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Health Glossary

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5 Star Centers - physician practices that 32BJ has partnered with to provide quality care to our members. There is a $0 copayment for services received at a 5 Star Center. Our 5 Star Centers are also NCQA Level 3 certified Patient Centered Medical Homes (PCMH). Click here to initiate a 5 Star Center search, or click here to view the 5 Star Center Interactive Google Map and 5 Star Center Maps (PDF).

5 Star Center Reps - a team of professionals who work very closely with their assigned 5 Star Center to make sure you get the help you need and address any issues you may have. 

Affordable Care Act (ACA) - the health reform legislation (sometimes called Obamacare) passed by Congress in 2010. Some of the reforms implemented by the Affordable Care Act include establishing Health Insurance Exchanges, or marketplaces, where individuals, families, and small businesses may purchase guaranteed issue qualified health insurance plans with affordable premiums.  Subsidies that reduce premiums and out of pocket costs are based on family income. For example, a family of four (4) qualifies for subsidies if they earn under $94,200. These plans satisfy the ACA’s individual mandate requiring those who don’t have health insurance buy a health insurance policy. 

Allowed Amount - the maximum the Fund will pay for a covered service. When you go in-network, the allowed amount is based on an agreement with the provider. When you go out-of-network, the allowed amount is based on the Fund’s payment rate of allowed charges to a network provider. 

Balance Billing - the practice of non-participating hospitals, clinics, doctors’ offices and other medical facilities billing patients for the balance between what they want to charge their patients for services and what the insurance company has already reimbursed them. 

Brand Name Drugs - are drugs that have a trade name and are protected by a patent. They are usually more expensive than generic drugs

Chronic Care Prescription Drug Discount Program (5 Star Wellness) - the Chronic Care Prescription Discount Program provides members and their eligible dependents with formulary brand and generic prescriptions with only a $5 co-payment for a 30-day supply or a $10 co-payment for a 90-day supply.  To be eligible for the Chronic Care Prescription Drug Discount Program, you must have one of the following diagnoses: asthma, diabetes, heart disease, chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD) hypertension, stroke, or high blood pressure. To participate in the program, all of your care must be coordinated by your primary care doctor at the 5 Star Center

Chronic Diseases - are long-lasting conditions that can be controlled but not cured. Examples of chronic conditions include: asthma, diabetes, heart disease, chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD) hypertension, stroke, or high blood pressure. 

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) - the Federal legislation allowing an employee or an employee's dependents to maintain group health insurance coverage through an employer's health insurance plan after the member leaves employment, at the individual's expense, for up to eighteen (18) months in certain circumstances.

Co-insurance - the percentage (30% or 50%) you pay toward eligible out-of-network medical expenses.

Co-pay or Co-payment - the flat-dollar fee you pay for office visits, hi-tech radiology, out-patient hospital visits, emergency room visits and hospital admissions and certain covered services (such as prescription drugs) when you use participating providers. The Plan then pays 100% of the remaining covered expenses.

Deductible - the dollar amount you must pay each calendar year before benefits become payable for covered out-of-network services.

Dependent - health insurance coverage extended to the spouse and eligible children of the primary insured member.  Children are covered up to age 26.

Drug Formulary - a list of prescription medications selected for coverage under the Plan. Drugs included on the drug formulary are based upon their efficacy, safety and cost-effectiveness.

Durable Medical Equipment (DME) - is medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, and prostheses.

Emergency - a condition whose symptoms are so serious that someone who is not a doctor, but who has average knowledge of health and medicine, could reasonably expect that, without immediate medical attention, the following would happen:

  • the patient’s health would be placed in serious jeopardy,
  • there would be serious problems with the patient’s body functions, organs or body parts,
  • there would be serious disfigurement, or
  • the patient or those around him or her would be placed in serious jeopardy, in the event of a behavioral health emergency,
  • severe chest pains, extensive bleeding and seizures are examples of emergency conditions.

Explanation of Benefits (EOB) - a document sent to you by the insurance company that details the health care services you received, the amount paid by the insurance company, and the amount you owe.

Freestanding Facility - a facility that is not part of a hospital, and in many cases the same type and level of care can be provided at a freestanding facility (i.e. radiology, laboratory) as a hospital outpatient department. Freestanding facilities do not have the $75 copay like hospital outpatient departments.

Generic Drugs - drugs that were once brand name drugs and have lost the patent protection or other exclusive rights and can now be copied for manufacture by other drug companies. They are always much less expensive than brand name drugs.

Health Care Exchange - the exchange is a government-regulated marketplace of insurance plans for sale with different tiers, or levels of coverage, offered to individuals without health care or to small companies.

HIPAA (Health Insurance Portability and Accountability Act of 1996) - legislation mandating specific privacy rules and practices for medical care providers and health insurance companies, designed to streamline the healthcare and insurance industries, and to protect the privacy and identity of healthcare consumers.

Hi-tech Radiology - employs the use of high technology imaging, including CAT, MRI, MRA and PET scans, and nuclear imaging, to both diagnose and treat disease visualized within the body. 

In-network Benefits - are benefits for covered services received from medical providers and suppliers who have contracted with the Fund or with the Fund’s benefit administrators, like Empire BlueCross BlueShield or Davis Vision. The providers and suppliers have agreed to provide services and supplies at a pre-negotiated rate. Services provided must fall within the scope of their individual professional licenses.

Inpatient - a term used to describe when a person is admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.

Lab/X-Ray - typically, lab/x-ray is any diagnostic lab test or diagnostic/therapeutic x-ray performed in support of basic health services.

Maintenance Drug - a prescribed drug intended for patients' ongoing or long-term use, for example, a drug used to treat high cholesterol.

Medically Necessary - as determined by the applicable third party administrator or the Fund, means services, supplies or equipment that satisfy all of the following criteria:

  • are provided by a doctor, hospital or other provider of health service,
  • are consistent with the symptoms or diagnosis and treatment of an illness or injury; or are preventive in nature, such as annual physical examinations, well-woman care, well-child care and immunizations, and are specified by the Plan as covered,
  • are not experimental or investigational, except as specified otherwise (refer to SPD),
  • meet the standard of good medical practice,
  • meet the medical and surgical appropriateness requirements established under the Plan’s administrators medical policy guidelines,
  • provide the most appropriate level and type of service that can be safely provided to the patient.
  • are not solely for the convenience of the patient, the family or the provider, and
  • are not primarily custodial.

The fact that a network provider may have prescribed, recommended or approved a service, supply or equipment does not, in itself, make it medically necessary.

Mental Health - a person’s medical condition associated with their psychological and emotional well-being.

Network - the same as in-network.

Nutritionista person who advises on matters of food and how nutrition impacts ones health.

Nurse Practitioner - an advanced practice nurse who is qualified to diagnose, treat, and prescribe medications within their specialty  without the direct supervision of a doctor. Many nurse practitioners serve as a patient’s primary care health provider.

Obamacare - officially called the Affordable Care Act, is a US law aimed at reforming the American health care system.

Out-of-network - provider/supplier means a doctor, other professional provider or durable medical equipment, home health care or home infusion supplier who is not in the Plan’s network for hospital, medical, mental health and substance abuse, pharmacy, vision or dental benefits. Out-of-network benefits are benefits for covered services provided by out-of-network providers and suppliers.

Outpatient Hospital Care - are services, medical procedures or tests that are done in a hospital-owned medical center without an overnight stay.  A $75 co-payment is charged for services provided in an outpatient hospital setting. Most of the services provided in an outpatient setting can be provided in an office or other medical setting like a Freestanding Facility that is not part of a hospital in which case office co-payments or no co-payment would be charged.

Participating Provider (or in-network provider) - a provider that has agreed to provide services, treatment and supplies at a pre-negotiated rate under the medical, hospital,  dental, prescription drug and vision plans.

Patient Centered Medical Homes (PCMH) - the medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It is a place where patients are treated with respect, dignity, and compassion, and enables strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

Primary Care - health care at a generalized rather than specialized level for people making an approach to a doctor or nurse for initial as well as ongoing treatment. 

Primary Care Physician (PCP) - a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The PCP is often referred to as one’s family doctor.

Specialist - a doctor who does not serve as a primary care physician, but who provides care specializing in a specific medical field, for example cardiology or orthopedics.  

Specialty Drugs- Specialty drugs are prescription medications that require special handling, administration or monitoring. These drugs are used to treat complex, chronic and often costly conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

Summary of Benefits and Coverage (SBC) - a chart that helps you understand your healthcare coverage and common healthcare terms. SBCs must be provided by all insurance companies and group health plans in a standard format and may only be different based on the specific benefits of each plan.

Summary of Material Modifications (SMM) - describes all the changes and/or clarifications that have been made to the Plan since the printing of the Plan’s current Summary Plan Description ("SPD").

Summary Plan Description (SPD) - is the main vehicle for communicating plan rights and obligations to participants and their beneficiaries. For the Health Fund, the SPD is the official plan document which determines the plan of benefits. To locate your current SPD, please use the What Are My Benefits tool.

What Are My Benefits - is an interactive tool created to give members the most up-to-date information about all their 32BJ benefits. 

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