have $500 rollover credits $0 Effective Annual Out-of-Pocket Maximum—includes annual deductible
(if you earn all incentives) 2013 2014 and beyond $1,150 $1,400 $2,300 $2,800
July 2012 5
Primary Care
Under the HAP, primary care is your golden ticket to better health. You and each enrolled family member get four free primary care visits every year. This means if you have three people in your family, your family can use up to 12 free visits—four per person. It’s all about easy access to higher quality for you and your family. It’s about choosing a family doctor who knows you and who cares about your “whole person” health—not just your list of conditions. It’s about making your primary care doctor your first choice for
everything from chronic disease managementto school physicals and remedies for that winter cold.
Visits to physicians with any of the following credentials are considered primary care:
General or family practitioners Internal medicine doctors Pediatricians
Family nurse practitioners OB/GYNs
Non-hospital urgent care services
Absolutely.
Primary care visits are good for:
What’s primary care
and why is it so
important?
Why would PG&E
add this as a free
benefit to the HAP?
So how do I choose a
primary care doctor?
Can I use my primary
care visits for
ongoing
management of
chronic diseases like
diabetes,
hypertension, and
asthma?
Tip
Primary care is
better care. Use it
first.
Single Coverage:
Everyday Care
Let’s say in 2013, you earn the full $1,250 in your Health Account, and your annual deductible is $1,000.
2013 Services HAP Benefit
Your Portion of Cost
Your Responsibility
4 primary care visits Free $0
2 specialty visits
($800 total charge)
20% after annual deductible
$800 toward annual deductible
4 generic mail-order prescriptions not on the free list
($400 total charge)
10% after annual deductible
$220
$200 toward annual deductible $20 for coinsurance
Your total 2013 charges $1,020
Your total 2013 charges after Health Account
$1,250
credits in Health Account $0
You have $230 rollover credits Even though you’re responsible for $1,020, your Health Account
covers the full cost and then some. You even have $230 left over for the next year.
2013 Health Account: $1,250
Paid by PG&EYour Responsibility: $1,020
(includes annual deductible)
$230 rollover
Example
#1
Note: This is only an example. Your actual care and costs will be different. See page 9 for information on where to find sample charges. Starting in
September 2012, you can model your estimated expenses with the
July 2012 7
Single Coverage:
Managing a Serious Illness
Let’s say in 2013, you earn the full $1,250 in your Health Account and you have a $1,000 annual deductible and a $2,400 annual out-of-pocket maximum (includes annual deductible).
2013 Services HAP Benefit
Your Portion of Cost
Your Responsibility
4 primary care visits Free $0
8 additional primary care visits ($720 total charge)
10%
no annual deductible
$72 toward annual out-of-pocket maximum 50 specialty visits ($20,000 total charge) 20% after annual deductible $2,328 $1,000 toward annual deductible $1,328 coinsurance up to annual out-of-pocket maximum
8 lab tests not on the free list ($1,600 total charge)
20% after annual deductible
$0
Met annual out-of-pocket maximum
4 generic mail-order
prescriptions not on the free list ($3,500 total charge)
10% after annual deductible
$0
Met annual out-of-pocket maximum
Your total 2013 charges $2,400
Your total 2013 charges after Health Account
$1,250
credits in Health Account
$1,150
The $1,250 in your Health Account covers your entire annual deductible and part of your coinsurance—and it reduces your annual out-of-pocket maximum.
In this case, you got $25,820 in total medical services and you only paid $1,150 out of your own pocket—the HAP and Health Account covered the rest.
Example
#2
2013 Health Account: $1,250
Paid by PG&E$1,150
Paid by You Your Responsibility: $2,400(annual out-of-pocket maximum)
Note: This is only an example. Your actual care and costs will be different. See page 9 for information on where to find sample charges. Starting in
September 2012, you can model your estimated expenses with the
Other Free Services
The HAP gives you a lot of other free services besides primary care visits:
Free preventive services (mammograms, pap smears, colonoscopies, immunizations)
To see the full list, go to www.pge.com/benefitspge and download Free Preventive Services—Anthem and Kaiser. Free prescription drugs for preventive care and chronic conditions, like insulin for diabetes
You pay nothing for the drugs on the free list when they’re prescribed by your doctor. See the Free Medications links at
www.pge.com/benefitspge for full lists of free prescriptions. Free maternity and well-baby visits to age 2
Does your little one have the sniffles? In addition to free well-baby visits, your baby gets four free primary care visits a year. After that, you’re responsible for just 10% of the cost for additional visits—with no annual deductible required. And the Health Account will help cover your coinsurance.
Services You’re Responsible For
Many services are subject to the annual deductible. This means your coinsurance—usually 10% or 20% of the covered charge—won’t kick in until after you’ve met the annual deductible.
But remember—you can use your Health Account to cover your annual deductible, so you end up paying nothing if you’ve earned all your healthy choice incentives.
Services that aren’t subject to the annual deductible include: Primary care doctor visits (after the first four, which are free) Urgent care clinic visits
Outpatient behavioral health visits
Free Meds
Anthem members:
Use the Express
Scripts mail-order
program.
Kaiser members:
Use a Kaiser
pharmacy or Kaiser’s
mail-order program.
July 2012 9
Chiropractic and Acupuncture Treatment
After you meet the annual deductible, you’re responsible for 10% of covered charges for the first five chiropractic visits and 20% for additional visits. The same benefits apply to acupuncture treatment. Remember, you can use the credits in your Health Account to help cover your costs.
Prescription Drugs
For medications that aren’t free, you’re responsible for 100% of the cost until you meet the annual deductible. After that, your coinsurance kicks in and you’re responsible for:
Retail drugs (up to three 30-day fills): 15% for generic; 25% for brand
Mail-order drugs: 10% for generic; 20% for brand
Specialist Visits, ER, and Hospitalizations
After you meet the annual deductible, you’re responsible for 20% of the covered charges for most specialist visits, emergency room visits, and hospitalizations.
Sound scary? Remember, your out-of-pocket costs are limited.
After you reach the annual out-of-pocket maximum, the plan pays 100% of covered charges for the rest of the year. And you can use the Health Account to help cover your costs.
New for Kaiser
Members
You’ll have access to
the American Specialty
Network.
You’ll be able to
self-refer for chiropractic
and acupuncture.
For Sample
Charges
Anthem members:
Log on to
www.anthem.com/ca/
pge and look for
Compare Facility Cost.
Kaiser members:
Log on to
my.kp.org/ca/pge
and check the Sample
Family Coverage: One-Year
Coverage for Having a Baby
Let’s say in 2013, you earn the full $2,500 in your Health Account, and your pregnant wife, Lisa, is the only one in your family who needs services that aren’t free.
The annual family deductible is $1,000 per person and no more than $2,000 for the entire family—so coinsurance kicks in for Lisa after she meets the $1,000 annual deductible. And the plan pays 100% of her covered charges after she meets the per-person annual out-of-pocket maximum—$2,400.
2013 Services HAP Benefit
Your Portion of Cost
Your Responsibility
4 primary care visits Free $0
8 maternity care visits
Free $0
4 lab tests not on the free list- ($800 total charge)
20% after annual deductible
$800 toward annual deductible
3 ultrasounds ($1,200 total charge) 20% after annual deductible $400 $200 toward annual deductible $200 coinsurance
Hospitalization for birth ($15,000 total charge)
20% after annual deductible
$1,200
Met annual out-of-pocket maximum
4 well-baby visits Free $0
Your total 2013 charges $2,400
Your total 2013 charges after Health Account
$2,500
credits in Health Account
$0
You have $100 rollover credits
Even though you’re responsible for $2,400, your Health Account covers the full cost and then some. You even have $100 left over for the next year.
Example
#3
2013 Health Account: $2,500
Paid by PG&E $100 rollover Your Responsibility: $2,400July 2012 11
Family Coverage: Two-Year
Coverage for Having a Baby
Now let’s assume your wife Lisa gets pregnant in 2013 and has the baby in 2014. Let’s also assume you earn the full amount of Health Account credits for 2013 and 2014 ($4,500 total).
The annual family deductible is $1,000 per person and no more than $2,000 for the entire family—so coinsurance kicks in for Lisa after she meets the $1,000 annual deductible. The plan pays 100% of her covered charges after she meets the per-person annual out-of-pocket maximum—$2,400.
2013 Services HAP Benefit
Your Portion of Cost
Your Responsibility
4 primary care visits Free $0
8 maternity care visits Free $0
4 lab tests not on the free list- ($800 total charge)
20% after annual deductible
$800 toward annual deductible
3 ultrasounds ($1,200 total charge)
20% after annual deductible
$400
$200 toward annual deductible $200 toward coinsurance
Your total 2013 charges $1,200
Your total 2013 charges after Health Account
$2,500
credits in Health Account $0
You have $1,300 rollover
2014 Services HAP Benefit
Your Portion of Cost
Your Responsibility
Hospitalization for birth ($15,000 total charge) 20% after annual deductible $2,400 $1,000 toward annual deductible $1,400 coinsurance up to annual out-of-pocket maximum
4 well-baby visits Free $0
Your total 2014 charges $2,400
Example
#4
2013 Health Account:
$2,500 Paid by PG&E
2014 Health Account:
$3,300 Paid by PG&E
$1,300 rollover $900 rollover 2013 Your Responsibility: $1,200(includes annual deductible)
2014
Your Responsibility: $2,400
(annual out-of-pocket maximum)
Note: This is only an example. Your actual care and costs will be different. See page 9 for
information on where to find sample charges. Starting in September 2012, you can model your
PG&E Couples
Are you and your spouse or registered domestic partner both PG&E Management and A&T employees? Here’s important information you need to know about the Health Account:
If one person is covered as a dependent, you’re treated as a
single family unit and you get one Health Account with the family contribution. The most you could get in 2013 is $2,500. Whoever is enrolled as the employee will be responsible for earning Health Account credits. Dependents can’t earn credits, even if they’re PG&E Management and A&T employees.
If you’re enrolled in separate plans as employees, you each get a Health Account. Contributions will be based on whether you each have single coverage or family coverage. For example, the husband enrolls in Kaiser and the wife enrolls herself and the children in Anthem. He gets the single Health Account contribution and she gets the family Health Account contribution. The most they could get in 2013 is $3,750 ($1,250 for his single coverage and $2,500 for her family coverage).
PG&E Union-Represented employees are not eligible for the Health Account in 2013.
Qualifying for Additional Credits
If you earn less than $22.95 / hour on January 1, 2013, you’ll get an extra $500 in your Health Account on January 1.
If you get a raise in 2013, you can still keep the extra $500 in your Health Account.