Promoting Health and Quality Care Your New Medical Plan for 2013

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1 Promoting Health and Quality Care Your New Medical Plan for 2013 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. 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. 1. Health Account Credits 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. July

2 2. Annual Deductible 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. 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 to zero every year. Your health plan works the same as your car insurance. You re responsible for paying a set amount of the cost before the plan pays. If you have single coverage, the annual is $1,000. If you have family coverage, the annual is $1,000 per person but no more than $2,000 for your entire family. Amounts that have accumulated toward the annual 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. 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: You have $250 rollover credits You have $500 rollover credits 3. Coinsurance After you meet the annual, 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 before coinsurance kicks in, like for extra primary care visits past your four free visits. July

3 4. Annual Out-of- Pocket Maximum 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. 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. The HAP protects you by limiting how much you re responsible for paying out of pocket every year. This limit is called the annual outof-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 whether with Health Account credits or your own cash count toward your annual out-ofpocket 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. The HAP pays 100% of your covered costs for the rest of the year after you meet the annual out-of-pocket maximum. Not many people have enough expenses to meet the annual out-of-pocket maximum. Like the annual, 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: $2,400 $4,800 at the most (includes annual ) Your 2013 Effective Out-of-Pocket Maximum: <$1,150> <$2,300 at the most> July

4 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, 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 ) $2,400 $2,400 / person $4,800 / family Plan pays 100% for most preventive and primary care (no annual required) Coinsurance Additional Primary Care (beyond 4 free visits) 10% (no annual ) 10% (no annual ) Specialty / Hospital Care/Other Coinsurance costs will never exceed annual out-of-pocket maximums Effective Annual Deductible (if you earn all incentives) and beyond You have $250 rollover credits You have $500 rollover credits Effective Annual Out-of-Pocket Maximum includes annual (if you earn all incentives) and beyond $1,150 $1,400 $2,300 $2,800 July

5 Primary Care 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? 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 management to 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: sports injuries Tip Primary care is better care. Use it first. July

6 Example #1 Single Coverage: Everyday Care Let s say in 2013, you earn the full $1,250 in your Health Account, and your annual is $1, Services HAP Benefit Your Portion of Cost Your Responsibility 4 primary care visits Free 2 specialty visits ($800 total charge) 4 generic mail-order prescriptions not on the free list ($400 total charge) 10% after annual $800 toward annual $220 $200 toward annual $20 for coinsurance Your total 2013 charges $1,020 Your total 2013 charges after Health Account $1,250 credits in Health Account 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. Your Responsibility: $1,020 (includes annual ) 2013 Health Account: $1,250 Paid by PG&E $230 rollover 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 Medical Expense Estimator, available at July

7 Example #2 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 and a $2,400 annual out-of-pocket maximum (includes annual ) Services HAP Benefit Your Portion of Cost Your Responsibility 4 primary care visits Free 8 additional primary care visits ($720 total charge) 50 specialty visits ($20,000 total charge) 8 lab tests not on the free list ($1,600 total charge) 4 generic mail-order prescriptions not on the free list ($3,500 total charge) 10% no annual 10% after annual $72 toward annual out-of-pocket maximum $2,328 $1,000 toward annual $1,328 coinsurance up to annual out-of-pocket maximum Met annual out-of-pocket maximum 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 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. Your Responsibility: $2,400 (annual out-of-pocket maximum) 2013 Health Account: $1,250 Paid by PG&E $1,150 Paid by You 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 Medical Expense Estimator, available at July

8 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 and download Free Preventive Services Anthem and Kaiser. Free Meds Anthem members: Use the Express Scripts mail-order program. Kaiser members: Use a Kaiser pharmacy or Kaiser s mail-order program. 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 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 required. And the Health Account will help cover your coinsurance. Services You re Responsible For Many services are subject to the annual. This means your coinsurance usually 10% or 20% of the covered charge won t kick in until after you ve met the annual. But remember you can use your Health Account to cover your annual, so you end up paying nothing if you ve earned all your healthy choice incentives. Services that aren t subject to the annual include: Primary care doctor visits (after the first four, which are free) Urgent care clinic visits Outpatient behavioral health visits July

9 New for Kaiser Members You ll have access to the American Specialty Network. You ll be able to selfrefer for chiropractic and acupuncture. For Sample Charges Anthem members: Log on to pge and look for Compare Facility Cost. Kaiser members: Log on to my.kp.org/ca/pge and check the Sample Fee List. Chiropractic and Acupuncture Treatment After you meet the annual, 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. 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, 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. July

10 Example #3 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 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. And the plan pays 100% of her covered charges after she meets the per-person annual out-of-pocket maximum $2, Services HAP Benefit Your Portion of Cost Your Responsibility 4 primary care visits Free 8 maternity care visits Free 4 lab tests not on the free list- ($800 total charge) 3 ultrasounds ($1,200 total charge) Hospitalization for birth ($15,000 total charge) $800 toward annual $400 $200 toward annual $200 coinsurance $1,200 Met annual out-of-pocket maximum 4 well-baby visits Free Your total 2013 charges $2,400 Your total 2013 charges after Health Account $2,500 credits in Health Account 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. Your Responsibility: $2,400 (annual out-of-pocket maximum) 2013 Health Account: $2,500 Paid by PG&E $100 rollover 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 Medical Expense Estimator, available at July

11 Example #4 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 Let s also assume you earn the full amount of Health Account credits for 2013 and 2014 ($4,500 total). The annual family 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. The plan pays 100% of her covered charges after she meets the per-person annual out-of-pocket maximum $2, Services HAP Benefit Your Portion of Cost Your Responsibility 4 primary care visits Free 8 maternity care visits Free 4 lab tests not on the free list- ($800 total charge) 3 ultrasounds ($1,200 total charge) $800 toward annual $400 $200 toward annual $200 toward coinsurance Your total 2013 charges $1,200 Your total 2013 charges after Health Account $2,500 credits in Health Account You have $1,300 rollover 2014 Services HAP Benefit Your Portion of Cost Your Responsibility Hospitalization for birth ($15,000 total charge) 4 well-baby visits Free Your total 2014 charges $2,400 $2,400 $1,000 toward annual $1,400 coinsurance up to annual out-of-pocket maximum 2013 Your Responsibility: $1,200 (includes annual ) 2014 Your Responsibility: $2,400 (annual out-of-pocket maximum) 2013 Health Account: $2,500 Paid by PG&E $1,300 rollover 2014 Health Account: $3,300 Paid by PG&E $900 rollover 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 Medical Expense Estimator, available at July

12 Family Coverage Reminder If your family only uses free primary care in 2013, you ll have the entire $2,500 to add to the $2,000 Health Account in This would cover your entire per-person family out-of-pocket maximum in 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 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. July PG&E refers to Pacific Gas and Electric Company, a subsidiary of PG&E Corporation Pacific Gas and Electric Company. All rights reserved.