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Medicare Glossary E - H from Humana
Understand Common Medicare Phrases
ELECTION PERIOD
The time when an eligible individual can choose a Medicare plan through a private insurer or Original Medicare.
ELIGIBILITY/MEDICAID
Refers to the process where the state decides a person is qualified for healthcare coverage through the Medicaid program.
ELIGIBILITY: MEDICARE PART A
You are eligible for Medicare Part A – Medicare’s hospital insurance – with no premium if:
- You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retirement Board
- You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements
- You or your spouse had Medicare-covered government employment
- You are under 65 and have End-Stage Renal Disease (ESRD)
If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if:
- You are age 65 or older and
- You are enrolled in Part B and
- You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the five years immediately before the month in which you enroll
ELIGIBILITY: MEDICARE PART B
You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the five years immediately before the month during which you enroll in Part B.
EMERGENCY CARE
Care given for a medical situation where you believe your health is in serious danger.
EMERGENCY ROOM (Hospital)
A portion of the hospital where emergency diagnosis and treatment of illness or injury is provided.
END-STAGE RENAL DISEASE (ESRD)
Permanent kidney failure requiring dialysis or a kidney transplant.
ENROLLMENT PERIOD
A certain range of days when you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.
ESTIMATED RETAIL PRICE
Average cost of a drug on the “open market.” This price is calculated from a national average wholesale price and does not take into account a prescription drug benefit, the actual cost of a specific drug, mail-order savings, or possible reimbursements to the dispensing pharmacy. Pricing may vary by pharmacy and by the specific quantity, strength, and dosage of the medication. Contact your pharmacy for details on pricing. Because retail pricing is subject to change, you may not know your actual cost until you fill the prescription.
EVIDENCE OF COVERAGE
A complete list of your benefits under a Medicare Advantage plan.
EXCLUSIONS
Items or services a health plan doesn’t cover, such as long-term care and custodial care in a nursing or private home.
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F
FEDERAL EMPLOYEE HEALTH BENEFITS
A benefits program for Federal employees, retirees and their survivors. Contact the U.S. Office of Personnel Management if you have questions about your Federal Employee Health Benefits
FORM
The way a medication is administered – for instance, a tablet or vial.
FORMULARY
A list of medications your plan covers – also known as a Drug List. Humana’s Medicare Drug List shows which drugs are covered and which drug tier they’re in – Preferred Generic, Preferred Brand, Non-Preferred Brand, or Specialty. See the definition for drug tier.
FREESTANDING RADIOLOGY FACILITY
A healthcare facility – usually in a building separate from a hospital or operating independently of a hospital – that provides certain imaging studies to help detect or diagnose a medical problem. Tests available may include scans such as MRI, CAT, and PET, as well as ultrasound and X-ray studies. Test results are interpreted by Board-certified radiologists and reported to the referring physician.
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G
GENERAL ENROLLMENT PERIOD (GEP)
January 1 through March 31 of each year. If you enroll in Medicare Part A or Part B during the General Enrollment Period, your coverage starts on July 1.
GRIEVANCE
A complaint about the way your healthcare provider is giving care. For example, you may file a grievance if you have a problem with the cleanliness of the healthcare facility, problems calling the plan, staff behavior, or operating hours. A complaint about a treatment or coverage decision should be filed as an appeal. See the definition for appeal.
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H
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (HIPAA)
Also sometimes called the “Kassebaum-Kennedy” law, HIPAA expands your healthcare coverage if you lose your job or if you move from one job to another. HIPAA protects you if you have pre-existing medical conditions or you have a problem getting health coverage and believe the problem is because of your past or present health. HIPAA also:
- Limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage
- Usually gives you credit for health coverage you have had in the past
- May give you special help with group health coverage when you lose coverage or have a new dependent
- In general, guarantees your right to renew your health coverage
HIPAA does not replace the states’ roles as primary regulators of insurance.
HEALTH MAINTENANCE ORGANIZATION (HMO)
A type of health plan that requires you to choose a primary care physician (PCP) to tend to most of your health needs. An HMO plan covers only the services you receive from in-network providers. With an HMO, your out-of-pocket costs are generally lower than with a Preferred Provider Organization (PPO) or Private Fee-for-Service (PFFS) plan, so it’s easier to predict your share of healthcare expenses. Costs and services vary by plan. Get more information on Humana Gold Plus HMO plans.
HMO PLAN
See the definition for Health Maintenance Organization (HMO).
HOME HEALTHCARE
Skilled nursing care and certain other healthcare you get in your home for the treatment of an illness or injury.
HOSPICE
A special way of caring for people who are terminally ill. Hospice care includes physical care for the patient, as well as counseling for the patient and his or her family. Hospice care is covered under Medicare Part A.
HOSPITAL
An institution that meets all of the following requirements:
- It must provide, for a fee, medical care and treatment of sick or injured persons on an inpatient basis
- It must provide or operate – either on its premises or in other prearranged facilities – medical, diagnostic, and major surgical facilities
- Care and treatment must be given or supervised by physicians
- Nursing services must be provided on a 24-hour basis and must be given by or supervised by graduate registered nurses
- It must be licensed by the laws of the jurisdiction where it is located and must run as a hospital as defined by those laws
- It must be primarily a:
- Convalescent, rest, or nursing home
- Facility providing custodial, educational, or rehabilitative care
- Facility for drug abusers or alcoholics
The term “hospital” also includes licensed psychiatric hospitals that are properly accredited to provide psychiatric, diagnostic, and therapeutic services for the treatment of patients who have mental illnesses. In addition, if services specifically for the treatment of a physical disability are provided in a licensed hospital, benefits will not be denied solely because that hospital is primarily of a rehabilitative nature and lacks major surgical facilities. However, the hospital must be accredited by one of the following:
- The Joint Commission on Accreditation of Healthcare Organizations
- The American Osteopathic Hospital Association
- The Commission on the Accreditation of Rehabilitative Facilities
HOSPITAL INSURANCE (PART A)
The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.
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