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Medical Services – Glossary

MS Manual 07/01/2025

plan of care is ONLY good for 60 days. If it expires, the assessment must be redone to re- determine need and/or establish eligibility date for ALF. Qualified Alien – An alien lawfully admitted and lawfully given the privilege of residing permanently in the United States. Qualified Entities (QE) – Designated agencies along with the Department of Human Services (DHS) that determine eligibility for the Presumptive Eligibility-Pregnant Woman category. Agencies outside of DHS must be approved and trained by the Department of Human Services. Recipient – Someone enrolled in Medicaid who actually received a health service for which Medicaid reimbursed the provider. Renewal – A periodic review of an approved Medicaid case to determine continued eligibility. Serious Mental Illness or Disorder – Schizophrenia, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; or other psychotic disorder. Skilled Level of Care – Services required on a 24 hour a day basis, delivered by licensed medical personnel in accordance with a medical care plan requiring a continuing assessment of needs and monitoring of response to plan of care. The services must be reasonable and necessary to the treatment of the individual’s illness or injury, i.e., be consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, accepted standards of medical practice, and in terms of duration and amount. Spend Down (SD) – The amount of money a beneficiary must pay towards medical expenses when income exceeds the Medicaid financial guidelines. A component of the medically needed program allows an individual or family whose income is over the Medically Needy Income Limit (MNIL) to use medical bills to spend excess income down to the MNIL. Substantial Gainful Activity – The performance of significant physical and/or mental work activities for pay, or profit or work activities generally performed for pay or profit.

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