CMS Technical Instructions: Reporting Race and Ethnicity in the T-MSIS Eligible File

This technical instruction document specifies requirements for reporting a beneficiary’s race in the RACE-INFORMATION-ELG00016 segment and ethnicity in the ETHNICITY-INFORMATION-ELG00015 segment both in the T-MSIS Eligible file. This document outlines the challenges of the differing standards for reporting race and ethnicity in T-MSIS. T-MSIS race and ethnicity values align with the 2011 Department of Health and Human Services (HHS) data standards, which are more granular than the OMB standard values used on most states’ Medicaid applications. This document provides instruction for states to report the RACE (ELG213) and ETHNICITY-CODE (ELG204) data elements in T-MSIS to reconcile these differing standards, as well as information on how to report race information for beneficiaries that are multiracial.

Race and ethnicity are two important beneficiary demographic data elements reported on the T-MSIS Eligible file and of interest to end users of T-MSIS data for analytic purposes. The Patient Protection and Affordable Care Act requires federal data collection efforts for health care to follow the 1997 OMB standards, although states can opt for more granular reporting as long as the categories reported  can be rolled up to the OMB standards.^[1]The T-MSIS race and ethnicity data elements currently align with the 2011 HHS Data Collection Standards for Race, Ethnicity, Sex, Primary Language and Disability Status (HHS Data Standards) published by the Office of the Assistant Secretary for Planning and Evaluation in October 2011. However, most states’ Medicaid applications collect race and ethnicity data at OMB standards, which is less granular.^[2][3][4]As the HHS data standards for race and ethnicity roll up to the OMB standards, the categories of race for “Asian Indian”, “Chinese”, “Filipino”, “Japanese”, “Korean”, “Vietnamese”, and “Other Asian” roll up to the OMB standard for race value of “Asian” , and the HHS data standards for the categories of ethnicity for “Mexican, Mexican American, Chicano/a”, “Puerto Rican”, “Cuban”, and “Another Hispanic, Latino, or Spanish origin” roll up to the OMB standard ethnicity value of “Hispanic or Latino/a”..

There is no single T-MSIS RACE (ELG213) valid value that captures a “multiracial” value for those beneficiaries that identify as multiracial. This is consistent with OMB guidance that reporting more than one race should take the form of multiple responses to a single question and not a single ‘‘multiracial’’ category.^[5] Some states have had questions regarding how to report valid values when beneficiaries self-identify in two or more race categories. Additionally, some states’ applications/systems only allow beneficiaries to report a “multiracial” category and are unsure how to translate “multiracial” to T-MSIS. See examples on how states can report multiple race values in the T-MSIS Eligible file by reporting multiple RACE-INFORMATION-ELG00016 segments in the Technical Instructions section below.

Race information is included in the calculation of a measure component for T-MSIS Priority Item (TPI) 32 – Beneficiary Demographics: Level 2.

• Eligible beneficiaries with AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR (ELG215) (formerly known as AMERICAN-INDIAN-ALASKAN-INDICATOR)  = 1 but do not have RACE = 003 (American Indian or Alaska Native).

Race and ethnicity data are also assessed through other T-MSIS state data quality measures. Some examples of these measures are below. States should refer to the Data Quality Tool (DQT) for a full listing of current data quality measures. 

• % of eligibles with unspecified, unknown, missing or invalid ethnicity
• % of eligibles with unspecified, unknown, missing or invalid race
• Ratio of errors for overlapping segment eff/end dates [RULE-2438] to all active RACE-INFORMATION (ELG00016) segments across all reporting and coverage periods
• Ratio of errors for overlapping segment eff/end dates [RULE-2413] to all active ETHNICITY-INFORMATION (ELG00015) segments across all reporting and coverage periods

For the RACE (ELG213) and ETHNICITY-CODE (ELG204) data elements, there are several valid values that refer to 
“Other”, “Unknown”, or “Unspecified” race and ethnicity categories. Please refer to Table 1 below, which describes the scenarios where these race and ethnicity categories should be reported in T-MSIS.

Table 1: Use of “Other”, “Unknown”, and “Unspecified” Race and Ethnicity Values in T-MSIS

There are several T-MSIS Race (ELG213) values that share a one-to-one mapping with the OMB standard values used on many states’ Medicaid applications and in their eligibility and enrollment systems, but there are other values that have a many-to-one mapping. This section contains instructions for situations where a state’s race and ethnicity values are less granular than the T-MSIS values and for situations where a state’s race and ethnicity values are more granular than the T-MSIS values.

Tables 2 and 3 shows an example scenario where the state uses race or ethnicity valid values equivalent to the OMB standard values and are less granular than the T-MSIS race and ethnicity valid values. Refer to the instructions following Table 3 for instruction on how to report race and ethnicity information in these situations.

Table 2: Scenario: State’s Race Valid Values are Less Granular than T-MSIS

Table 3: Scenario: State’s Ethnicity Valid Values are Less Granular than T-MSIS

• States should use the T-MSIS RACE (ELG213) valid value of “011” (Asian Unknown) when detailed Asian race codes (“004” through “009”) (E.g., Asian Indian, Chinese, Filipino, etc.) are not available. States should not use “010” (Other Asian) or “017” (Unspecified) in this instance.
• States should use the T-MSIS RACE (ELG213) valid value of “016” (Native Hawaiian or Other Pacific Islander Unknown) when detailed Native Hawaiian and Other Pacific Islander race codes (“012” through “014”) (e.g., Guamanian or Chamorro, Samoan, etc.) are not available. States should not use “015” (Other Pacific Islander) or “017” (Unspecified) in this instance.
• State should use the T-MSIS RACE (ELG213) valid value of “018” (Other) when they have a corresponding generic category to capture all other races. States should not use “017” (Unspecified) in this instance.
• RACE-OTHER (ELG214) is null. RACE-OTHER (ELG214) is only populated when RACE (ELG213) is “010” (Other Asian) or “015” (Other Pacific Islander). It would not be expected for RACE (ELG213) to be populated with “010” (Other Asian) or “015” (Other Pacific Islander) when the state’s race values are less granular than T-MSIS.
• States should use the T-MSIS ETHNICITY-CODE (ELG204) valid value of “5” (Hispanic or Latino/a Unknown) when detailed Hispanic or Latino/a ethnicity codes (“1” through “3”) (e.g., Puerto Rican, Cuban, etc.) are not available. State should not use “6” (Ethnicity Unspecified) in this instance.
• State should use the T-MSIS ETHNICITY-CODE (ELG204) valid value of “6” (Ethnicity Unspecified) when the ethnicity is unknown because the beneficiary did not provide their ethnicity or there was not opportunity offered to the beneficiary to provide it.
• ETHNICITY-OTHER (ELG271) is null. ETHNICITY-OTHER (ELG271) is only populated when ETHNICITY-CODE (ELG204) is “4” (Another Hispanic, Latino/a, or Spanish origin). It would not be expected for ETHNICITY-CODE (ELG204) to be populated with “4” (Another Hispanic, Latino/a, or Spanish origin) when the state’s ethnicity values are less granular than T-MSIS.

Tables 4 and 5 show a scenario where the state’s race or ethnicity valid values are more granular than the T-MSIS race and ethnicity valid values. The more granular values provided in tables 4 and 5 are meant to be examples, not an exhaustive list of the potential options that could be reported. Refer to the instructions following Table 4 for instruction on how to report race and ethnicity information in these situations.

Table 4: Scenario: State’s Race Valid Values are More Granular than T-MSIS

Table 5: Scenario: State’s Ethnicity Valid Values are More Granular than T-MSIS

• States should use the T-MSIS RACE (ELG213) valid value of “010” (Other Asian) when the state captures more detailed Asian race values than is available to report in T-MSIS (e.g., Cambodian, Indonesian, Laotian, Malaysian, Thai). States should also use the data element RACE-OTHER (ELG214) to report the more specific Asian race in this free-text field.
• States should use the T-MSIS RACE (ELG213) valid value of “015” (Other Pacific Islander) when the state captures more detailed Pacific Islander race values than is available to report in T-MSIS (e.g., Fijian, Tongan, Marshallese). States should also use the data element RACE-OTHER (ELG214) to report the more specific Pacific Islander race in this free-text field.
• State should use the T-MSIS RACE (ELG213) valid value of “018” (Other) when the state captures more detailed race values than is available to report in T-MSIS that are not Other Asian or Other Pacific Islander (e.g., Aboriginal Australian, Sami, Berber). States should also use the data element RACE-OTHER (ELG214) to report the more specific other race in this free-text field.
• States should use the T-MSIS ETHNICITY-CODE (ELG204) valid value of “4” (Another Hispanic, Latino/a, or Spanish origin) when the state captures more detailed Hispanic or Latino/a ethnicity codes than is available to report in T-MSIS. States should also use the data element ETHNICITY-OTHER (ELG271) to report the more specific ethnicity value in this free-text field.

States can report beneficiaries with multiple simultaneously active values for RACE (ELG213), as the data element is a primary key for the RACE-INFORMATION-ELG00016 segment. The T-MSIS technical requirements expect that the RACE (ELG213) and RACE-OTHER (ELG214) values are different on each simultaneously active segment for a given beneficiary.

States can also report beneficiaries with multiple simultaneously active values for ETHNICITY-CODE (ELG204), as the data element is a primary key for the ETHNICITY-INFORMATION-ELG00015 segment. The T-MSIS technical requirements expect that the ETHNICITY-CODE (ELG204) values are different on each simultaneously active segment for a given beneficiary.

States should use the instructions above to determine the appropriate T-MSIS race and ethnicity valid values to report, depending on whether their state race valid values are more or less granular than the T-MSIS values, and if multiple values apply to a given beneficiary, the state can report all of the applicable values. Three examples of situations where individuals self-identify multiple racial categories or self-identify multiple ethnic categories and how to report them in T-MSIS follows:

• Example 1: The state captures an individual’s self-identified racial categories as: Black or African American, Korean, and Thai. The state values are more granular than the T-MSIS RACE (ELG213) values. In T-MSIS, we would expect the following RACE-INFORMATION-ELG00016 segments for this individual.

Table 6: Example 1: Individual Reporting Multiple Racial Categories in T-MSIS – State’s Race values are more granular than T-MSIS

• Example 2: The state captures an individual’s self-identified racial categories as: White and Asian. The state values are less granular than the T-MSIS RACE (ELG213) values. In T-MSIS, we would expect the following RACE-INFORMATION-ELG00016 segments for this individual. 

Table 7: Example 2: Individual Reporting Multiple Racial Categories in T-MSIS – State’s Race values are less granular than T-MSIS

• Example 3: The state captures an individual’s self-identified ethnicity as: Mexican, Mexican American, Chicano/a; Puerto Rican; and Honduran. The state values are more granular than the T-MSIS ETHNICITY-CODE (ELG204) values. In T-MSIS, we would expect the following ETHNICITY-INFORMATION-ELG00015 segments for this individual.

Table 8: Example 3: Individual Reporting Multiple Ethnic Categories in T-MSIS – State’s Ethnicity values are more granular than T-MSIS

If state systems/applications were not previously allowing beneficiaries to report multiple race values and it is therefore necessary to update their systems/applications to capture multiple RACE values, only beneficiaries enrolled (or re-enrolled) after application updates were put in place are expected to be reported with multiple race values (when applicable because the beneficiary has reported multiple races).  Historical data for prior/current beneficiaries – those enrolled before the application update – will not include multiple races at the beneficiary level because it would not have been possible for the beneficiary to have declared multiple races at the time. If a beneficiary enrolls or re-enrolls after the application update and reports multiple race values, the RACE-DECLARATION-EFF-DATE on the beneficiary’s RACE-INFORMATION-ELIGIBLE-ELG00016 segments capturing the race values should reflect the date of enrollment using the updated application. Race and ethnicity data from the state’s Medicaid application or any data system that uses federal match to support it is expected to comply with ACA and OMB standards (ACA Sec. 4302; e.g., minimum code set, multiple choice, self-reported) and must be provided to T-MSIS. While states cannot require that a beneficiary provide race and/or ethnicity information on their Medicaid/CHIP application, they should at least encourage it. If the state can also report to T-MSIS race or ethnicity data from any other state application or system not supported by federal match (and therefore not necessarily held to the same ACA and OMB standards), reporting of this data is considered a useful and necessary supplement to the data available from the state’s Medicaid application.