CMS Technical Instructions: Reporting ELIGIBILITY-TERMINATION-REASON Following an Individual’s Loss of Eligibility

Complete and consistent state reporting of an individual’s eligibility status, including any changes, will be a critical component of CMS monitoring states’ transitions back to normal eligibility and enrollment operations in Medicaid and the Children’s Health Insurance Program (CHIP) after the end of the Public Health Emergency. This technical instruction document notes expectations for state reporting of ELIGIBILITY-TERMINATION-REASON (ELG095), previously known as ELIGIBILITY-CHANGE-REASON in the ELIGIBILITY-DETERMINANTS-ELG00005 segment of the T-MSIS Eligible File as well as reporting guidelines for several new data elements in the ELG0005 segment.

ELIGIBILITY-TERMINATION-REASON, which is on the ELIGIBILITY-DETERMINANTS-ELG00005 segment, should be populated when a change to an individual’s eligibility status results in a complete loss/termination of coverage. Using a default such as value ‘21’ (Unknown) or ‘22’ (Other) for all circumstances is not valid. If “22” (Other) value is reported, the ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT must be populated with a state-specific reason for termination.

Information about changes to an individual’s eligibility status should be identified using a state’s eligibility determination system. For example, if an individual qualified for Medicaid via Modified Adjusted Gross Income (MAGI) and now has excess income that no longer qualifies that individual for Medicaid, a value of ‘01’ (Excess income) should be reported in the ELIGIBILITY-TERMINATION-REASON data element field on the individual’s last ELIGIBILITY-DETERMINANTS-ELG00005 segment containing the eligibility group that the beneficiary is no longer eligible for beyond the end date of the segment.

ELIGIBILITY-REDETERMINATION-DATE, ELIGIBILITY-EXTENSION-CODE, and CONTINUOUS-ELIGIBILITY-CODE are new data elements as of the T-MSIS V4.0 Data Dictionary. ELIGIBILITY-REDETERMINATION-DATE should be populated with a valid date value that represents the last date the state is required to perform a renewal or redetermination of the individual’s eligibility. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported.

ELIGIBILITY-EXTENSION-CODE should be reported with a code from the T-MSIS Valid Values List that identifies the authority used to extend eligibility during the period of coverage. This code should correspond to the eligibility characteristics, including eligibility redetermination date, with which the code is being reported. If the authority used to extend eligibility is not stated in the Valid Values, the state can report a value of “995” (Other) and report the authority in the ELIGIBILITY-EXTENSION-OTHER-TEXT field.

Similarly, CONTINUOUS-ELIGIBILITY-CODE should be reported with a code from the T-MSIS Valid Values List that identifies the authority used to provide continuous eligibility during the period of coverage. If the authority is not stated in the Valid Values, the state can report a value of “995” (Other) and report the authority in the CONTINUOUS-ELIGIBILITY-OTHER-TEXT field.