PG&E's Medicare Plan Options — General Information
The following subsection is meant to give you an overview of the general types of plans that PG&E offers for Medicare-eligible members. Also see "Medicare."
Anthem Blue Cross-Administered Plans
The Comprehensive Access Plan (CAP), the Retiree Optional Plan (ROP), and the Medicare Supplemental Plans (MSP), administered by Anthem Blue Cross, are self-funded medical plans available to Medicare-eligible Retirees and Medicare-eligible Surviving Dependents, regardless of where they live. These plans provide Medicare secondary coverage, plus primary prescription drug coverage. This means Medicare processes your claims first (except prescription drugs claims), and the CAP, and the ROP plans pay only the difference necessary to make your total reimbursement (Medicare's payment plus the PG&E plan's payment) equal to the amount a non-Medicare member would receive. You still may be required to pay part of the claim.
If your enrolled dependents are not Medicare-eligible, they will receive the under-65 benefits offered by the plan in which you are enrolled (NAP, CAP, or ROP), and the Anthem Blue Cross-administered plan will remain the primary payer for their claims. However, if a dependent becomes Medicare-eligible, Medicare will then become the primary payer for that dependent too, and the Anthem Blue Cross-administered plan will become secondary.
In calculating medical benefits under the PG&E plans when you are Medicare-eligible, the plans require Anthem Blue Cross to assume you are enrolled in both Part A and Part B of Medicare and to pay benefits accordingly. Anthem Blue Cross makes this assumption even if you do not participate in or apply for Medicare benefits to which you are entitled. Therefore, to maximize reimbursement, you should enroll in both Part A and Part B of Medicare when you first become Medicare-eligible.
Under the CAP Plan, the PG&E Medicare Supplemental Plan and the Retiree Optional Plan, when Medicare is the primary payer, claims should be submitted to Medicare first and then to Anthem Blue Cross along with copies of the "Explanation of Medicare Benefits" (EOMB) statements which indicate how much Medicare has paid. If you do not enroll in Medicare when eligible, benefits from these plans will be reduced by the amount Medicare would have paid had you been enrolled in Medicare. If you would like to avoid the hassle of submitting claims to both Medicare and Anthem Blue Cross, you can call Anthem Blue Cross Member Services and ask for a "Medicare Crossover" form. By completing this form, you are directing Medicare to electronically forward claims to Anthem Blue Cross for further processing, once Medicare has done its initial processing.
If you do not enroll in Medicare Part A and Part B, you are not eligible to enroll in the PG&E Medicare Supplemental Plan.
The following matrix shows the order in which Anthem Blue Cross and Medicare process claims when:
  • You and your spouse are covered by an Anthem Blue Cross-administered plan, and
  • You and your spouse are also covered under your spouse's medical plan.
 
If Claim Is For:
This Plan Pays 1st
This Plan Pays 2nd
This Plan Pays 3rd
Retiree not Medicare-eligible and Spouse employed and under 65 (without Medicare)
Retiree
Company
Spouse's
N/A
Spouse
Spouse's
Company
N/A
Retiree not Medicare-eligible and Spouse employed and over 65 (with Medicare)
Retiree
Company
Spouse's
N/A
Spouse
Spouse's*
Medicare
Company
Retiree not Medicare-eligible and Spouse retired and not Medicare-eligible
Retiree
Company
Spouse's
N/A
Spouse
Spouse's
Company
N/A
Retiree not Medicare-eligible and Spouse retired and Medicare-eligible
Retiree
Company
Spouse's
N/A
Spouse
Medicare
Spouse's
Company
Retiree Medicare-eligible and Spouse employed and under 65 (without Medicare)
Retiree
Spouse's
Medicare
Company
Spouse
Spouse's
Company
N/A
Retiree Medicare-eligible and Spouse employed and over 65 (with Medicare)
Retiree
Spouse's1
Medicare
Company
Spouse
Spouse's
Medicare
Company
Retiree Medicare-eligible and Spouse retired and not Medicare-eligible
Retiree
Medicare
Company
Spouse's
Spouse
Spouse's
Company
N/A
Retiree Medicare-eligible and Spouse retired and Medicare-eligible
Retiree
Medicare
Company
Spouse's
Spouse
Medicare
Spouse's
Company
* Assumes spouse has elected his/her employer's medical plan
How the CAP Integrates With Medicare: Two Examples
The following examples assume that:
  • You have paid your annual deductible for Medicare Part B, and you have met your calendar year deductible on the CAP Plan
  • The CAP Plan benefit for surgical expenses is 100%
  • Physician's billed charges for surgical procedure are $4,370
  • Medicare's "allowed" amount for this service is $3,800
  • Medicare pays 80% of the allowed amount, equalling $3,040
Example #1: Physician accepts Medicare assignment as payment in full
Covered charges (Medicare allowed amount)
$3,800
CAP Plan benefit
$3,800
Medicare pays 80% of allowed amount
$3,040
CAP Plan pays
$760
Total paid to physician
(physician agrees to accept $3,800 as payment in full)
$3,800
You pay
$0
Example #2: Physician does not accept Medicare assignment as payment in full
Physician's billed charges for service
(up to 115% of Medicare allowed amount)
$4,370
Covered charges (Medicare's allowed amount)
$3,800
CAP Plan benefit
$3,800
Medicare pays 80% of allowed amount
$3,040
CAP Plan pays
$760
Total paid to physician
$3,800
You pay
$570
Note: When the physician does not accept Medicare assignment as payment in full, you are responsible for the difference between the physician's billed charges (up to 115% of Medicare's allowed amount) and Medicare's allowed amount. If the physician bills more than 115% of Medicare's allowed amount, that amount is considered a provider write-off.
How the ROP Integrates With Medicare: Two Examples
The examples below assume that:
  • You have paid your annual deductible for Medicare Part B, and you have met your calendar year deductible on the ROP Plan
  • Your annual out of pocket maximum has been met
  • The ROP Plan benefit for surgical expenses is 70%
  • Physician's billed charges for surgical procedure are $4,370
  • Medicare's "allowed" amount for this service is $3,800
  • Medicare pays 80% of the allowed amount, equaling $3,040
Note: Since the Plan pays the difference between the amount Medicare pays and the amount the Plan would pay absent Medicare, the ROP Plan does not pay a benefit until the annual out of pocket maximum has been met. The annual out of pocket maximum on the ROP Plan is $4,000/individual up to $8,000/family per calendar year, including the calendar year deductible.
Example #1: Physician accepts Medicare assignment as payment in full. Member's annual out of pocket maximum has been met.
Covered charges (Medicare allowed amount)
$3,800
ROP Plan benefit
(100% of the allowed amount since the member's out-of-pocket maximum has been met)
$3,800
Medicare pays 80% of allowed amount
$3,040
ROP Plan pays
$760
Total paid to physician
(physician agrees to accept $3,800 as payment in full)
$3,800
You pay
$0
Example #2: Physician does not accept Medicare assignment as payment in full. Member's annual out of pocket maximum has been met.
Physician's billed charges for service
(up to 115% of Medicare allowed amount)
$4,370
Covered charges (Medicare's allowed amount)
$3,800
ROP Plan benefit
(pays 100% of the covered charges since the member's out of pocket maximum has been met)
$3,800
Medicare pays 80% of allowed amount
$3,040
ROP Plan pays
$ 760
Total paid to physician
$3,800
You pay
$570
Note: When the physician does not accept Medicare assignment as payment in full, you are responsible for the difference between the physician's billed charges (up to 115% of Medicare's allowed amount) and Medicare's allowed amount. If the physician bills more than 115% of Medicare's allowed amount, that amount is considered a provider write-off.
How the MSP Integrates With Medicare: Two Examples
The following examples assume that:
  • You have paid your annual deductible for Medicare Part B
  • The MSP Plan benefit for surgical expenses is 80%
  • Physician's billed charges for surgical procedure are $4,370
  • Medicare's "allowed" amount for this service is $3,800
  • Medicare pays 80% of the allowed amount, equaling $3,040
Note: If you are enrolled in the PG&E MSP Plan, your medical plan coverage is a supplement to Medicare. For example, if Medicare pays 80% of the allowed charges for covered services, the MSP will pay 80% of the 20% Medicare did not pay.
Example #1: Physician accepts Medicare assignment as payment in full
Covered charges (Medicare allowed amount)
$3,800
MSP Plan benefit
$3,800
Medicare pays 80% of allowed amount
$3,040
MSP pays
(80% of the 20% Medicare did not pay)
$608
Total paid to physician
(physician agrees to accept $3,800 as payment in full)
$3,648
You pay
$152
Example #2: Physician does not accept Medicare assignment as payment in full
Physician's billed charges for service
(up to 115% of Medicare allowed amount)
$ 4,370
Covered charges (Medicare's allowed amount)
$ 3,800
MSP Plan benefit
$ 3,800
Medicare pays 80% of allowed amount
$ 3,040
MSP Plan pays
(80% of the 20% Medicare did not pay)
$608
Total paid to physician
$3,648
You pay
$722
When the physician does not accept Medicare assignment as payment in full, you are responsible for the difference between the physician's billed charges (up to 115% of Medicare's allowed amount) and Medicare's allowed amount. If the physician bills more than 115% of Medicare's allowed amount, that amount is considered a provider write-off.
Medicare Coordination of Benefits (COB) HMO Plans
The Company sponsors two HMOs that use the Medicare Coordination of Benefits (COB) method for interacting with Medicare. These two Medicare HMO plans are the Blue Shield Medicare Coordination of Benefits HMO and the Health Net Medicare Coordination of Benefits HMO. Eligibility for a particular HMO is based on your home address, and HMOs are not offered in all areas. The Company also sponsors a Health Net Medicare Advantage HMO called Health Net Seniority Plus that is described in the next subsection.
This type of plan provides medical care through the HMO's network of physicians and hospitals, and you pay designated copayments for services that you receive from the HMO. In general, the HMO will coordinate all payments with Medicare, and you will not be responsible for any additional payments beyond the designated copayments. You may also receive medical care from providers outside of the HMO and receive Medicare's standard level of reimbursement.
Enrollment in a Medicare COB HMO plan requires members to be enrolled in Medicare Parts A and B. By enrolling in one of these plans, you will also be enrolling in the HMO's Medicare Part D prescription drug coverage. The Part D coverage is considered an "enhanced" Part D plan. This means the Plan has better benefits than the standard Medicare Part D, without any deductibles or gaps in coverage. The Medicare COB HMO plans require new enrollees to complete enrollment applications. If you are enrolled in a Medicare COB HMO and wish to change plans or drop coverage at some future date, you will need to fill out a form to disenroll from the plan's Part D coverage. Call the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time) for information and/or the appropriate form.
For more information about HMOs, see the "Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)" subsection in this subsection. For summary information about each HMO's benefits for Medicare-eligible members, see the charts in the Medicare HMOs section.
Medicare Advantage HMOs
The Company sponsors the following HMOs that are Medicare Advantage HMO plans: Health Net Seniority Plus and Kaiser Senior Advantage (North and South). Eligibility for each particular HMO is based on your home address, and Medicare Advantage HMOs are not offered in all areas.
A Medicare Advantage HMO operates like a Medicare COB HMO plan, except it only allows you to seek coverage through the Medicare HMO's network of physicians and hospitals and requires that you assign or "give away" your Medicare benefits to the HMO. By doing so, you can no longer use your Medicare benefits outside of the Medicare Advantage HMO network. However, the premiums for Medicare Advantage HMO plans are typically lower than those of Medicare COB HMOs.
If you enroll in a Medicare Advantage HMO, you will automatically be enrolled in the Medicare HMO's Part D prescription drug coverage, which is included as part of the Medicare Advantage Plan's benefits.
The Part D coverage is considered an "enhanced" Part D plan. This means the Plan has better benefits than the standard Medicare Part D, without any deductibles or gaps in coverage. The Medicare Advantage HMO plans require new enrollees to complete enrollment applications.
If you wish to change plans or drop Company-sponsored medical plan coverage at some future date, you will need to fill out a Medicare Disenrollment Form so that the Medicare Advantage Plan can release your Medicare benefits back to you. Call the PG&E Benefits Service Center for more information and/or the appropriate form.
For more information about HMOs, see "Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)" in this subsection.