Retiree Medical Home

PG&E-Sponsored Retiree Medical Plans

When you’re ready to retire and each year during Open Enrollment, you’ll get a Personalized Enrollment Worksheet showing the medical plan options available to you. The options are based on:

Whether you’re eligible for Medicare

AND

Where you live

Notify the PG&E Benefits Service Center right away when you or a dependent becomes eligible for Medicare: 1-866-271-8144. Otherwise, you may be offered the wrong medical plans—and you'll have to pay back any PG&E-sponsored retiree medical benefits you received when you should have received Medicare benefits instead. The amounts you have to repay may be substantial.

CORRESPONDING NON-MEDICARE AND MEDICARE PLANS

Dependents whose Medicare eligibility is different than your own can enroll in a corresponding plan:

ID CARDS

Changing medical plans? Adding a dependent? You’ll get your new ID card:

  • Within 10 business days after your coverage becomes effective if you enroll when you retire
  • By January if you enroll during Open Enrollment
  • Within 10 business days after your change takes effect if you enroll midyear

If you don’t receive your new ID card on time, call your medical plan directly. If you need to see a doctor before your ID card arrives, use your confirmation statement as proof of coverage.

Don’t want to wait? You can print a copy of your ID card from your plan’s website. Anthem members also can print temporary ID cards for their prescription drug plan coverage at express-scripts.com.

PG&E-SPONSORED NON-MEDICARE PLANS

Here’s a snapshot of the PG&E-sponsored non-Medicare plans. For details, see the Medical Plan Comparison Chart.

Network Access Plan (NAP)*

You can use any licensed provider**

COSTS
Annual deductible
Lower out-of-pocket costs when you use network providers

Comprehensive Access Plan (CAP)*

Available if you live outside the NAP’s service area

You can use any licensed provider**

COSTS
Annual deductible
You may be able to lower your costs by using network providers

Retiree Optional Plan (ROP)*

You can use any licensed provider**

COSTS
Annual deductible
Lower monthly premium contributions than the NAP and CAP—but higher out-of-pocket costs for services
You may be able to lower your costs by using network providers

Blue Shield HMO Health Net HMO Kaiser Permanente EPO

Available for some ZIP codes

These plans cover most services in full—but you must use your plan’s network of providers located in California to receive coverage

COSTS
No deductible
You pay a copayment for office visits and other services
No charge for some services, such as hospital stays

*Under the NAP and CAP, Anthem Blue Cross administers medical benefits and Beacon Health Options administers mental health and substance use disorder benefits. Under the ROP, Anthem Blue Cross administers both medical benefits and mental health and substance use disorder benefits. Express Scripts administers prescription drug benefits for the NAP, CAP and ROP. Under the Health Net HMO and Kaiser Permanente EPO, inpatient substance use disorder benefits can be administered by the plan or by Beacon Health Options.

**Only urgent/emergency care is covered outside the U.S.

PG&E-SPONSORED MEDICARE PLANS

Here’s a snapshot of the PG&E-sponsored Medicare plans. For details, see the Medical Plan Comparison Chart.

Comprehensive Access Plan (CAP)*

You can use any licensed provider**

Provides secondary coverage to Medicare Parts A and B

Won’t pay any amount covered by Medicare

DO NOT ENROLL in any Medicare Part D plan that is not sponsored by PG&E. If you do, your PG&E-sponsored medical and prescription drug coverage will be terminated. You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

NOTES
If you don’t enroll in Medicare Part B, you’ll have to pay amounts Medicare would have covered***

Retiree Optional Plan (ROP)*

You can use any licensed provider**

Lower monthly premium contributions—and higher out-of-pocket costs for services

Provides secondary coverage to Medicare Parts A and B

Together with Medicare, ensures you get at least 70% coverage for eligible expenses after you pay deductibles (the ROP pays nothing when Medicare pays more than 70%)

Won’t pay any amount covered by Medicare

DO NOT ENROLL in any Medicare Part D plan that is not sponsored by PG&E. If you do, your PG&E-sponsored medical and prescription drug coverage will be terminated. You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

NOTES
If you don’t enroll in Medicare Part B, you’ll have to pay amounts Medicare would have covered***

Medicare Supplemental Plan (MSP)*

Available only to Medicare-eligible retirees and dependents enrolled in both Medicare Part A and Part B

You can use any licensed provider**

Provides secondary coverage to Medicare Parts A and B

Pays 80% of eligible expenses not paid by Medicare after you pay $100 deductible

Won’t pay any amount covered by Medicare

DO NOT ENROLL in any Medicare Part D plan that is not sponsored by PG&E. If you do, your PG&E-sponsored medical and prescription drug coverage will be terminated. You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

NOTES
If you don’t enroll in Medicare Part B, you can’t enroll in the MSP

MSP has two lifetime maximums:

  • A $10,000 lifetime maximum on medical benefits for each member—plus
  • A separate $10,000 prescription drug lifetime maximum benefit for each member
Every year, the plan restores up to $1,000 toward each of these two maximums
Lifetime maximums do not include amounts paid by Medicare

Reach the maximum? Call the PG&E Benefits Service Center as soon as Anthem or Express Scripts notifies you that you’ve reached the $10,000 lifetime maximum.
You can choose another plan in your service area within 31 days after you reach one or both lifetime maximums.
You’ll have to pay any new deductibles in full if you switch plans midyear.

*Under the CAP, Anthem Blue Cross administers medical benefits and Beacon Health Options administers mental health and substance use disorder benefits. Under the MSP and ROP, Anthem Blue Cross administers both medical benefits and mental health and substance use disorder benefits. Express Scripts administers prescription drug benefits for the CAP, MSP and ROP.

**Only urgent/emergency care is covered outside the U.S.

***Even if you have Medicare Parts A and B, you still may be required to pay part of the claim for expenses not covered at 100% by the CAP or ROP, like X-rays, which are covered at 90% under the CAP and 70% under the ROP.

Medicare Coordination of Benefits (COB) HMOs
Blue Shield Medicare COB HMO Health Net Medicare COB HMO

Benefits are highest when you use your HMO’s provider network:
You pay a copayment at the time of service
Your HMO will coordinate all payments with Medicare
Usually, you’ll have no additional payments beyond your copayment

You can use licensed providers outside the HMO’s network:
You’ll get traditional Medicare coverage at the standard level of Medicare benefits

You’ll get your HMO’s Medicare Part D prescription drug coverage:
Better benefits than the standard Medicare Part D prescription drug benefit
No prescription drug deductible or gaps in coverage

DO NOT ENROLL in any Medicare Part D plan that is not sponsored by PG&E. If you do, your PG&E-sponsored medical and prescription drug coverage will be terminated. You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

NOTES

Special enrollment rules:
You must be enrolled in Medicare Parts A and B to enroll in a Medicare COB HMO plan.

You’ll need to complete a separate enrollment form for each Medicare-eligible person enrolling.

Blue Shield Medicare COB HMO: For each Medicare-eligible person enrolling, you’ll need to complete a separate enrollment application for your HMO’s Medicare Part D prescription drug coverage.

Health Net Medicare COB HMO: For each Medicare-eligible person enrolling, you’ll need to complete two forms—one form to enroll in the HMO and another form to enroll in the SilverScript Medicare Prescription Drug Program.

Download the form(s) from Mercer BenefitsCentral or call the PG&E Benefits Service Center to request the form(s) be mailed to you.

What happens if you don’t follow the rules?
Not enrolled in Medicare Parts A and B? Didn’t turn in the separate enrollment form for your HMO’s Medicare Part D prescription drug coverage?

If you don’t follow ALL of the rules, you won’t have Medicare COB coverage. Instead, you’ll be automatically enrolled in the Comprehensive Access Plan (CAP), and you’ll be responsible for monthly premium contributions for that plan.* You won’t be able to elect a Medicare COB HMO until the next Open Enrollment.

*Covered family members will be enrolled in the Comprehensive Access Plan (CAP) if they’re Medicare-eligible—or in the Network Access Plan (NAP) or CAP if they’re not Medicare-eligible, depending on your home ZIP code. See Corresponding non-Medicare and Medicare plans for details.

Medicare Advantage HMOs
Kaiser Permanente Senior Advantage (North and South) Health Net Seniority Plus

You must use your HMO’s provider network of doctors and hospitals—except for medical emergencies.
You assign or give away control of your Medicare benefits to the HMO when you enroll
You can’t use your Medicare benefits outside of your HMO’s network
Coverage costs are typically lower than for Medicare COB HMOs

You’ll get your HMO’s Medicare Part D prescription drug coverage:
Better benefits than the standard Medicare Part D prescription drug benefit
No prescription drug deductible or gaps in coverage

DO NOT ENROLL in any Medicare Part D plan that is not sponsored by PG&E. If you do, your PG&E-sponsored medical and prescription drug coverage will be terminated. You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

NOTES

Special enrollment rules:

You must be enrolled in Medicare Parts A and B to enroll in a Medicare Advantage HMO plan

You’ll need to complete and sign a Medicare Advantage HMO enrollment form for each Medicare-eligible person enrolling BEFORE your coverage starts

The form authorizes assignment of your Medicare Part A and B benefits to the HMO, and acknowledges that you’ll be enrolled in your HMO’s Medicare Part D prescription drug coverage

Kaiser Permanente Senior Advantage: For each Medicare-eligible person enrolling, you’ll need to complete a Medicare HMO enrollment form (you may need to complete other forms or respond to other communications from Kaiser before your enrollment can be finalized).

Health Net Seniority Plus: For each Medicare-eligible person enrolling, you’ll need to complete a Medicare HMO enrollment form.

Download the Medicare HMO enrollment form from Mercer BenefitsCentral or call the PG&E Benefits Service Center to request the form be mailed to you.

What happens if you don’t follow the rules? Not enrolled in Medicare Parts A and B? Didn’t turn in the Medicare Advantage HMO enrollment form on time?

If you don’t follow ALL of the rules, you won’t have Medicare Advantage HMO coverage. Instead, you’ll be automatically enrolled in the Comprehensive Access Plan (CAP), and you’ll be responsible for monthly premium contributions for that plan.* You won’t be able to elect a Medicare Advantage HMO plan until the next Open Enrollment.

*Covered family members will be enrolled in the Comprehensive Access Plan (CAP) if they’re Medicare-eligible—or in the Network Access Plan (NAP) or CAP if they’re not Medicare-eligible, depending on your home ZIP code. See Corresponding non-Medicare and Medicare plans for details.

HOW MEDICARE WORKS WITH PG&E PLANS

All PG&E-sponsored Medicare plans work together with Medicare—even if you’re not enrolled in Medicare Parts A and B.

Most PG&E plans coordinate benefits with Medicare. However, with the Medicare Advantage HMOs, you assign your Medicare benefits to the HMO. This allows Medicare to reimburse the HMO instead of reimbursing you.

Medicare is always your primary coverage, and your PG&E coverage is secondary. This means Medicare pays benefits first, and your PG&E plan pays any remaining eligible benefits second.

If you’re not enrolled in Medicare Parts A and B, you won’t get full benefits.

PG&E PRESCRIPTION DRUG COVERAGE AND MEDICARE

All PG&E-sponsored plans have better prescription drug benefits than the basic Medicare Part D prescription drug benefit.

PG&E plans don’t coordinate prescription drug benefits with Medicare, except for some drugs covered by Medicare Part B.

Anthem plans:
Comprehensive Access Plan (CAP)
Medicare Supplemental Plan (MSP)
Retiree Optional Plan (ROP)
Medicare COB HMOs
Medicare Advantage HMOs

You have prescription drug coverage through Express Scripts.

It’s not a Medicare Part D prescription drug plan.

You’re automatically enrolled in the HMO’s Medicare Part D prescription drug plan—which is better than the standard Medicare Part D prescription drug plan.

DO NOT ENROLL in any Medicare Part D prescription drug plan or Medicare Advantage plan that is not sponsored by PG&E.

If you enroll in a Medicare Part D prescription drug plan or in any other external plan:

  • You and your enrolled dependents will be disenrolled from your PG&E-sponsored plan—AND
  • You will lose all of your prescription drug and medical coverage through PG&E.

That’s because if you enroll in an external plan, your Medicare benefits will be paid to that plan—not to your PG&E-sponsored plan.

You can re-enroll in a PG&E-sponsored retiree medical plan during the next Open Enrollment, as long as you’re eligible.

WANT TO SWITCH OUT OF A MEDICARE HMO?

In most cases, you'll need to disenroll from your HMO to regain control of your Medicare benefits so you can use them. Here's how:

  1. Elect your new plan during Open Enrollment.
  2. Call the PG&E Benefits Service Center to find out if you need a Medicare HMO disenrollment form. If the answer is “yes,” each enrolled family member will need to complete a Medicare HMO disenrollment form. You can download the form from Mercer BenefitsCentral or ask the PG&E Benefits Service Center to mail it to you.
  3. Mail or fax your completed Medicare HMO disenrollment form directly to your Medicare HMO plan by the deadline provided to you. The HMOs don’t allow email submissions.

Moving?

Before you move:

  1. Call the PG&E Benefits Service Center and tell them you’re moving.
  2. Ask the PG&E Benefits Service Center if your Medicare COB or Medicare Advantage HMO plan will be available at your new home address. If it won’t be available, you’ll need to:
    • Elect a new medical plan
    • Ask the PG&E Benefits Service Center if you need to fill out a Medicare HMO disenrollment form for your plan. If the answer is “yes,” each enrolled family member will need to complete a Medicare HMO disenrollment form.
    • Note: If you move out of the service area and you report your address change to the Centers for Medicare & Medicaid Services (CMS), you won’t need a disenrollment form.
  3. Mail or fax your completed HMO disenrollment form(s) directly to your Medicare HMO plan BEFORE the end of the month in which you report your address change.

Late form?

It could cost you. If your medical plan gets your completed Medicare HMO disenrollment form after the deadline, you could have unpaid claims under your new plan.You’ll be responsible for paying those claims.