EL-10-004-5

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

EL-10-004-5

Data Quality Measure

Last updated

Key Information

Measure Name	% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02, 03, or 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01)
File Type	ELG
Measure ID	EL-10-004-5
Measure Type	Non-Claims Percentage
Content area	ELG MCR MULTI

Validation

Validation Type	Inferential

Measure Priority

Measure Priority	Medium
Focus Area	Managed care
Category	Program participation

Claim Information

Claim Type	N/A
Adjustment Type	N/A
Crossover Type	N/A

Thresholds

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

Data Elements

DD Data Element	MSIS-IDENTIFICATION-NUM • RESTRICTED-BENEFITS-CODE • MANAGED-CARE-PLAN-TYPE
DD Data Element Number	ELG082 • ELG097 • ELG193

Annotation

Calculate the percentage of restricted benefit eligibles enrolled in comprehensive managed care

Specification

STEP 1: Enrolled on the last day of DQ report month

Define the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:

1. ENROLLMENT-EFF-DATE <= last day of the DQ report month

2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

3. MSIS-IDENTIFICATION-NUM is not missing

STEP 2: Eligibility determinants on the last day of DQ report month

Using the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:

1. PRIMARY-ELIGIBILITY-GROUP-IND = 1

2a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month

3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missing

OR

2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing

3b. ELIGIBILITY-DETERMINANT-END-DATE is missing

STEP 3: Restricted benefit eligibles

Of the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “6”)

STEP 4: Managed care enrollment on the last day of DQ report month

Using the MSIS IDs that meet the criteria from STEP 3, join to segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:

1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month

2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missing

OR

1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing

2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missing

STEP 5: Identify individuals in a comprehensive managed care plan

Select MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"

STEP 6: Calculate percentage

Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3

Published Date	Data Guide Version	DQM	Action	Field	Before	After
03/27/2024	3.22.0	EL-10-004-5	UPDATE	Measure name	% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02 through 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01)	% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02, 03, or 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01)
03/27/2024	3.22.0	EL-10-004-5	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 3: Restricted benefit eligiblesOf the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “4” or “5” or “6”)STEP 4: Managed care enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 5: Identify individuals in a comprehensive managed care planSelect MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 3: Restricted benefit eligiblesOf the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “6”)STEP 4: Managed care enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 5: Identify individuals in a comprehensive managed care planSelect MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3