EL-10-004-5

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Measure Name	% of MSIS IDs with restricted benefit (RESTRICTED-BENEFITS-CODE = 02, 03, or 06) enrolled in comprehensive managed care (MANAGED-CARE-PLAN-TYPE = 01)
File Type	ELG
Measure ID	EL-10-004-5
Measure Type	Non-Claims Percentage
Content area	ELG MCR MULTI

Validation Type	Inferential

Measure Priority	Medium
Focus Area	Managed care
Category	Program participation

Claim Type	N/A
Adjustment Type	N/A
Crossover Type	N/A

Minimum	0
Maximum	0.3
TA Minimun	0
TA Maximum	0.4
Longitudinal Threshold	N/A
For TA (for including in compliance training)	TA- Inferential
For TA (Longitudinal)	No

DD Data Element	RESTRICTED-BENEFITS-CODE • MSIS-IDENTIFICATION-NUM • MANAGED-CARE-PLAN-TYPE
DD Data Element Number	ELG097 • ELG082 • ELG193

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EL-10-004-5	UPDATE	Annotation	Calculate the percentage of restricted benefit eligibles enrolled in comprehensive managed care	N/A
11/20/2025	4.0.22	EL-10-004-5	UPDATE	Specification	STEP 1: Enrolled on the last day of DQ report monthDefine the eligible population from segment ENROLLMENT-TIME-SPAN-ELG00021 by keeping active records that satisfy the following criteria:1. ENROLLMENT-EFF-DATE <= last day of the DQ report month 2. ENROLLMENT-END-DATE >= last day of the DQ report month OR missing3. MSIS-IDENTIFICATION-NUM is not missingSTEP 2: Eligibility determinants on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 1, join to segment ELIGIBILITY-DETERMINANTS-ELG00005 by keeping records that satisfy the following criteria:1. PRIMARY-ELIGIBILITY-GROUP-IND = 12a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missingOR2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing3b. ELIGIBILITY-DETERMINANT-END-DATE is missingSTEP 3: Restricted benefit eligiblesOf the MSIS IDs that meet the criteria from STEP 2, further refine the population using RESTRICTED-BENEFITS-CODE = (“2” or “3” or “6”)STEP 4: Managed care enrollment on the last day of DQ report monthUsing the MSIS IDs that meet the criteria from STEP 3, join to segment MANAGED-CARE-PARTICIPATION-ELG00014 by keeping records that satisfy the following criteria:1a. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE <= last day of the DQ report month2a. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE >= last day of the DQ report month OR missingOR1b. MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE is missing2b. MANAGED-CARE-PLAN-ENROLLMENT-END-DATE is missingSTEP 5: Identify individuals in a comprehensive managed care planSelect MSIS IDs from STEP 4 where MANAGED-CARE-PLAN-TYPE = "01"STEP 6: Calculate percentageDivide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3	N/A
04/24/2025	4.0.7	EL-10-004-5	ADD	N/A		Created

EL-10-004-5

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements