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Anthem Medicare Life and Health Medicare Plan: A Medicare Supplement PPO plan offered by Anthem Blue Cross and available to Retired Members with Medicare Parts A and B.

Beneficiary: Any person or legal entity (such as a living trust) receiving or entitled to receive a benefit provided by LACERS in the event of the Member’s death.

Carrier: A health insurance organization (medical or dental) that LACERS has contracted with to provide health insurance to Retired Members.

Centers for Medicare & Medicaid Services (CMS): The federal agency that administers the Medicare program. CMS works in partnership with the states to administer Medicaid, the State Children’s Health Insurance Program (SCHIP) and health insurance portability standards.

City Service: Only those periods during which you were a Member of LACERS and 1) received compensation from the City as an employee or 2) received temporary disability Workers’ Compensation benefits and paid contributions to the Plan.

City Service Credit: The component of your benefit calculation based on your hours worked. Full-time employees receive 0.03835 years of City Service Credit per pay period. The Service Credit for part-time employees will be prorated for each pay period.

Claim: A plan participant’s request to a benefit plan or insurer for the payment of certain benefits.

CMS: See Centers for Medicare & Medicaid Services.

COBRA: See Consolidated Omnibus Budget Reconciliation Act of 1986.

Co-Insurance: The percentage of the approved cost of a medical/dental service that you have to pay after meeting the deductible. When seeking out-of-network care, you may have to pay any amount charged above the approved cost of the service as well.

Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA ): COBRA provides certain former employees, Retired Members, spouses, former spouses and dependent children the right to temporary continuation of health coverage at the group premium rate plus an administrative fee.

Continuance: A lifetime monthly benefit provided to a qualified beneficiary as a result of the death of a Retired Member.

Copayment (Copay): The predetermined (flat) fee that an individual pays for certain health care services.

Deductible: The amount an individual must pay for health care expenses before insurance covers costs. PPO health plans usually have calendar-year deductible amounts.

Deduction: An amount taken from a Member’s monthly retirement allowance to cover the difference between the plan premium and the Member’s available subsidy.

Dependent: A spouse, domestic partner or eligible child or grandchild enrolled in the Member’s LACERS health plan.

Dual Care: A LACERS medical insurance option available to Members whose households consist of at least one enrollee (Member or dependent) covered by both Medicare Parts A and B, and another person who is either under age 65 or at least age 65 with Medicare Part B only.

Formulary: A listing of prescription medications that is covered by a medical plan.

Full-Time Student: A person who is attending a recognized educational institution and primarily supported by a Retired Member. Full-time is defined by the institution.

Generic Drug: Chemically equivalent copy of a brand-name drug whose patent is expired. Generic drugs typically are less expensive and sold under the common name for the drug, not the brand name.

Health Maintenance Organization (HMO): A prepaid medical group practice plan that provides a comprehensive predetermined medical care benefit package. HMOs are both insurers and providers of health care.

Maximum Out-of-Pocket Payment: The largest amount of money a person will pay annually in addition to premium payments and their insurance plan’s deductible. The out-of-pocket payment is usually the sum of co-insurance payments made by an enrollee.

Medical Premium Reimbursement Program (MPRP):  A LACERS program that reimburses Members who have non-LACERS medical plans for their plan premiums up to the amount of their subsidy eligibility. These Members must live outside California or reside outside of a LACERS HMO zip code service area.

Member: A LACERS Retired Member or an eligible Survivor.

MPRP: See Medical Premium Reimbursement Program.

Network: A defined group of providers who have contracted with a health insurance company to supply a full range of primary and acute health care services.

PCP: See Primary Care Physician.

Power of Attorney (POA): Power to act for another; the legal authority to act for another person in legal and business matters.

PPO: See Preferred Provider Organization.

Preferred Provider Organization (PPO): Group of hospitals and physicians that contract on a fee-for-service basis with employees, insurance companies or third party administrators to provide comprehensive medical coverage. Using in-network services allows more of an individual’s costs to be covered. An individual can go out-of-network to receive care, but
usually at a higher cost.

Premium: The monthly cost of insurance coverage for a LACERS Retired Member and any dependents.

Primary Care Physician (PCP): A health care provider in a managed care plan responsible for coordinating all care for an individual patient, including providing direct care services and referring the patient to a specialist and hospital care.

Reasonable and Customary (R & C) Fee: Average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the maximum amount of money they will approve for a specific test or procedure. When out-of-network fees are higher than the R & C amount, the individual receiving the service is responsible for paying the difference.

Retired Member: A person retired from LACERS on either a service or a disability pension.

Senior Plan: A medical insurance plan that coordinates with Medicare Parts A, B, and D.

Subsidy: A benefit for eligible LACERS Retired Members and their eligible Surviving Spouses/Domestic Partners that assists with the cost of health insurance. It is applied toward the cost of the Member’s monthly premium. Only Retired Members may be eligible for dental subsidies (NOT dependents or eligible Surviving Spouses/Domestic Partners).

Survivor: An eligible surviving spouse or domestic partner of a LACERS Member who is eligible for a Continuance or Survivorship benefit from LACERS.

UCR: Usual and Customary Rates. See Reasonable and Customary (R & C) Fee.