CMS Guidance: Reporting Restricted-Benefits-Code in the T-MSIS Eligible File

Guidance History

Date	Description of Change
2/24/2020	Original Guidance Issued

Brief Issue Description

This guidance addresses the issues that are relevant to states when they report the RESTRICTED-BENEFITS-CODE (ELG097) data element in the T-MSIS Eligible file. It describes the challenges faced by states in the reporting process, provides instructions on how to report this code, and clarifies the logical relationships between RESTRICTED-BENEFITS-CODE and related data elements in the T-MSIS Eligible file, including DUAL-ELIGIBLE-CODE (ELG085), CHIP-CODE (ELG049), WAIVER-TYPE (ELG173), and MFP-ENROLLMENT-EFF-DATE (ELG155).

Background Discussion

The data element RESTRICTED-BENEFITS-CODE (ELG097) is in the ELIGIBILITY-DETERMINANTS-ELG00005 segment in the T-MSIS Eligible file. The field is intended to capture the scope of Medicaid benefits to which an individual is entitled. For analytic purposes, it is important to ensure that reporting to the RESTRICTED-BENEFITS-CODE is consistent and accurate, especially when users are trying to identify individuals entitled to Medicaid benefits that are not comprehensive.

There are three levels of Medicaid benefits:

Full-scope benefits, which means that the beneficiary is entitled to all mandatory benefits (such as inpatient and outpatient hospital, home health, and physician services, among others) and optional benefits (such as prescription drugs, dental services, and physical therapy) covered under the Medicaid state plan. Traditional Medicaid is an example of full-scope benefits.
Non-full-scope but comprehensive benefits, which means that the beneficiary is entitled to a restricted set of benefits relative to full-scope coverage, but that the coverage still meets the Minimum Essential Coverage (MEC) standard laid out in the Affordable Care Act (ACA).^[1] Examples of non-full-scope but comprehensive benefits include coverage of pregnancy-related Medicaid benefits^[2] and the medically needy program in many states.
Limited benefits (also referred to as restricted or partial benefits), which means that the beneficiary is entitled to only a restricted set of benefits that do not meet the MEC standard. Examples are benefit packages for family planning only, tuberculosis-related services only, or emergency-only services for non-qualified non-citizens.

Table 1 shows the valid values and descriptions for RESTRICTED-BENEFITS-CODE (ELG097) as currently specified in version 2.3 of the T-MSIS Data Dictionary. The table also shows forthcoming proposed changes to the valid values.

Table 1. RESTRICTED-BENEFITS-CODE (ELG097) valid values and descriptions, T-MSIS Data Dictionary v2.3 and planned valid values and descriptions

V2.3 Valid Value	V2.3 Valid Value Description	Proposed Change Type	Proposed Change Description
1	Individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits.	None	Not applicable
2	Individual is eligible for Medicaid or Medicaid-Expansion CHIP, but only entitled to restricted benefits based on alien status.	None	Not applicable
3	Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status (e.g., QMB, SLMB, QDWI, QI).	None	Not applicable
4	Individual is eligible for Medicaid or CHIP but only entitled to restricted benefits for pregnancy-related services.	Valid value description change	Individual is eligible for Medicaid or CHIP but is only entitled to restricted benefits for pregnancy-related services, including services that do and those that do not meet the Minimum Essential Coverage standard.
5	Individual is eligible for Medicaid or Medicaid-Expansion CHIP but, for reasons other than alien, dual-eligibility or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy or other criteria).	Valid value description change	Individual is eligible for Medicaid or Medicaid-Expansion CHIP, but for reasons other than alien, dual-eligibility, or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy, or other criteria) that meet the standard for Minimum Essential Coverage.
None	None	New valid value code (“E”)	E: Individual is eligible for Medicaid or Medicaid-Expansion CHIP, but for reasons other than alien, dual-eligibility, or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based on substance abuse, medically needy, or other criteria) that do not meet the standard for Minimum Essential Coverage.
6	Individual is eligible for Medicaid or Medicaid-Expansion CHIP but only entitled to restricted benefits for family planning services.	None	Not applicable
7	Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.	None	Not applicable
D	Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities.	None	Not applicable
A	Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005. PRTF grants assist States to help provide community alternatives to psychiatric resident treatment facilities for children.	Valid value description	Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005.
B	Individual is eligible for Medicaid and entitled to Medicaid benefits using a Health Opportunity Account (HOA).	None	Not applicable
C	Individual is eligible for separate CHIP dental coverage (supplemental dental wraparound benefit to employer-sponsored insurance).	None	Not applicable

QI = Qualifying Individual; QDWI = Qualified Disabled and Working Individual; QMB = Qualified Medicare Beneficiary; SLMB = Specific Low-Income Medicare Beneficiary

Challenges

Although the name of the data element refers to restricted benefits, the RESTRICTED-BENEFITS-CODE data element encompasses a broader scope of benefit options from full-scope to comprehensive to limited benefits. For example, the RESTRICTED-BENEFITS-CODE valid values below are typically included for the purpose of benchmarking to other sources that count comprehensive benefits, such as the Medicaid and CHIP Eligibility and Enrollment Performance Indicators.

1: Individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits
4: Individual is eligible for Medicaid or CHIP but only entitled to restricted benefits for pregnancy-related services
7: Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005
A: Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005.
B: Individual is eligible for Medicaid and entitled to Medicaid benefits using a Health Opportunity Account [HOA])^[3]
D: Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities)

The current set of values does not differentiate between the two groups of non-full-scope beneficiaries: those with MEC and those without MEC. For valid value 4, (Individual is eligible for Medicaid or CHIP but is only entitled to restricted benefits for pregnancy-related services), coverage is comprehensive in some states but not in others, which makes the data more challenging to use. All but three states provide comprehensive benefits to women eligible for Medicaid because they are pregnant, but the description of valid value 4 does not specify whether it is intended to capture the Medicaid beneficiaries whose benefits meet the MEC standard. For other restricted benefits, valid value 5 comprises a very wide array of programs that range from the most comprehensive to the most limited. The value indicates that an individual is eligible for Medicaid or Medicaid-Expansion CHIP but for reasons other than alien, dual-eligibility, or pregnancy-related status is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy or other criteria). Therefore, for every state, the data cannot be used to cleanly differentiate between two critical groups of beneficiaries not entitled to full-scope benefits: (1) those with comprehensive coverage and (2) those with limited (non-comprehensive) coverage. Similarly, the description for valid value 5 does not specify whether this group is intended to include medically needy beneficiaries whose benefits meet the MEC standard. Additionally, because group 5 is defined so broadly, states may vary substantially in the types of beneficiaries they are placing in this category.

States have also been inconsistent in their reporting of RESTRICTED-BENEFITS-CODE for their CHIP beneficiaries. In some cases, they have left the code blank for CHIP beneficiaries, but in other cases, states have been reporting CHIP beneficiaries as having restricted benefits because they perceive the CHIP package of benefits as limited compared with full-scope Medicaid benefits.

The proposed changes to the RESTRICTED-BENEFITS-CODE data element in the T-MSIS Data Dictionary and summarized in Table 1 are designed to address the challenges above.

CMS Guidance

When reporting to RESTRICTED-BENEFITS-CODE, states should refer to the guidance in this section for additional clarification on how to interpret each of the valid values for this data element. In addition, the guidance includes information on the logical relationships between RESTRICTED-BENEFITS-CODE and other data elements in the T-MSIS Eligible file.

Full Scope and Comprehensive Benefits

As mentioned, six valid values for RESTRICTED-BENEFITS-CODE (1, 4, 7, A, B, and D) are intended to capture individuals who are eligible for comprehensive Medicaid or CHIP benefits, depending on the individual’s particular coverage, such as alternative benchmark-equivalent coverage, PRTF, HOA, or MFP. These six values are also intended to capture individuals who are eligible for comprehensive Medicaid or CHIP benefits via a traditional pathway. RESTRICTED-BENEFITS-CODE 1 should be used for individuals who have full-scope benefits for either Medicaid or CHIP (Medicaid-Expansion or Separate CHIP). The other values represent comprehensive coverage options. RESTRICTED-BENEFITS-CODE 4 should also be used for individuals who are entitled to restricted benefits for pregnancy-related services; this would encompass both pregnancy-related benefits that do and do not meet the MEC standard.^[4]

Limited Benefits

The following valid values for RESTRICTED-BENEFITS-CODE are intended to capture individuals who are eligible for a limited set of Medicaid or CHIP benefits because of certain circumstances.

RESTRICTED-BENEFITS-CODE 2 is intended for individuals who are eligible for a limited set of Medicaid or Medicaid Expansion CHIP benefits based on their alien status, including qualified non-citizens who entered the United States before August 1996, qualified immigrants who entered at the end of the five -year waiting period, and qualified immigrants exempt from the five-year waiting period.
RESTRICTED-BENEFITS-CODE 6 is intended for individuals whose Medicaid benefits are restricted to family planning services, which may be received, for example, through a Section 1115 family planning waiver. The code is not intended for individuals who may be eligible for services related to family planning via traditional Medicaid.

CHIP Beneficiaries

States should not leave RESTRICTED-BENEFITS-CODE blank for CHIP beneficiaries reported in their T-MSIS Eligible file submissions. If an individual is entitled to the full scope of Medicaid-Expansion or Separate CHIP benefits, states should code the individual as RESTRICTED-BENEFITS-CODE 1 (individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits).

Some individuals eligible for Medicaid-Expansion CHIP may only be entitled to a limited set of CHIP benefits. States should use RESTRICTED-BENEFITS-CODE 2 for individuals who are eligible for Medicaid-Expansion CHIP but whose benefits under this program are limited because of their alien status. Medicaid-Expansion CHIP beneficiaries should never be reported to restricted benefits code C (Individual is eligible for separate CHIP dental coverage [supplemental dental wraparound benefit to employer-sponsored insurance]).
Separate CHIP beneficiaries should never be reported with the following valid values for RESTRICTED-BENEFITS-CODE:

7: Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.
A: Individual is eligible for Medicaid and entitled to benefits under the PRTF Demonstration Grant Program, as enacted by the Deficit Reduction Act of 2005.
B: Individual is eligible for Medicaid and entitled to Medicaid benefits using a HOA
D: Individual is eligible for Medicaid and entitled to benefits under a MFP rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities.

In general, we would expect most Separate CHIP beneficiaries to be eligible for the full scope of CHIP benefits, but there are some noteworthy exceptions. Some individuals who are eligible for Separate CHIP also receive supplemental dental benefits in addition to health insurance coverage through an employer. Individuals who are enrolled in a Separate CHIP program and who receive a supplemental dental wraparound benefit to employer-sponsored insurance should be coded with RESTRICTED-BENEFITS-CODE C. Such children are eligible to enroll in the dental-only supplemental coverage even if their group health plan or other health insurance coverage includes some dental benefits. In the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Congress added a provision that allows states to provide dental-only supplemental coverage to children who have health insurance coverage through an employer but are uninsured or underinsured with respect to dental coverage.^[5] Some states might use CHIP funds to cover pregnant women under the “unborn child” option^[6] or under an 1115 waiver to their CHIP program, in which case they would be classified under RESTRICTED-BENEFITS-CODE 4 to indicate a restricted package of pregnancy-only services.

Other Restricted Benefits

A planned change to the definition of RESTRICTED-BENEFITS-CODE 5 and the proposed addition of valid value E will allow users to distinguish between other restricted benefits that do meet the MEC standard (valid value 5) and those that do not meet the MEC standard (new valid value E). RESTRICTED-BENEFITS-CODE 5 is intended to capture all other individuals who are not eligible for full-scope Medicaid or Medicaid-Expansion CHIP benefits but whose benefits do meet the MEC standard. Some examples of what might be included in this code are benefits provided under a medically needy program, 1115 demonstrations that are not captured under Alternative Benefit Plans (RESTRICTED-BENEFIT-CODE 7), tuberculosis-only coverage, or the inmate coverage exclusion.^[7] If a state offers limited benefits for medically needy individuals that do not meet the MEC standard, or if a state offers other benefits that neither fit into any other RESTRICTED-BENEFITS-CODE nor meet the MEC standard, the state should report these individuals to the new valid value RESTRICTED-BENEFITS-CODE E.

RESTRICTED-BENEFITS-CODE and Relationships with other Data Elements in the T-MSIS Eligible File

Table 2 lays out several scenarios for RESTRICTED-BENEFITS-CODE reporting and the relevant logical relationships for reporting to other data elements in the T-MSIS Eligible file. The relationships between these data elements and RESTRICTED-BENEFITS-CODE is being assessed in the State Data Quality Technical Assistance (DQ TA) process. Also being assessed are the frequencies of the values reported for RESTRICTED-BENEFITS-CODE as well as the extent to which the reporting of this data element is complete.

Table 2: RESTRICTED-BENEFITS-CODE (ELG097) Logical Relationships with other Data Elements in the T-MSIS Eligible File

RESTRICTED-BENEFITS-CODE valid value	RESTRICTED-BENEFITS-CODE Valid Value Description	Data Element in the T-MSIS Eligible File	Expected Valid Values and Descriptions for Data Elements in the T-MSIS Eligible File	Comments
3	Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status (e.g., QMB, SLMB, QDWI, QI).	DUAL-ELIGIBLE-CODE (ELG085)	01: QMB Only 03: SLMB Only 05: QDWI 06: QI	For other dual eligible categories (e.g., QMB Plus, SLMB Plus), the individual is entitled to full Medicaid benefits, so reporting restricted benefits would not apply, and a RESTRICTED-BENEFITS-CODE of 1 would be expected.
6	Individual is eligible for Medicaid or Medicaid-Expansion CHIP but only entitled to restricted benefits for family planning services.	WAIVER-TYPE (ELG173)	24: 1115 Family Planning Demonstration
7	Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.	ELIGIBILITY-GROUP (ELG087)	72: Adult Group - Individuals at or below 133% FPL, age 19 through 64, newly eligible for all states 73: Adult Group - Individuals at or below 133% FPL, ages 19 through 64, not newly eligible for non-1905z(3) states 74: Adult Group - Individuals at or below 133% FPL, ages 19 through 64 - not newly eligible parent/ caretaker-relative(s) in 1905z(3) states 75: Adult Group - Individuals at or below 133% FPL, ages 19 through 64, not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states Other eligibility group code categories that states can enroll into alternative benefit plans on a mandatory or optional basis^[8]	For not newly eligible individuals, depending on the state’s 1905(z)(3) status as designated by CMS for enhanced FMAP rates will affect which ELIGIBILITY-GROUP (ELG087) valid values are applicable.^[9] States can also enroll additional populations into benchmark-equivalent coverage beyond the new adult VIII group either mandatorily or optionally.
C	Individual is eligible for Separate CHIP dental coverage (supplemental dental wraparound benefit to employer-sponsored insurance)	CHIP-CODE (ELG054)	3: Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program for the month. States using Separate CHIP have used CHIP funds to create separate programs outside of their Medicaid programs.
D	Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities.	MFP-ENROLLMENT-EFF-DATE (ELG155)	Date that is on or before the ELIGIBILITY-DETERMINANTS-ELG00005 segment effective date, ELIGIBILITY-DETERMINANT-EFF-DATE (ELG099)

Proposed updates to the T-MSIS Data Dictionary

Revise the valid value description of RESTRICTED-BENEFITS-CODE 4 to include both benefits restricted to pregnancy-related services that meet MEC standards and non-MEC standards to address any potential confusion among states. Users can differentiate between the MEC and non-MEC non-full-scope pregnancy benefits with a feasible and reliable work-around. RESTRICTED-BENEFITS-CODE 4 is either MEC or non-MEC for an entire state program, so users can create state-specific rules to correctly classify this group by using guidance on designating states’ pregnancy-related services; the guidance was issued in February 2016 by the Secretary of the Department of Health and Human Services.^[10]
Revise the valid value description of RESTRICTED-BENEFITS-CODE 5 to specify other restricted benefits that meet MEC standards. Add new valid value “E” to specify other restricted benefits not meeting MEC standards.

[1] MEC, also known as qualifying health coverage, is any insurance plan that meets the ACA requirement for having health coverage.
[2] As of February 16, 2016, according to the Secretary of the Department of Health and Human Services, all states except for Arkansas, Idaho, and South Dakota offered comprehensive Medicaid benefits to women who were eligible for Medicaid because of pregnancy. See Medicaid Secretary-approved Minimum Essential Coverage (PDF, 204.13 KB)
[3] HOA refers to a five-year demonstration that began in 2007. Under the program, the state Medicaid program placed a pre-determined amount of money per year in the HOA. If all this money is spent on health care services before the end of the year, the recipient is responsible for paying 10 percent of additional costs up to $250 per adult and $100 per child. Only one state, South Carolina, piloted the program.
[4] As of February 2016, Arkansas, Idaho, and South Dakota were the only states offering pregnancy-related services that do not meet the MEC standard.
[5] CHIPRA Section 2110(b)(5).
[6] The unborn child option permits states to consider the fetus a “targeted low-income child” for purposes of CHIP coverage.
[7] 42 Code of Federal Regulations (CFR) 435.1010 and Centers for Medicare & Medicaid Services, see State Health Official Letter #16-007 (PDF, 185.88 KB). Accessed March 13, 2019.
[8] Benchmark-equivalent coverage is required for the new adult VIII eligibility group, but there are additional populations that states can enroll into this category either mandatorily or optionally.
[9] For additional information, refer to T-MSIS Reporting Reminder: ELIGIBILITY-GROUP (72-75) for the Medicaid Expansion Population in the T-MSIS Eligible file.
[10] Medicaid Secretary-Approved MEC (PDF, 204.13 KB) (PDF 204.13 KB).