ELG.005.087

ELIGIBILITY-GROUP

Data Element

DE Number

ELG087

System DE Number

ELG.005.087

File Name

ELG - ELIGIBLE

File Segment Number

ELG00005

File Segment Name

ELIGIBILITY-DETERMINANTS

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The eligibility group applicable to the individual based on the eligibility determination process. The valid value list of eligibility groups aligns with those being used in the Medicaid and CHIP Program Data System (MACPro).
Size	X(2)
FLF Start Position	59
FLF Stop Position	60
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be in Eligibility Group List (VVL) 2. If value is "26", then Dual Eligible Code value must be "06" 3. Conditional 4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014. 5. If value is in [72,73,74,75], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06" 6. If associated CHIP Code value is "2", then value must be in [07,31,61] 7. If associated CHIP Code value is 3,then value must be in [61,62,63,64,65,66,67,68] 8. Value must be 2 characters 9. If value is "23", then Dual Eligible Code value must be in [01,02] 10. If value is "25", then Dual Eligible Code value must be in [03,04] 11. If value is "24", then Dual Eligible Code value must be "05" 12. If value is "26", then Dual Eligible Code value must be "06"

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-2135	If eligibility group is populated on an eligibility determinants segment from an ELG file, then the eligibility group value reported must be in the list of valid values for eligibility group.
RULE-6276	If a segment is an eligibility determinants segment from an ELG file, the eligibility group value reported must be compatible with the specified T-MSIS picture format: X(2).
RULE-7409	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is M-CHIP, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is equal to '07', '31', or '61'
RULE-7410	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is for S-CHIP, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is equal to '61', '62', '63', '64', '65', '66', '67' or '68'
RULE-7411	If a segment is a eligibility determinants segment from an ELG file, and the MSIS ID is populated and the restricted benefits code is equal to '6', and the primary eligibility group indicator is equal to '1' and eligibility determinant end date is greater than or equal to '01/01/2015', then the eligibility group is equal to one of the following values: '35','70'.
RULE-7422	If a segment is a variable demographics eligibility segment from an ELG file, and the chip code is for Medicaid, then the max(variable demographics eligibility effective date, 2015-01-01) is greater than or equal to eligibility determinants effective date and the variable demographics eligibility end date is less than or equal to eligibility determinants end date and the eligibility determinants end date is greater than or equal to '2015-01-01' and the primary eligibility group indicator is equal to '1' and the eligibility group is not equal to '61', '62', '63', '64', '65', '66', '67' or '68'
RULE-7447	If a segment is a eligibility determinants segment from an ELG file, and the msis identification number is a non-null value and the eligibility determinants.primary eligibility group indicator is equal to '1' and eligibility determinant end date is greater than or equal to '01/01/2015', then the eligibility determinants has a non-null value for eligibility group.
RULE-7553	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated, and the primary eligibility group indicator is '1' and the dual eligible code is for QMB-only ('01'), and the eligibility determinants end date is greater than or equal to '2015-01-01', then the eligibility group is equal to '23'.
RULE-7554	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated, and the primary eligibility group indicator is '1' and the dual eligible code is for QDWI ('05'), and the eligibility determinants end date is greater than or equal to '2015-01-01', then the eligibility group is equal to '24'.
RULE-7555	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated, and the primary eligibility group indicator is '1' and the dual eligible code is for SLMB-only ('03'), and the eligibility determinants end date is greater than or equal to '2015-01-01', then the eligibility group is equal to '25'.
RULE-7556	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated, and the primary eligibility group indicator is '1' and the dual eligible code is for QI ('06'), and the eligibility determinants end date is greater than or equal to '2015-01-01', then the eligibility group is equal to '26'.

Measure ID	Measure Name
EL-3-015-20	% of MSIS IDs with ELIGIBILITY-GROUP = 73 (adult group - not newly eligible for non 1905z(3) states) if the state reported MBES enrollment for this group
RULE-7447	% of record segments with missing Eligibility Group
EL-3-026-35	% of MSIS IDs with ELIGIBILITY-GROUP = 11 (Individuals Receiving SSI) if the state is not a 1634 or SSI criteria state
EL-3-027-36	% of MSIS IDs with ELIGIBILITY-GROUP = 12 (Aged, Blind and Disabled Individuals in 209(b) States) if the state is not a 209(b) state
EL-3-016_1-33	% of MSIS IDs with ELIGIBILITY-GROUP = 73, 74, or 75 (adult group - not newly eligible) if the state reported MBES enrollment for this group
EL-3-019_1-34	% of MSIS IDs with ELIGIBILITY-GROUP = 73, 74, or 75 (adult group - not newly eligible) if the state did not report MBES enrollment for this group
RULE-7553	% of record segments with DUAL-ELIGIBLE-CODE = 1 (QMB only) that do not have ELIGIBILITY-GROUP = 23 (Qualified Medicare Beneficiaries)
RULE-7554	% of record segments with DUAL-ELIGIBLE-CODE = 5 (QDWI) that do not have ELIGIBILITY-GROUP = 24 (Qualified Disabled and Working Individuals)
RULE-7555	% of record segments with DUAL-ELIGIBLE-CODE = 3 (SLMB only) that do not have ELIGIBILITY-GROUP = 25 (Specified Low Income Medicare Beneficiaries)
RULE-7556	% of record segments with DUAL-ELIGIBLE-CODE = 6 (QI) that do not have ELIGIBILITY-GROUP = 26 (Qualifying Individuals)
EL-3-012-17	% of M-CHIP and S-CHIP eligibles with a non-CHIP eligibility group
RULE-2135	% of record segments with an invalid Eligibility Group
EL-3-016-21	% of MSIS IDs with ELIGIBILITY-GROUP = 74 or 75 (adult group - not newly eligible in 1905z(3) states) if the state reported MBES enrollment for these groups
EL-3-018-23	% of MSIS IDs with ELIGIBILITY-GROUP = 73 (adult group - not newly eligible for non 1905z(3) states) if the state did not report MBES enrollment for this group
EL-3-019-24	% of MSIS IDs with ELIGIBILITY-GROUP = 74 or 75 (adult group - not newly eligible in 1905z(3) states) if the state did not report MBES enrollment for these groups
RULE-7411	% of segments indicating family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning eligibility group
EL-3-030-39	% of MSIS IDs Age < 19 without a valid Eligibility Group
EL-3-031-40	% of MSIS IDs Age 19 - 64 without a valid Eligibility Group
EL-3-032-41	% of MSIS IDs Age 65+ without a valid Eligibility Group
EL-3-033-42	% of MSIS IDs with ELIGIBILITY-GROUP = 11 (Individuals Receiving SSI) without full benefits
EL-3-034-43	% of MSIS IDs with ELIGIBILITY-GROUP = 05 (Pregnant Women) where SEX is not equal to “M” with Age 40-44
RULE-7419	% of segments with ELIGIBILITY-GROUP = 23 through 26 (QMB, QDWI, SLMB or QI) without valid DUAL-ELIGIBLE-CODE 01 through 10
EL-3-013-18	% of Medicaid MSIS IDs with a CHIP Eligibility Group
EL-3-000-12	% of MSIS IDs without a valid Eligibility Group
EL-3-001_1-13	# of distinct mandatory eligibility group values
EL-3-001-1	# of MSIS IDs with a valid Eligibility Group
EL-3-002-7	% of MSIS IDs in ELIGIBILITY-GROUP = 23 through 26 (QMB, QDWI, SLMB or QI) with valid DUAL-ELIGIBLE-CODE 01 through 10
EL-3-005-6	Ticket to Work (TTW): % of ELIGIBILITY-GROUP = 48 or 49 (TTW Basic or TTW Medical Improvements) with Age 16-64
EL-3-007-4	Pregnant Women (PW): % of MSIS IDs in ELIGIBILITY-GROUP = 05, 53, 67 or 68 (PW groups) with Age 13-64
EL-3-008-8	% of foster care children (ELIGIBILITY-GROUP = 08, 09 or 30)
EL-3-009-5	Foster Care: % of MSIS IDs in ELIGIBILITY-GROUP = 08, 09 or 30 (Foster Care Children groups) with Age <26
EL-3-010-9	% of MSIS IDs in ELIGIBILITY-GROUP = 34 (BCCP) that are aged 16-65
EL-3-011-10	% of MSIS IDs in ELIGIBILITY-GROUP = 34 (BCCP) that are female
EL-12-001-1	Eligibility Group values
EL-3-014-19	% of MSIS IDs with ELIGIBILITY-GROUP = 72 (adult group - newly eligible for all states) if the state reported MBES enrollment for this group
EL-3-017-22	% of MSIS IDs with ELIGIBILITY-GROUP = 72 (adult group - newly eligible for all states) if the state did not report MBES enrollment for this group
EL-3-020-25	% of MSIS IDs in M-CHIP reported without an M-CHIP Eligibility Group
EL-3-021-26	% of MSIS IDs in S-CHIP reported without an S-CHIP Eligibility Group
EL-3-022-27	# of distinct mandatory eligibility group values populated for children, pregnant women, caretakers, and foster children (ELIGIBILITY-GROUP = 01, 05, 06, 07, 08 or 09)
EL-3-023-28	# of distinct mandatory eligibility group values populated for transitional medical assistance (ELIGIBILITY-GROUP = 02 or 03)
EL-3-024-29	# of distinct mandatory eligibility group values populated for duals (ELIGIBILITY-GROUP = 23, 24, 25, 26)
EL-3-025-30	# of distinct mandatory eligibility group values for SSI or ABD individuals (ELIGIBILITY-GROUP = 11 or 12)
EL-6-025-25	% family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning eligibility group
MIS-1-026-26	% distinct MSIS IDs with only missing values in any active segment: ELIGIBILITY-GROUP (ELG00005)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/12/2024	3.29.0	ELG.005.087	UPDATE	Coding requirement	Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06"	1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [72,73,74,75], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [07,31,61]7. If associated CHIP Code value is 3,then value must be in [61,62,63,64,65,66,67,68]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in [01,02]10. If value is "25", then Dual Eligible Code value must be in [03,04]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06"
08/28/2023	3.12.0	ELG.005.087	UPDATE	Coding requirement	1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"	Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06"
03/12/2025	3.35.0	ELIGIBILITY-GROUP (ELG087)	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION ELIGIBILITY-GROUP \| 20250301 \| 99991231 \| 77 \| Other optional eligibility for reasonable classifications of children under 21
04/17/2020	2.4.0	ELIGIBILITY-GROUP ELG087	ADD	Data Dictionary - Valid Values	N/A	Data Element Name\| DE ID\| Code\| Description\| Effective Date\| End Date\| ELIGIBILITY-GROUP\| ELG087\| 76\| Uninsured Individual eligible for COVID-19 testing\| 3/18/2020\| 12/31/9999\|
05/13/2022	3.0.0	ELG087	UPDATE	Data Dictionary	DE NO\| DATA ELEMENT NAME\|CODING REQUIREMENT\| ELG087\|ELIGIBILITY-GROUP\|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06".	DE NO\| DATA ELEMENT NAME\|CODING REQUIREMENT\| ELG087\|ELIGIBILITY-GROUP\|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7".
03/19/2021	3.0.0	ELIGIBILITY-GROUP	UPDATE	Data Dictionary - Valid Values	\|Data Element\|Effective Date\|End Date\|Value\|Name\| \|ELIGIBILITY-GROUP\|00010101\|99991231\|10\|Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.\|	N/A