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Medicare Glossary Q - T from Humana
Understand Frequently Used Medicare Keywords
QUANTITY
The drug amount your doctor prescribes – for example, 30 tablets.
QUANTITY LIMIT
Appears on: Rx Calculator
Definition: A limit on coverage based on the length of time or amount that can be dispensed for this medication to ensure the appropriate dose and usage based on the FDA label recommendations.
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REFERRAL
A written OK from your primary care physician for you to see a specialist or to receive certain services.
RESPITE CARE
Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so the usual caregiver can rest or take some time off.
ROUTINE PHYSICAL EXAM
A type of doctor’s office visit that may include:
- Discussing your lifestyle – diet, stress level, exercise, etc.
- Reviewing your medical and family health history
- Performing a system examination – heart, lungs, throat, thyroid, ears, skin, joints, etc.
- Measuring your height, weight, blood pressure, and pulse
The exam could also include lab studies and other tests or screenings appropriate for your age and gender, such as a mammogram or prostate specific antigen blood test, an electrocardiogram (EKG), and immunizations.
ROOM AND BOARD
All the services a facility provides on its own behalf, including room, meals, and all general services and activities needed for the care of inpatients.
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SERVICE AREA
The geographic area where a health plan accepts members. For Medicare plans that require you to use in-network doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan’s service area.
SKILLED CARE
A type of healthcare given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.
SKILLED NURSING CARE
A level of care that must be given or supervised by Registered Nurses – for example, intravenous injections, tube feeding, oxygen to help you breathe, and changing sterile dressings on a wound. Any service that could be done safely by an average non-medical person without the supervision of a Registered Nurse is not considered skilled care.
SKILLED NURSING FACILITY (SNF)
A facility that meets specific regulatory certification requirements and primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital. A skilled nursing facility is an institution that meets all of the following requirements:
- It must primarily and continuously provide, for a fee, skilled nursing care and related services to persons recovering from an injury or sickness. Such care must be provided on an inpatient basis
- It must provide 24-hour-a-day nursing services by or under the supervision of graduate Registered Nurses.
- It must maintain a daily medical record of each inpatient
- It must provide each patient with a planned program of medical care and treatment by or under the supervision of a physician
- It must be approved as a skilled nursing facility under the Medicare program or be qualified to receive such approval if requested
SPECIAL CIRCUMSTANCES
Situations that, according to the Centers for Medicare & Medicaid Services, allow a person to make a coverage change. These special circumstances include, but are not limited to:
- Making a permanent move to a new Medicare Advantage plan or prescription drug plan service area
- Enrollment into or out of an employer group health plan sponsored by a Medicare Advantage plan
- Medicare entitlement is made retroactive
- Individual is dually eligible for both Medicare and Medicaid benefits
- Loss of creditable prescription drug coverage
SPECIAL ELECTION PERIOD
A set time that a beneficiary can change Medicare plans or return to Original Medicare. Examples of special election situations are:
- You move outside the service area
- Your Medicare Advantage Organization violates its contract with you
- The organization does not renew its contract with CMS
Other exceptional conditions may exist, as determined by CMS.
SPECIAL ENROLLMENT PERIOD (SEP)
A set time when you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period because you or your spouse were employed and had group health plan coverage through the employer or union. You can sign up at any time you are covered under the group plan. You have eight months from the time employment or group coverage ends to sign up. The eight-month SEP starts the month after the employment ends or the group health coverage ends, whichever comes first.
SPECIALIST
A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.
SPECIALTY DRUG
Highest cost drugs, including high technology and self-administered injectable medications.
SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB)
A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
SUMMARY OF BENEFITS
A brief description or outline of your coverage, including the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.
SUPPLIER
Generally, any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.
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TERMS AND CONDITIONS OF PAYMENT (PFFS Plans)
Any Medicare doctor, specialist, or hospital that accepts Medicare payment and accepts the terms, conditions and payment rate of the Humana Gold Choice PFFS plan.
An Insurance Company with a Medicare Advantage contract to offer a Private Fee-for-Service plan available to anyone enrolled in both Part A and Part B of Medicare through age or disability. Enrollment period restrictions apply, call Humana for details. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan's terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Website at www.humana-medicare.com/humana-gold-choice-terms-conditions.asp.
THERAPEUTIC ALTERNATIVE
Drugs that aren’t exactly the same as another drug, but can serve as a substitution with the full expectation that they will produce the same clinical effect and safety profile as the prescribed product.
TRANSLATOR
Someone who translates the enrollment documentation to the enrollee and who is fully competent in both English and the enrollee’s native language.
TRICARE
TRICARE is the Department of Defense’s worldwide healthcare program for active duty and retired uniformed services members and their families. TRICARE For Life is available for all dual TRICARE-Medicare-eligible uniformed services retirees and Medicare-eligible family members under age 65 who are also entitled to Medicare Part A because of a disability or chronic renal disease.
TOTALLY DISABLED
When, because of injury or sickness, you aren’t able to perform your occupation or any occupation for which you are fit by reason of education, training, or experience.
TREATMENT
Something done to help with a health problem – for example, medicine or surgery.
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