EL-11-001-1

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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 Type	Inferential

Measure Priority	Medium
Focus Area	N/A
Category	Program participation

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

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

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

Annotation	N/A
Specification	N/A

Published Date	Data Guide Version	DQM	Action	Field	Before	After
11/20/2025	4.0.22	EL-11-001-1	UPDATE	Annotation	Compute the percentage of full dual-eligibles receiving private insurance	N/A
11/20/2025	4.0.22	EL-11-001-1	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 month 3a. 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: Unique Full DualsOf 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 monthUsing 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 month2a. ELIG-PRSN-MAIN-END-DATE >= last day of the DQ report month OR missingOR1b. ELIG-PRSN-MAIN-EFF-DATE is missing2b. ELIG-PRSN-MAIN-END-DATE is missingSTEP 5: Private health insuranceOf 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 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-11-001-1	ADD	N/A		Created

EL-11-001-1

Key Information

Validation

Measure Priority

Claim Information

Thresholds

Data Elements