ELG.005.097

RESTRICTED-BENEFITS-CODE

Data Element

DE Number

ELG097

System DE Number

ELG.005.097

File Name

ELG - ELIGIBLE

File Segment Number

ELG00005

File Segment Name

ELIGIBILITY-DETERMINANTS

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.
Size	X(1)
FLF Start Position	79
FLF Stop Position	79
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in Restricted Benefits Code List (VVL) 3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23" 6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25" 7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00" 8. Mandatory 9. If value is "6" then Eligibility Group(ELG.005.087) must be in [35,70] 10. If value is "7" then Eligibility Group (ELG.005.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06" 11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F" 12. (Non-Citizen) if value equals "2", then associated IMMIGRATION-STATUS (ELG.003.042) value must be equal to "3" 13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment 14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23" 15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25" 16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-2154	If restricted benefits code is populated on an eligibility determinants segment from an ELG file, then the restricted benefits code value reported must be in the list of valid values for restricted benefits code.
RULE-6490	If a segment is an eligibility determinants segment from an ELG file, the restricted benefits code value reported must be compatible with the specified T-MSIS picture format: X(1).
RULE-7370	If a segment is a eligibility determinants segment from an ELG file, and the MSIS ID is populated,then the restricted benefits code must be populated.
RULE-7421	If a segment is an eligibility determinants segment from an ELG file, and the MSIS ID is populated and the dual eligible code is equal to one of the following values: '01', '03', '05', '06' and the primary eligibility group indicator is equal to '1' and the eligibility determinant effective and end dates overlap with the reported enrollment effective and end dates, then restricted benefits code is equal to '3'.
RULE-7427	If a segment is a waiver participation segment from an ELG file, and the waiver participation segment has a family planning demonstration waiver type and and waiver participation end date is greater than the states T-MSIS cutover date and the effective and end dates on the waiver participation segment fall within the effective and end dates of one or more continuous eligibility determinants segments, and the eligibility determinants has a primary eligibility group indicator equal to '1', then the restricted benefits code is equal to '6'.
RULE-7428	If restricted benefits code is for S-CHIP dental on an eligibility determinants segment from an ELG file, and the eligibility determinants has a primary eligibility group indicator equal to '1' and the eligibility determinants end date is greater than or equal to the T-MSIS cutover date, then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous variable demographics eligibility segments and the CHIP code must be for S-CHIP for the month on the variable demographic eligibility segment.
RULE-7429	If MSIS ID is populated on an mfp information segment from an ELG file and the MFP information end date is greater than or equal to the T-MSIS cutover date, then the effective date and end date on the mfp information segment must fall within the effective and end dates of one or more continuous eligibility determinants segments and the primary eligibility group indicator is equal to '1' and the restricted benefits code must be for Medicaid Money Follows the Person (MFP) rebalancing demonstration on the eligibility determinants segment.
RULE-7529	If restricted benefits code is for restricted benefits based on noncitizen status on an eligibility determinants segment from an ELG file, and eligibility determinants has a primary eligibility group indicator equal to '1' and the eligibility determinants end date is greater than or equal to the T-MSIS cutover date, then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous variable demographics eligibility segments and the immigration status must be for a noncitizen eligible only for payment for emergency services on the variable demographics eligibility segment.
RULE-7810	If restricted benefits code is for Money Follows the Person (MFP) on an eligibility determinants segment from an ELG file, and the primary eligibility group indicator is equal to '1' and the eligibility determinants end date is greater than or equal to the T-MSIS cutover date, then the effective date and end date on the eligibility determinants segment must fall within the effective and end dates of one or more continuous mfp information segments.

Measure ID	Measure Name
EL-6-043-43	% of MSIS IDs Age 19 - 64 with restricted benefits (RESTRICTED-BENEFITS-CODE = "02", "03", or "06")
EL-6-034-34	% of MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1
EL-6-032-35	% of MSIS IDs with restricted benefits code designating MFP participation (RESTRICTED-BENEFITS-CODE = D) that are not found on MFP-INFORMATION-ELG00010 for the same month
EL-6-037-37	% of MSIS IDs with an IMMIGRATION-STATUS = 3 (Eligible for payment for emergency services only) but RESTRICTED-BENEFITS-CODE does not equal 2 or 4
RULE-7427	Family Planning (FP): % of FP-waiver segments (WAIVER TYPE = 24) that do not have RESTRICTED-BENEFITS-CODE = 6 (FP)
EL-3-029-38	% of MSIS IDs with RESTRICTED-BENEFITS-CODE = "4" that have SEX = “M”
RULE-7370	% of segments missing RESTRICTED-BENEFITS-CODE (ELG00005)
RULE-7411	% of segments indicating family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning eligibility group
EL-6-039-39	% of MSIS IDs with a RESTRICTED-BENEFITS-CODE = 2 (Noncitizen restricted benefits code status)
EL-6-042-42	% of MSIS IDs Age < 19 with restricted benefits (RESTRICTED-BENEFITS-CODE = "02", "03", or "06")
EL-6-033-33	% of MSIS IDs with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but a non-qualified alien immigration status (IMMIGRATION-STATUS not 1, 2, 3, or 4)
EL-6-044-44	% of MSIS IDs Age 65+ with restricted benefits (RESTRICTED-BENEFITS-CODE = "02", "03", or "06")
EL-6-045-45	% of MSIS IDs Age < 19 without a valid Restricted Benefits Code
EL-6-046-46	% of MSIS IDs Age 19 - 64 without a valid Restricted Benefits Code
EL-6-047-47	% of MSIS IDs Age 65+ without a valid Restricted Benefits Code
RULE-2157	% of record segments with an alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but CITIZENSHIP-IND = 1 or 2 (U.S. Citizen or U.S. National)
RULE-7529	% of record segments with an alien noncitizen restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) but IMMIGRATION-STATUS does not equal 3 (Eligible for payment for emergency services only)
EL-3-033-42	% of MSIS IDs with ELIGIBILITY-GROUP = 11 (Individuals Receiving SSI) without full benefits
RULE-7420	% of segments (RESTRICTED-BENEFITS-CODE = 3) without a partial dual code (DUAL-ELIGIBLE-CODE not 01, 03, 05, 06)
RULE-7421	% of segments (DUAL-ELIGIBLE-CODE = 01, 03, 05, 06) without an RBC of dual (RESTRICTED-BENEFITS-CODE not 3)
EL-6-025-25	% family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning eligibility group
EL-6-011-11	# of MFP participants also identified with a Restricted Benefits flag designating MFP participation (RESTRICTED-BENEFITS-CODE = D)
EL-15-001-1	% difference between full-benefit T-MSIS enrollment count (EL-6-023-23) and PI enrollment count (Medicaid + CHIP)
EL-6-023-23	# of full-benefit enrollees
EL-6-024-24	Restricted Benefit Code values
ALL-13-001-1	% of MSIS IDs limited to family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning services (PROGRAM-TYPE not equal 2)
ALL-13-002-2	% of MSIS IDs limited to family planning (RESTRICTED-BENEFITS-CODE = 6) with non-family planning services (PROGRAM-TYPE not equal 2)
ALL-13-003-3	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with non-emergency room services
ALL-13-004-4	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with non-emergency room services
EL-6-022-22	Family Planning (FP): % MSIS IDs with FP-waivers (WAIVER TYPE = 24) that have RESTRICTED-BENEFIT-CODE = 6 (FP)
EL-10-004-5	% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02, 03, or 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01)
ALL-13-003-5	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related
ALL-13-004-6	% of MSIS IDs with alien restricted benefits code status (RESTRICTED-BENEFITS-CODE = 2) with services that are not emergency room or pregnancy-related
EL-6-026-26	% of RBC duals (RESTRICTED-BENEFITS-CODE = 3 or G) without a partial dual code (DUAL-ELIGIBLE-CODE not 01, 03, 05, 06)
EL-6-027-27	% of partial duals (DUAL-ELIGIBLE-CODE = 01, 03, 05, 06) without an RBC of dual (RESTRICTED-BENEFITS-CODE not 3 or G)
MIS-1-032-32	% distinct MSIS IDs with only missing values in any active segment: RESTRICTED-BENEFITS-CODE (ELG00005)
EL-6-030-30	% of MSIS IDs with S-CHIP dental coverage (RESTRICTED-BENEFITS-CODE = C) that are not S-CHIP (CHIP-CODE not 3)
EL-6-031-31	% of MFP participants that do not have restricted benefits code designating MFP participation (RESTRICTED-BENEFITS-CODE not D)
EL-6-032-32	% of MSIS IDs with restricted benefits code designating MFP participation (RESTRICTED-BENEFITS-CODE = D) that are not found on MFP-INFORMATION-ELG00010 for the same month

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
11/06/2026	4.0.40	ELG.005.097	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is in [1,7] then Eligibility Group (ELG.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated IMMIGRATION-STATUS (ELG.003.042) value must be equal to "3"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.005.087) must be in [35,70]10. If value is "7" then Eligibility Group (ELG.005.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated IMMIGRATION-STATUS (ELG.003.042) value must be equal to "3"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]
10/08/2026	4.0.38	ELG.005.097	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is in [1,7] then Eligibility Group (ELG.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is in [1,7] then Eligibility Group (ELG.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated IMMIGRATION-STATUS (ELG.003.042) value must be equal to "3"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]
04/24/2025	4.0.7	ELG.005.097	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is in [1,7] then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]	1. Value must be 1 character2. Value must be in Restricted Benefits Code List (VVL)3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"8. Mandatory9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is in [1,7] then Eligibility Group (ELG.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]
09/16/2024	4.0.0	ELG.005.097	UPDATE	File segment	None	48
09/16/2024	4.0.0	ELG.005.097	ADD	N/A		Created