Glossary

Health care words can sometimes be confusing. Here are some definitions to help you understand common health care words. If you are an L.A. Care member and would like more help in understanding these words, please call us. We will be happy to explain them to you.

Access
Your ability as a patient to get medical care.

Acetaminophen
The generic name for the pain reliever commonly known as Tylenol.

Applicant
A person who is applying for health care benefits to cover themselves, or to cover other family members such as a child that he/she is responsible for.

Authorization
An approval to receive health care benefits.

Beneficiary
A person who receives health care benefits.

Benefits
The health services and medicines paid for by your health plan. Also known as a benefit package, plan benefit, or covered service.

Benefit Levels
The amount of services you are allowed to receive, based on your contract with the health plan.

Benefit Year
Twelve (12) month period beginning each year on July 1 at 12:01 am.

Billed Claims
Costs or charges that are sent to a health plan or insurer from a provider. In order for providers to receive payment for the services they provide, providers must submit a claim to the health plan or insurer.

Brand Name Medicine
Medication that is protected by a patent, and can only be made by one company. Generic substitutes that cost less and are equally effective, are sometimes available for these medications.

California Children Services (CCS)
Open to Healthy Families Program members under the age of 19 who have a handicapping condition that is covered by CCS. L.A. Care Participating Providers refer eligible members to the local CCS program when medically necessary. Members who receive certain covered services through CCS will continue to receive the rest of their covered services through L.A. Care Participating Providers. Your Primary Care Physician will continue to provide all your primary care services and referrals for specialty care and hospitals when you need them. For information on CCS, call the Los Angeles County CCS Program at (626) 858-2100.

Civil Rights Act, 1964 (Title VI)
This law states that "No person in the United States shall, on grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." This means that it is illegal for any person or organization to discriminate against you on the basis of your ethnic background or birthplace.

Complaint
Members or doctors may make a complaint when there is a disagreement about services, billing, or general procedure.

Copayment (Healthy Families)
A pre-determined charge you pay for each health care visit or service you use, usually collected at the time you get the service.

Covered Health Care Services
The health services and medicines paid for by your health plan. Covered health care services are also called a benefit package, plan benefit, covered service, or plan benefits.

Department of Health Services (DHS)
California state agency that is dedicated to protecting and improving the health of all Californians.

Disability
A physical or mental injury, illness, or condition that completely or seriously limits your ability to do the activities of daily living.

Disenrollment
When a member leaves L.A. Care Health Plan and any of its Plan Partners for any reason.

Drug Formulary
L.A. Care uses a drug formulary or list of approved drugs that have been chosen for their safety and effectiveness. Your doctor should normally order drugs from the approved list. The Medi-Cal formulary lists the drugs that are paid for by the Medi-Cal program.

Durable Medical Equipment (DME)
Medical equipment that can be used again and again over time. Examples include oxygen and oxygen equipment, blood glucose monitors, wheel chairs, and insulin pumps.

Emergency Services
The immediate care that is necessary when you have a condition, illness, or injury that could lead to death or serious problems if not treated.

Enrollee
A person who has joined L.A. Care.

Experimental or Investigational
Medical services that show promise in treating certain conditions, but have not been approved by the Food and Drug Administration.

Evidence of Coverage and Disclosure Statement
A book that tells you what services are covered or not covered, and how to use your L.A. Care Health Plan.

Family Planning Services
Advice and planning to help you determine the number of children you want, and when you want to have them. Birth control is an important part of family planning.

Family Premium (Healthy Families)
The monthly family contribution that is made to help pay for health care coverage.

Federally Qualified Health Centers (FQHCs)
Health centers located in areas where there may not be enough qualified physicians to serve all the local residents. These centers may be partially funded by a government grant.

Generic Medicine
A medication that has the same ingredients as a brand name medicine but may have a different name. Generic medications often cost less that brand name medicines.

Grievance
If you have a problem with your quality of care, method of receiving care, or other issues, you may file a grievance in writing.

Health Care Options
The company that helps Medi-Cal beneficiaries enroll or disenroll in a managed care health plan. You can call them at 1 (800) 430-4263.

Health Care Services
All of the following are health care services:
- doctor services
- hospital inpatient services
- outpatient services
- diagnostic laboratory services
- radiological services for either diagnosis or treatment
- home health services
- preventive health services
- emergency health care services

Healthy Families Program
A health coverage program that provides low cost health, dental, and vision coverage for kids.

Eligibility Requirements
The guidelines that must be met before you can enroll in a health plan.

Hospice Care
Care and services provided in a home or facility by a licensed or certified provider that are:
(1) Designed to provide care and support to individuals who have a terminal illness;
(2) Directed and coordinated by medical professionals; and
(3) Pre-authorized by L.A. Care.

Hospital
A place you can get inpatient and outpatient care from doctors or nurses.

Inpatient Care
Services provided to a patient who has been admitted to a hospital.

Interpreter
A person who can translate a conversation for people who do not speak the same language. An interpreter explains what each person says to the other, without changing the meaning.

L.A. Care Health Plan
A non-profit health maintenance organization (HMO) that participates in the Medi-Cal, Healthy Families and CaliforniaKids Programs.

Maintenance Drug
Any drug taken on a long-term basis to treat a chronic medical problem.

Managed Risk Medical Insurance Board (MRMIB)
The State agency that administers the Healthy Families Program.

Medi-Cal
A state and federal health insurance program that provides health care coverage to those with low incomes. Most Medi-Cal recipients in Los Angeles County are enrolled under Medi-Cal managed care. For Eligibility Requirements click here.

Medical Group
A physician group that your doctor or primary care physician (PCP) belongs to.

Medically Necessary
A medical procedure or treatment that is needed to treat a problem identified by your doctor.

Member
A person who has joined L.A. Care.

Member Services Department
Department at each L.A. Care office where L.A. Care employees can help you by answering questions and concerns. Contact Us.

Mental Health Services
Usually therapy, counseling or medical care provided by a psychiatrist, psychologist, licensed clinical social worker, or marriage, family and child counselor. Mental health services can include diagnosis or treatment of mental or emotional disorders, or the mental or emotional problems that can arise when you or a member of your family is ill.

Occupational Therapy
Treatment given under the direction of a physician, and provided by a certified occupational therapist using arts, crafts, or specific training in daily living skills. Occupational therapy is designed to improve and maintain your ability to function after an illness or injury.

Office of Civil Rights
The office that handles complaints about discrimination against people for any reason.

Orthotic
An orthopedic appliance or apparatus used to support, align, prevent or correct physical deformities, designed to improve your ability to move and function.

Outpatient
Medical treatment that may be provided in a doctor's office or in a hospital that does not involve an overnight stay.

Participating Hospital
A licensed hospital that has a contract agreement with L.A. Care to provide covered services to healthplan members.

Participating Provider
A physician, hospital, pharmacy, or other provider that has a contract to provide covered services to L.A. Care Members.

Participating Specialist or Specialist Physician
A doctor who is not your Primary Care Physician (PCP), who provides covered services to you when your PCP refers you to the specialist for care.

Physical Therapy
Treatment provided under the direction of a physician, by a registered physical therapist. Physical therapy uses treatments such as ultrasound, heat and massage, to reduce pain and improve the function of your muscles or bones, or to improve the function of your respiratory system.

Physician
A medical doctor

Plan Benefits The health services and medicines that are paid for by your health plan. Also known as a benefit package, plan benefit, or covered service.

Plan Partners (Medi-Cal)
Health plans that work with L.A. Care to provide health care services to Medi-Cal beneficiaries. The five plans include Blue Cross of California, Care1st Health Plan, Community Health Plan (CHP), Kaiser Permanente, and UHP Health Care.

Prosthesis
An appliance or device used to replace a missing part of the body.

Providers
Any individual or facility that provides covered health care services to you.

Primary Care Physician (PCP)
The doctor you choose to give you most of your health care.

Provider Directory
A list of providers who have agreed to provide health care services to L.A. Care members.

Referral
The process through which your primary care physician helps you to get health care from other providers. A referral must be authorized by L.A. Care.

Regional Community Advisory Committees (RCAC)
RCACs are made up of L.A. Care members, advocates, doctors and other health care providers. They give advice to L.A. Care Health Plan on how best to serve health plan members and their communities. The RCACs meet once a month to share ideas and concerns.

Second Opinion
A consultation with another doctor about a specific health concern. You may get a second opinion when you do not agree with recommendations made by your PCP.

Service Area
The geographic area covered by L.A. Care, which includes Los Angeles County, excluding Catalina Island.

Skilled Nursing Facility
A facility licensed by the California State Department of Health Services to provide skilled nursing services. You may be sent to a Skilled Nursing Facilities if your condition is serious, but does not need hospitalization.

Speech Therapy Treatment
Speech therapy, directed by your physician, is provided by a licensed speech pathologist or speech therapist to treat speech-related problems that are caused by a disease or injury.

Subscriber
A person who is eligible for and has enrolled in L.A. Care, whose premium has been paid to L.A. Care. Also known as a "Member".

Transfer
When you change your PCP or Plan Partner.

Tylenol
A common pain reliever available in all drug stores. The generic name is acetaminophen.

Urgent Services
Covered services provided to treat a medical or mental condition that could become an emergency if not diagnosed and/or treated in a timely manner.