ELIGIBILITY-DETERMINANTS

File Segment

File Segment Number

ELG00005

File Name

ELG - ELIGIBLE

Last updated

No Updates

Data Elements Reference

DE Number	System DE Number	Data Element	Definition	Valid Values
ELG079	ELG.005.079	RECORD-ID	The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).	ELG079 Values
ELG080	ELG.005.080	SUBMITTING-STATE	A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.	ELG080 Values
ELG081	ELG.005.081	RECORD-NUMBER	A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.	N/A
ELG082	ELG.005.082	MSIS-IDENTIFICATION-NUM	A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572	N/A
ELG083	ELG.005.083	MSIS-CASE-NUM	The state-assigned number which uniquely identifies the Medicaid case to which the enrollee belongs. The definition of a case varies. There are single-person cases (mostly aged and blind/disabled) and multi-person cases (mostly TANF) in which all members of the case have the same case number, but a unique identification number. A warning for longitudinal research efforts: a case numbers associated with an individual may change over time.	N/A
ELG084	ELG.005.084	MEDICAID-BASIS-OF-ELIGIBILITY	[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]	ELG084 Values
ELG085	ELG.005.085	DUAL-ELIGIBLE-CODE	Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits.	ELG085 Values
ELG086	ELG.005.086	PRIMARY-ELIGIBILITY-GROUP-IND	A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to "1"(YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = "1"; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = "0".	ELG086 Values
ELG087	ELG.005.087	ELIGIBILITY-GROUP	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).	ELG087 Values
ELG088	ELG.005.088	LEVEL-OF-CARE-STATUS	The level of care required to meet an individual's needs and to determine LTSS program eligibility.	ELG088 Values
ELG089	ELG.005.089	SSDI-IND	A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA).	ELG089 Values
ELG090	ELG.005.090	SSI-IND	A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).	ELG090 Values
ELG091	ELG.005.091	SSI-STATE-SUPPLEMENT-STATUS-CODE	Indicates the individual's State Supplemental Income Status.	ELG091 Values
ELG092	ELG.005.092	SSI-STATUS	Indicates the individual's SSI Status.	ELG092 Values
ELG093	ELG.005.093	STATE-SPEC-ELIG-GROUP	The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values (before January 1, 2014) and Eligibility Group values (on or after January 1, 2014). This field should not include information that already appears elsewhere on the Eligible File record even if it is part of the MAS and BOE or Eligibility Group algorithm (e.g., age information computed from Date of Birth or County Code).	N/A
ELG094	ELG.005.094	CONCEPTION-TO-BIRTH-IND	A flag to identify children eligible through the conception to birth option, which is available only through a separate State CHIP Program.	ELG094 Values
ELG095	ELG.005.095	ELIGIBILITY-CHANGE-REASON	The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value "21" (Other) or "22" (Unknown), then the state should not report the co-occurring value "21" and/or "22" to T-MSIS. If there are multiple co-occurring distinct values between "01" and "19", then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of "01" through "19", CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.	ELG095 Values
ELG096	ELG.005.096	MAINTENANCE-ASSISTANCE-STATUS	[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]	ELG096 Values
ELG097	ELG.005.097	RESTRICTED-BENEFITS-CODE	A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.	ELG097 Values
ELG098	ELG.005.098	TANF-CASH-CODE	A flag that indicates whether the individual received Federal Temporary Assistance for Needy Families (TANF) benefits.	ELG098 Values
ELG099	ELG.005.099	ELIGIBILITY-DETERMINANT-EFF-DATE	The first calendar day on which all of the other data elements in the same segment were effective.	N/A
ELG100	ELG.005.100	ELIGIBILITY-DETERMINANT-END-DATE	The last calendar day on which all of the other data elements in the same segment were effective.	N/A
ELG101	ELG.005.101	STATE-NOTATION	A free text field for the submitting state to enter whatever information it chooses.	N/A

Definition: A record to capture factors that influence an individual's eligibility for basic Medicaid/CHIP, as well as the various waivers and demonstrations.
File Segment Length: 1000