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Reporting Eligibility Group (Eligibility)

Brief Issue Description

CMS has retired Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) and replaced them with Eligibility Group values as the principal eligibility classification coding system in T-MSIS.    

Background Discussion

Historically in MSIS, the national standard eligibility classification coding system was based on a combination of two MSIS data elements—Maintenance Assistance Status (MAS) and Medicaid Basis of Eligibility (BOE). Due to changes in policy over time, most notably the Affordable Care Act (ACA), MAS and BOE have become obsolete, and CMS has replaced them with a new eligibility classification coding system. The new eligibility classification code set is known as Eligibility Group. The T-MSIS Eligible file ELG00005 segment known as the Eligibility Determinants segment captures all MAS, BOE, and Eligibility Group values.

The T-MSIS data dictionary defines 72 Eligibility Group values. The T-MSIS V2.0 data dictionary defines 30 values as Mandatory coverage groups; however, 4 of them represent Medicaid expansion via the new eligibility group for adults, which states are no longer required to cover. (The Supreme Court ruled that each state may choose whether to implement Medicaid expansion through the adult group; however, the court did not amend the federal statutes and regulations so the adult group continues to be classified as a mandatory eligibility group in statute and regulations.) This means (1) 26 mandatory coverage categories are expected to be assigned to eligible individuals in every state, and (2) 46 non-mandatory coverage categories may or may not be applicable to eligible individuals in a given state depending on the Medicaid and Children's Health Insurance Program (CHIP) State Plan and waiver arrangements (see Table 1).

Table 1. T-MSIS V2.0 data dictionary categorization of Eligibility Groups
Category Eligibility Group Values
Mandatory* 26
Non-Mandatory: Medically Needy 6
Non-Mandatory: Optional* 37
Non-Mandatory: 1115 Expansion 3
Total 72

*Here, the categories of Medicaid expansion via the new adult group are considered Optional categories, but the T-MSIS V2.0 data dictionary considers them Mandatory.

When to transition from MAS and BOE to Eligibility Group

States were expected to cease reporting of MAS and BOE for any coverage periods that began on or after January 1, 2014.  Instead, anyone determined or redetermined to be eligible for Medicaid or CHIP on or after January 1, 2014, must be reported to CMS via T-MSIS with the new Eligibility Group value for those post-January 1, 2014, coverage periods. For this reason, CMS expects to classify all T-MSIS ELG00005 eligibility determinants segments with segment effective dates on or after January 1, 2014, by Eligibility Group values. All T-MSIS ELG00005 eligibility determinants segments MAS and BOE classifies should have a segment end date on or before December 31, 2014.

CMS Guidance

CMS identifies 26 distinct Eligibility Groups as “Mandatory Coverage” groups that every state must assign to eligible individuals in T-MSIS for coverage periods beginning on or after January 1, 2014. States must report the remaining 46 Eligibility Groups to T-MSIS to the extent they apply to each state’s Medicaid and CHIP State Plans and State Plan waivers. The manner in which states assign any Eligibility Group value to an eligible individual and report in T-MSIS (that is, whether they assign Eligibility Group value as a direct result of the eligibility determination process or during T-MSIS file production) must be consistent with the state’s Medicaid and/or CHIP State Plan or State Plan waiver. States should report all eligible individuals to T-MSIS with valid and accurate Eligibility Groups for any coverage period effective on or after January 1, 2014, and for any coverage period that ends on or after December 31, 2014. States should refer to their Medicaid and CHIP State Plan, State Plan Amendments, and State Plan Waivers to determine the appropriate Eligibility Group to assign to an eligible individual.

T-MSIS File Type
T-MSIS Coding Blog


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