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Brief Issue Description

This guidance outlines the challenges states have faced when reporting the indicator for an eligible individual’s primary eligibility group (PRIMARY-ELIGIBILITY-GROUP-IND) in their T-MSIS Eligibility Determinant segment (ELG00005) and recommends best practices for states’ reporting. There are many different pathways to Medicaid and CHIP eligibility based on different factors such as age, pregnancy, status as a former foster care youth, and need for long term services and supports. Each state elects specific options related to eligibility and has its own processes and systems for conducting an eligibility determination and assigning an eligible individual to aid categories, program codes, money codes, and/or disability statuses.

Background Discussion

Most individuals enrolled in Medicaid or CHIP should be reported with a single primary eligibility group segment for each period that the person is eligible. The PRIMARY-ELIGIBILITY-GROUP-IND field is used to flag this eligibility segment as the key, or “primary,” eligibility classification that should be associated with that person. It is expected that most people are eligible for only one group, but there are instances where that classification can change over time. In addition, some state systems maintain records for individuals with multiple eligibility groups that have overlapping periods of time.

CMS Guidance

States should submit a full set of eligibility records (ELIGIBILITY-DETERMINANTS-ELG00005) to T-MSIS, along with the date spans for which each of these cases is active. Segments should contain a PRIMARY-ELIGIBILITY-GROUP-IND (“1” = Yes; “0” = No) for all time periods in which a person is eligible. For any given time period that a person is eligible, a segment with PRIMARY-ELIGIBILTY-GROUP-IND = “1” must exist. There cannot be a time period where a person has eligibility but only segments with PRIMARY-ELIGIBILITY-GROUP-IND = “0” exist.

For individuals with consistent enrollment criteria and ongoing Medicaid enrollment, it is likely that only one continuous period of eligibility is submitted. As shown in Table 1 (PDF, 61.43 KB) below, using an individual in the Eligibility Group = ‘01’ (Parents and Other Caretaker Relatives) as an example, that segment would be assigned PRIMARY-ELIGIBILTY-GROUP-IND = 1 (primary).

Some eligible individuals may have different eligibility group segments over a period of time. For example, an individual who is eligible in the T-MSIS Eligibility Group for Parents (code 01) beginning in February, and who receives a pay raise effective at the end of April, will become ineligible for the parent group due to income. However, because he still meets all other eligibility criteria of the parent group (except for income), he is transitioned to transitional medical assistance (Eligibility Group code 02). As shown in Table 2 (PDF, 61.75 KB), his primary eligibility group for February through April would be the parent group segment and then beginning in May his primary eligibility group indicator would be the Transitional Medical Assistance eligibility group.

Finally, in some instances, a small number of states might encounter situations where eligibles enrolled in Medicaid or CHIP may be reported to more than one group during a particular period of time. In other words, they have multiple active eligibility segments with overlapping time periods of eligibility. In these instances, states need to determine which eligibility segment is assigned the primary eligibility group indicator. For any given time period that a person is eligible, only one eligibility segment should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = “1” (Yes). The second eligibility segment (and any others) for the same time period would be assigned “0” (No) to flag that it is not the primary eligibility group.

For example, a 22-year old woman meets all of the criteria for enrollment in the former foster care group (she’s under age 26, she was enrolled in the state’s Medicaid program when she aged out of foster care at age 18, and she’s a state resident). However, if she’s pregnant and her income is below the income threshold for the pregnant women group, there might be an overlap in time that she remains eligible for the former foster care group (T-MSIS Eligibility Group code 09) but then also establishes eligibility for the pregnant women group (code 05).  In this situation, she may be shown in the state’s system as being eligible in two different eligibility groups and the state needs to assign one eligibility group indicator as primary and the other eligibility group as secondary. Table 3 (PDF, 64.02 KB) illustrates how the state should make this assignment. Eligibility group segment #1 is the primary eligibility group through April and is assigned primary eligibility indicator = 1. The individual has established eligibility as a pregnant woman in April (segment #2) which overlaps with the former foster care and is determined to be the secondary group and assigned primary eligibility indicator = 0. However, in May and going forward, the pregnant woman group is the only eligibility segment and changes to become the primary eligibility group (segment #3) and is now assigned primary eligibility indicator = 1. Primary eligibility is established when there are overlapping segments and there is never a period of eligibility where the individual only has secondary eligibility.

A hierarchy exists for many Medicaid and CHIP eligibility groups which can help states to determine which eligibility group is the correct group to assign as primary1 Mandatory eligibility groups always come before optional groups in the hierarchy, and many eligibility groups have specific restrictions that prohibit an individual from being eligible in one group if she or he is eligible for other specific groups. For example, in order to be eligible for the new eligibility group for adults (the expansion group), an individual cannot be eligible for any other mandatory eligibility group. If the primary assignment  is not clear from the hierarchy, people should be flagged as being in the primary eligibility group that has the most generous benefit package or lowest out-of-pocket costs for which the state has affirmed their eligibility. Where the benefits are the same, the primary eligibility group should be their most persistent eligibility group. For example, a 15 year-old child in title IV-E foster care would have the “children with title IV-E adoption assistance, foster care, or guardianship care” group (T-MSIS Code 08) as their primary eligibility group, even if their income was such that they also qualified  for the eligibility group for “infants and children under age 19” (T-MSIS code 07). If a state maintains multiple eligibility segments with overlapping time periods, but is not able to determine a hierarchy, CMS and state staff can work together to address any unique considerations to determine a feasible solution.

The MITA Guidance (ZIP, 12.63 MB) available on Medicaid.gov provides the eligibility group hierarchy.

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