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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

EL-11-001-1

Data Quality Measure
Last updated

Key Information

Measure Name % of full duals (DUAL-ELIGIBLE-CODE = 02, 04, and 08) receiving private health insurance (TPL-HEALTH-INSURANCE = 1)
File Type ELG
Measure ID EL-11-001-1
Measure Type Non-Claims Percentage
Content area ELG MULTI TPL TPL

Validation

Validation Type Inferential

Measure Priority

Measure Priority Medium
Focus Area N/A
Category Program participation

Claim Information

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

Thresholds

Minimum 0
Maximum 0.5
TA Minimun 0
TA Maximum 0.6
Longitudinal Threshold N/A
For TA
(for including in compliance training) 		TA- Inferential
For TA
(Longitudinal) 		No

Data Elements

DD Data Element MSIS-IDENTIFICATION-NUM • DUAL-ELIGIBLE-CODE • TPL-HEALTH-INSURANCE-COVERAGE-IND
DD Data Element Number ELG082 • ELG085 • TPL020

Annotation Compute the percentage of full dual-eligibles receiving private insurance
Specification STEP 1: Enrolled on the last day of DQ report month

Define 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 missing

3. MSIS-IDENTIFICATION-NUM is not missing



STEP 2: Eligibility determinants on the last day of DQ report month

Using 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 = 1

2a. ELIGIBILITY-DETERMINANT-EFF-DATE <= last day of the DQ report month

3a. ELIGIBILITY-DETERMINANT-END-DATE >= last day of the DQ report month OR missing

OR

2b. ELIGIBILITY-DETERMINANT-EFF-DATE is missing

3b. ELIGIBILITY-DETERMINANT-END-DATE is missing



STEP 3: Unique Full Duals

Of the MSIS IDs that meet the criteria from STEP 2, further refine the population using:

1. DUAL-ELIGIBLE-CODE = “02” or “04” or “08”



STEP 4: TPL eligible person on the last day of DQ report month

Using the MSIS IDs that meet the criteria from STEP 3, join to segment TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 by keeping active records that satisfy the following criteria:

1a. ELIG-PRSN-MAIN-EFF-DATE <= last day of the DQ report month

2a. ELIG-PRSN-MAIN-END-DATE >= last day of the DQ report month OR missing

OR

1b. ELIG-PRSN-MAIN-EFF-DATE is missing

2b. ELIG-PRSN-MAIN-END-DATE is missing



STEP 5: Private health insurance

Of the MSIS IDs that meet the criteria from STEP 4, select those with private insurance:

1. TPL-HEALTH-INSURANCE-COVERAGE-IND = "1"



STEP 6: Calculate percentage

Divide the count of unique MSIS IDs from STEP 5 by the count of unique MSIS IDs from STEP 3