CMS Guidance: Reporting Restricted-Benefits-Code in the T-MSIS Eligible File

This guidance addresses the issues that are relevant to states when they report the RESTRICTED-BENEFITS-CODE (ELG097) data element in the T-MSIS Eligible file. It describes the challenges faced by states in the reporting process, provides instructions on how to report this code, and clarifies the logical relationships between RESTRICTED-BENEFITS-CODE and related data elements in the T-MSIS Eligible file, including DUAL-ELIGIBLE-CODE (ELG085), CHIP-CODE (ELG049), WAIVER-TYPE (ELG173), and MFP-ENROLLMENT-EFF-DATE (ELG155).

The data element RESTRICTED-BENEFITS-CODE (ELG097) is in the ELIGIBILITY-DETERMINANTS-ELG00005 segment in the T-MSIS Eligible file. The field is intended to capture the scope of Medicaid benefits to which an individual is entitled. For analytic purposes, it is important to ensure that reporting to the RESTRICTED-BENEFITS-CODE is consistent and accurate, especially when users are trying to identify individuals entitled to Medicaid benefits that are not comprehensive.

There are three levels of Medicaid benefits:

1. Full-scope benefits, which means that the beneficiary is entitled to all mandatory benefits (such as inpatient and outpatient hospital, home health, and physician services, among others) and optional benefits (such as prescription drugs, dental services, and physical therapy) covered under the Medicaid state plan. Traditional Medicaid is an example of full-scope benefits.
2. Non-full-scope but comprehensive benefits, which means that the beneficiary is entitled to a restricted set of benefits relative to full-scope coverage, but that the coverage still meets the Minimum Essential Coverage (MEC) standard laid out in the Affordable Care Act (ACA).^[1] Examples of non-full-scope but comprehensive benefits include coverage of pregnancy-related Medicaid benefits^[2] and the medically needy program in many states.
3. Limited benefits (also referred to as restricted or partial benefits), which means that the beneficiary is entitled to only a restricted set of benefits that do not meet the MEC standard. Examples are benefit packages for family planning only, tuberculosis-related services only, or emergency-only services for non-qualified non-citizens.

Although the name of the data element refers to restricted benefits, the RESTRICTED-BENEFITS-CODE data element encompasses a broader scope of benefit options from full-scope to comprehensive to limited benefits.

The values for RESTRICTED-BENEFITS-CODE do not always differentiate between the two groups of non-full-scope beneficiaries: those with MEC and those without MEC. For example, all but three states provide comprehensive benefits to women eligible for Medicaid because they are pregnant, but the description of valid value 4 did not specify whether it was intended to identify the Medicaid beneficiaries whose benefits meet the MEC standard. For other restricted benefits, valid value 5 comprised a very wide array of programs that range from the most comprehensive to the most limited. The value indicated that an individual was eligible for Medicaid or Medicaid-Expansion CHIP but for reasons other than alien, dual-eligibility, or pregnancy-related status was only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy or other criteria). Therefore, for every state, the data could not be used to cleanly differentiate between two critical groups of beneficiaries not entitled to full-scope benefits: (1) those with comprehensive coverage and (2) those with limited (non-comprehensive) coverage. Similarly, the description for valid value 5 did not specify whether this group is intended to include medically needy beneficiaries whose benefits meet the MEC standard. Additionally, because group 5 was defined so broadly, states could vary substantially in the types of beneficiaries they were reporting in this category.

States have also been inconsistent in their reporting of RESTRICTED-BENEFITS-CODE for their CHIP beneficiaries. In some cases, they have left the code blank for CHIP beneficiaries, but in other cases, states have been reporting CHIP beneficiaries as having restricted benefits because they perceive the CHIP package of benefits as limited compared with full-scope Medicaid benefits.

When reporting to RESTRICTED-BENEFITS-CODE, states should refer to the guidance in this section for additional clarification on how to interpret each of the valid values for this data element. In addition, the guidance includes information on the logical relationships between RESTRICTED-BENEFITS-CODE and other data elements in the T-MSIS Eligible file.

Six valid values for RESTRICTED-BENEFITS-CODE (values 1, 4, 7, A, B, and D) are intended to identify individuals who are eligible for comprehensive Medicaid or CHIP benefits, depending on the individual’s particular coverage, such as alternative benchmark-equivalent coverage, psychiatric residential treatment facility (PRTF) program, health opportunity accounts (HOA)^[3], or Money Follow the Person (MFP). . These six values are also intended to identify individuals who are eligible for comprehensive Medicaid or CHIP benefits via a traditional pathway. RESTRICTED-BENEFITS-CODE value 1 should be used for individuals who have full-scope benefits for either Medicaid or CHIP (Medicaid-Expansion or Separate CHIP). The other values represent comprehensive coverage options. RESTRICTED-BENEFITS-CODE value 4 should also be used for individuals who are entitled to restricted benefits for pregnancy-related services; this would encompass both pregnancy-related benefits that do and do not meet the MEC standard.^[4]

The following valid values for RESTRICTED-BENEFITS-CODE are intended to capture individuals who are eligible for a limited set of Medicaid or CHIP benefits because of certain circumstances.

• RESTRICTED-BENEFITS-CODE value 2 is intended for individuals who are eligible for a limited set of Medicaid or Medicaid Expansion CHIP benefits based on their noncitizen status, including qualified non-citizens who entered the United States before August 1996, qualified immigrants who entered at the end of the five -year waiting period, and qualified immigrants exempt from the five-year waiting period.
• RESTRICTED-BENEFITS-CODE value 6 is intended for individuals whose Medicaid benefits are restricted to family planning services, which may be received, for example, through a Section 1115 family planning demonstration. The value is not intended for individuals who may be eligible for services related to family planning via traditional Medicaid.

States should not leave RESTRICTED-BENEFITS-CODE blank for CHIP beneficiaries reported in their T-MSIS Eligible file submissions. If an individual is entitled to the full scope of Medicaid-Expansion or Separate CHIP benefits, states should code the individual as RESTRICTED-BENEFITS-CODE value 1 (individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits).

Some individuals eligible for Medicaid-Expansion CHIP may only be entitled to a limited set of CHIP benefits. States should use RESTRICTED-BENEFITS-CODE value 2 for individuals who are eligible for Medicaid-Expansion CHIP but whose benefits under this program are limited because of their noncitizen status. Medicaid-Expansion CHIP beneficiaries should never be reported with restricted benefits code value C (Individual is eligible for separate CHIP dental coverage [supplemental dental wraparound benefit to employer-sponsored insurance]).
Separate CHIP beneficiaries should never be reported with the following valid values for RESTRICTED-BENEFITS-CODE:

• 7: Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.
• A: Individual is eligible for Medicaid and entitled to benefits under the PRTF Demonstration Grant Program, as enacted by the Deficit Reduction Act of 2005.
• B: Individual is eligible for Medicaid and entitled to Medicaid benefits using a HOA
• D: Individual is eligible for Medicaid and entitled to benefits under a MFP rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities.
• 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.
• G: Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status Medicare Part B-Immunosuppressive Drug (ID) End-Stage Renal Disease (ESRD) Benefit.

In general, we would expect most Separate CHIP beneficiaries to be eligible for the full scope of CHIP benefits, but there are some noteworthy exceptions. Some individuals who are eligible for Separate CHIP also receive supplemental dental benefits in addition to health insurance coverage through an employer. Individuals who are enrolled in a Separate CHIP program and who receive a supplemental dental wraparound benefit to employer-sponsored insurance should be coded with RESTRICTED-BENEFITS-CODE value C. Such children are eligible to enroll in the dental-only supplemental coverage even if their group health plan or other health insurance coverage includes some dental benefits. In the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Congress added a provision that allows states to provide dental-only supplemental coverage to children who have health insurance coverage through an employer but are uninsured or underinsured with respect to dental coverage.^[5] Some states might use CHIP funds to cover pregnant women under the “unborn child” option^[6] or under an 1115 demonstration, in which case they would be classified under RESTRICTED-BENEFITS-CODE value 4 to indicate a restricted package of pregnancy-only services.

A change to the definition of RESTRICTED-BENEFITS-CODE value 5 and the addition of valid value E in May 2020 allows users to distinguish between other restricted benefits that do meet the MEC standard (valid value 5) and those that do not meet the MEC standard (new valid value E). RESTRICTED-BENEFITS-CODE value 5 is intended to capture all other individuals who are not eligible for full-scope Medicaid or Medicaid-Expansion CHIP benefits but whose benefits do meet the MEC standard. Some examples of what might be included in this code are benefits provided under a medically needy program, 1115 demonstrations that are not captured under Alternative Benefit Plans (RESTRICTED-BENEFIT-CODE value 7), tuberculosis-only coverage, or the inmate coverage exclusion.^[7] If a state offers limited benefits for medically needy individuals that do not meet the MEC standard, or if a state offers other benefits that neither fit into any other RESTRICTED-BENEFITS-CODE nor meet the MEC standard, the state should report these individuals to the new RESTRICTED-BENEFITS-CODE value E.

Table 1 lays out several scenarios for RESTRICTED-BENEFITS-CODE reporting and the relevant logical relationships for reporting to other data elements in the T-MSIS Eligible file. The relationships between some of these data elements and RESTRICTED-BENEFITS-CODE values is being assessed in the State Data Quality Technical Assistance (DQ TA) process. Also being assessed are the frequencies of the values reported for RESTRICTED-BENEFITS-CODE as well as the extent to which the reporting of this data element is complete.

Table 2: RESTRICTED-BENEFITS-CODE (ELG097) Logical Relationships with other Data Elements in the T-MSIS Eligible File