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CMS Guidance: Reporting Individuals Who Receive Medicaid Coverage for COVID-19 Testing in the T-MSIS Eligible File

Brief Issue Description

This guidance specifies state reporting requirements for Transformed Medicaid Statistical Information (T-MSIS) enrollment data for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing. Coronavirus Disease 2019, or COVID-19, is a respiratory disease caused by a novel coronavirus.[1]  The U.S. Secretary of Health and Human Services Alex M. Azar II declared a public health emergency as a result of confirmed cases of COVID-19 in the United States. The declaration is retroactive to January 27, 2020.[2]  This document provides guidance to states for reporting these individuals in the T-MSIS Eligible file.

Background Discussion

Context

Section 6004(a)(3) of the Families First Coronavirus Response Act (FFCRA) added Section 1902(a)(10)(A)(ii)(XXIII) to the Social Security Act (the Act).[3]  During any portion of the public health emergency period beginning March 18, 2020, this provision permits states to temporarily cover uninsured individuals through an optional Medicaid eligibility group for the limited purpose of COVID-19 testing. Such medical assistance, as limited by clause XVIII in the text following Section 1902(a)(10)(G) of the Act, includes: in vitro diagnostic products for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and any visit for COVID–19 testing-related services for which payment may be made under the State plan. For the purposes of this eligibility group, states should refer to section 1902(ss) of the Act, as amended by FFCRA and the CARES Act, regarding the definition of an uninsured individual. 

Challenges

States adopting the new optional Medicaid eligibility group for the provision of the authorized COVID-19 related services must accurately report this information in the T-MSIS Eligible file. For analytic purposes, it is important to ensure consistent and accurate reporting of individuals who receive coverage only for COVID-19 diagnostic products and testing-related services. In addition, as things are rapidly changing, states are encouraged to periodically review the COVID-19 FAQs published by the Centers for Medicare & Medicaid Services (CMS).[4]   

CMS Guidance

To address the completeness and accuracy of reporting individuals newly eligible for coverage for COVID-19 testing under Medicaid, CMS has provided the following guidance to report enrollment on the Eligible file.

There are two data elements in the Eligible file that should be reported to document a beneficiary’s enrollment in Medicaid as defined by Section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act: ELIGIBILITY-GROUP (ELG087) and RESTRICTED-BENEFITS-CODE (ELG097). Table 1 shows the forthcoming proposed changes to the valid values for these data elements in the T-MSIS Data Dictionary to accommodate reporting individuals who receive coverage only for COVID-19 diagnostic products and testing-related services.

Tables 1 and 2. T-MSIS Data Dictionary planned valid values and descriptions to capture a beneficiary’s enrollment on the Eligible file as defined by Section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act

Table 1. ELIGIBILITY-GROUP (ELG087)
Code Eligibility Group Short Description Citation Type Category
76 Uninsured Individual eligible for COVID-19 testing Uninsured individuals who are eligible for medical assistance for COVID-19 diagnostic products and any visit described as a COVID–19 testing-related service for which payment may be made under the State plan during any portion of the public health emergency period, beginning March 18, 2020. 1902(a)(10) (A)(ii)(XXIII) Family/Adult Optional
Table 2. RESTRICTED-BENEFITS-CODE (ELG097)
Code Description
F[5] Individual is eligible for Medicaid but is only entitled to restricted benefits for medical assistance for COVID-19 diagnostic products and any visit described as a COVID–19 testing-related service for which payment may be made under the State plan during any portion of the public health emergency period, beginning March 18, 2020, as described in Sections 1902(a)(10)(A)(ii)(XXIII), 1902(ss) and clause XVIII in the matter following 1902(a)(10)(G) of the Social Security Act.

There is one segment on the Eligible file that should be reported to document an individual’s enrollment in Medicaid as defined by Section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act.

  • ELIGIBILITY-DETERMINANTS-ELG00005
    • ELIGIBILITY-GROUP (ELG087): A value of “76” (Uninsured Individual eligible for COVID-19 testing) should be reported.
    • RESTRICTED-BENEFITS-CODE (ELG097): A value of “F” (Individual is eligible for Medicaid but is only entitled to restricted benefits for medical assistance for COVID-19 diagnostic products and any visit described as a COVID–19 testing-related service for which payment may be made under the State plan during any portion of the public health emergency period, beginning March 18, 2020, as described in Sections 1902(a)(10)(A)(ii)(XXIII), 1902(ss) and clause XVIII in the matter following 1902(a)(10)(G) of the Social Security Act.) should be reported.

Because these individuals eligible for COVID-19 testing and testing-related services are covered by Medicaid they should also be reported with CHIP-CODE “1” in the VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 segment and ENROLLMENT-TYPE “1” in the ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 segment.

[1] Coronavirus Disease 2019 (COVID-19)

[2] Determination that a Public Health Emergency Exists

[3] H.R.6201 - Families First Coronavirus Response Act

[4] COVID-19 FAQs

[5] CMS is recommending RESTRICTED-BENEFITS-CODE ‘F’ for individuals who receive coverage only for COVID-19 diagnostic products and testing-related services instead of code ‘E’ because valid value ‘E’ has been recommended as a new valid value per recent T-MSIS Coding Blog Guidance

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