Mandatory Changes at 65
For members covered under the LAFRA medical insurance, it's important to note that upon reaching the age of 65, there are adjustments made in premiums and dues, and it is mandatory to sign up for Medicare, otherwise your coverage under the LAFRA PPO Medical Plan will be terminated on the first day of the month in which you turn 65.
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If you have qualified for eligibility in Part “A” and Part “B” of Medicare you must enroll in both Part “A” and Part “B” in order to maintain eligibility for supplemental coverage under this Plan.
For Persons Enrolled in Part “A” and “B” of Medicare
The Plan will pay the inpatient Hospital deductible and coinsurance during the periods of extended confinement in which you or your eligible Dependent is receiving Medicare Part “A” benefits. The Plan will reimburse the Part “B” deductible amount and pay 20% of the charges allowed by Medicare plus 80% of any unpaid balance, but not an amount that would exceed that which the Plan would pay in the absence of other insurance.
For Persons Enrolled in Part “B” of Medicare
The Plan will pay the current Hospital benefits, less laboratory and x-ray charges covered under Part “B.” The Plan will reimburse the Part “B” deductible amount and pay 20% of the charges allowed by Medicare plus 80% of any unpaid balance, but not an amount that would exceed that which the Plan would pay it the absence of other insurance.
Payment of Claims
You, your eligible Dependent, the Physician or Hospital must submit all expenses to Medicare for payment. A request for payment form is included with your Medicare handbook or you may obtain the forms from your local Social Security office.
In order to be reimbursed by the medical Plan, you, your eligible Dependent, the Physician or Hospital must submit the “Explanation of Medicare Benefits” voucher and an itemized bill to the medical Plan. You may indicate on the voucher if you wish the reimbursement check to be issued to you, the Physician or to the Hospital. No vouchers will be returned. Please keep a copy of the voucher, for your records, before you mail it.
A $10 PPO co-pay or a $20 Non-PPO co-pay will be assessed for charges made by a Provider at any time that the Plan is reimbursing in the absence of payment by a primary payor.