Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)
As an alternative to electing an Anthem Blue Cross-administered plan, you may choose a Health Maintenance Organization (HMO), an Exclusive Provider Organization (EPO), or Medicare HMO, if you are eligible and one is available in your ZIP code. To be eligible to join an HMO or EPO, you must live in that plan's service area. Membership may not be available throughout an entire county; precise service areas are specified by home ZIP code. Because of the ongoing nature of HMO and EPO service territory changes, we recommend that you verify the service area and provider availability with each plan vendor.
More information on eligibility and the different types of HMO plans for Medicare-eligible members is included under PG&E's Medicare Plan Options – General Information in this subsection. Also see information on specific HMO benefits in the Non-Medicare and Medicare HMOs subsections.
How HMOs and the Kaiser EPO Work
Health Maintenance Organizations (HMOs) and the Kaiser EPO provide a full range of health care services on a prepaid basis. These Company-sponsored plans have no deductibles, but some services require copayments. Each year, the Company publishes a high-level summary of each plan's benefits in its Open Enrollment guides. To find out more about each plan's benefits, call the plan vendor.
When selecting an HMO or EPO, not only should you look at the plan's network of doctors and hospitals, you also should look at the quality of the plan. The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates the quality of HMOs. The NCQA reviews health plan records, interviews health plan staff, and grades the results from consumer surveys conducted by independent survey organizations. For additional information visit their website at www.ncqa.org.
All HMOs currently offered by the Company are accredited. To learn more about the quality of each of the HMOs offered by the Company, you can review the Pacific Business Group on Health's website at www.pbgh.org. The Pacific Business Group on Health provides consumer health education materials on West Coast health plans.
When you join an HMO or the Kaiser EPO, you will receive an identification card. You and your eligible family members must receive all of your medical care through the HMO's or EPO's medical groups (doctors, clinics, hospitals, and pharmacies) in order for services to be covered. You may be reimbursed when using a non-HMO/non-EPO doctor or hospital but only in the event of an emergency that is life-threatening or likely to cause serious bodily harm.
In addition, you will also receive an Evidence of Coverage (EOC) directly from the HMO and Kaiser EPO members will receive a Summary Plan Description (SPD) from Kaiser. Your EOC or SPD will provide detailed information about covered services, your copayments or coinsurance, referral and authorization requirements, and the claims and appeals processes. Please keep and use your EOC or SPD as a reference document along with any updates that you receive. If you have any questions about your EOC/SPD or if you do not automatically receive your EOC/SPD, call your plan vendor at the telephone number listed in your HMO's summary of benefits at the end of this section.
This document, together with the EOC or SPD you receive from your plan vendor when you enroll, any updates to the EOC/SPD you receive from your plan vendor, the Open Enrollment communications material you receive from the Company on an annual basis, and any summaries of material modifications, constitute your summary plan description for your plan benefits. In case of conflict between any documents and the EOC/SPD, the EOC/SPD is the binding document between the plan and its members, and the EOC or SPD will govern.
Additional information that is pertinent to and constitutes your summary plan description for the plan benefits is included in the following sections of this Handbook: What to Do…, Mental Health and Substance Abuse Coverage, Rules, Regulations & Administrative Information, and "COBRA and Conversion to an Individual Medical Policy" in the Health Care Participation section.
Primary Care Physicians (PCPs)
For all of the HMO plans, you and your dependents will be assigned a primary care physician (PCP) when you first join the plan. Later, if you want to change your primary care physician, you may do so by calling your HMO's member services number. If you join an HMO and your doctor does not belong to that HMO or the doctor you have selected subsequently discontinues his or her association with the HMO, you will need to select another primary care physician within that HMO for the rest of the plan year. You may not change medical plans until the next Open Enrollment period, unless you move out of your HMO's service area. Please remember, you have a responsibility to coordinate your medical care in accordance with the provisions of the plan that you select to ensure all your medical needs are appropriately met.
In most HMOs, your PCP will be a member of a medical group or independent physician association (IPA). Please note that you generally will be required to use a specialist also associated with your PCP's medical group or IPA unless you receive specific authorization from your HMO. Please talk to your HMO or refer to your HMO's Evidence of Coverage regarding the role of the medical group or IPA in your particular HMO's benefit coverage.
HMO Service Areas
If you move out of your plan's service area, you may enroll in another plan effective the first day of the month following notification of your move, provided you request re-enrollment within 31 days after the move (for more information see the What to Do… section of the Handbook). For re-enrollment, contact the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
Available HMOs/EPOs
Not all plans are offered in all counties. In addition, the Company does not necessarily contract with providers to include all of their service territories, and availability is limited in some counties.
As of the date of this Handbook, the following HMOs/EPOs are offered to eligible retirees and surviving dependents who:
  • are not Medicare-eligible:
    • Blue Shield Access+ HMO
    • Health Net HMO
    • Kaiser Permanente EPO (Northern and Southern Region)
  • are Medicare-eligible:
    • Blue Shield Medicare Coordination of Benefits (COB) HMO
    • Health Net Medicare COB HMO
    • Health Net Seniority Plus Medicare Advantage Plan
    • Kaiser Senior Advantage Medicare Advantage Plan (Northern and Southern Region)
For more information about a specific HMO or EPO, see the summary of benefits for each plan included in the Non-Medicare HMOs and EPOs and the Medicare HMOs subsections. You may also call the HMO or EPO directly at the number listed in its summary or the Contacts section.