How HMOs and the Kaiser EPO Work
Retirees and Surviving Dependents Under Kaiser EPO Effective 1/1/2013
Beginning January 1, 2013, Kaiser benefits for retirees and surviving dependents who are not on Medicare will be administered under a Kaiser Exclusive Provider Organization (EPO) arrangement. The Kaiser EPO plan for non-Medicare members is a PG&E self-insured plan and is not an HMO.
The Health Maintenance Organizations (HMOs) and the Kaiser Exclusive Provider Organization (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, HMO members will 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 plan'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 Prescription Drug Coverage, Mental Health and Substance Abuse Coverage, Health Care Participation and the Rules, Regulations & Administrative Information sections.