Restricted benefits (Apr)

SAS Name

EL_RSTRCT_BNFT_FLG_4

CODE INDICATING THE SCOPE OF MEDICAID BENEFITS TO WHICH AN ELIGIBLE IS ENTITLED FOR THE RESPECTIVE MONTH.

Comments

USER NOTE: X IS ASSIGNED WHEN WE FIND A MONTHLY PHARMACY PLUS STATE-SPECIFIC ELIGIBILITY CODE AND MONTHLY ELIGIBLE MEDICARE BENEFICIARY CODE VALUE = 0. Y IS ASSIGNED WHEN WE FIND A MONTHLY PHARMACY PLUS STATE-SPECIFIC ELIGIBILITY CODE AND MONTHLY ELIGIBLE MEDICARE BENEFICIARY CODE VALUE = 1, 2, OR 3 AND MONTHLY MEDICARE DUAL CODE = 51, 53 OR 56. Z IS ASSIGNED WHEN WE FIND A MONTHLY PHARMACY PLUS STATE-SPECIFIC ELIGIBILITY CODE AND MONTHLY ELIGIBLE BENEFICIARY CODE VALUE = 1, 2, OR 3 AND MONTHLY MEDICARE DUAL CODE IS NOT = 51, 53, OR 56.
USER NOTE: WHEN SOMEONE HAS CLAIMS BUT NO ELIGIBILITY INFORMATION, THIS DATA ELEMENT IS 9-FILLED.
NOTE: IN MAX 2006, VALUES 7, 8, A, AND B WERE ADDED TO THE FILE.
NOTE: IN MAX 2008, VALUE W WAS ADDED TO THE FILE AND A CLARIFICATION NOTE WAS ADDED ABOUT THE VALUE ASSIGNED WHEN SOMEONE HAS CLAIMS BUT NO ELIGIBILITY INFORMATION.
NOTE: IN MAX 2009, ENROLLMENT IN PREMIUM ASSISTANCE PROGRAMS (VALUE W) WAS EXPANDED TO INCLUDE ADDITIONAL STATES BUT ONLY WHEN THE ENROLLEES WERE CLEARLY IDENTIFIABLE.
NOTE: IN MAX 2010, NEW JERSEY WAS ADDED TO THE LIST OF STATES WITH ENROLLMENT IN PREMIUM ASSISTANCE PROGRAMS (VALUE W).

SOURCE: MSIS ELIGIBILITY FILES: 'RESTRICTED-BENEFITS-FLAG'.

Code	Code value
0	INDIVIDUAL IS NOT ELIGIBLE FOR MEDICAID DURING THE MONTH.
1	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH AND IS ENTITLED TO THE FULL SCOPE OF MEDICAID BENEFITS.
2	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH BUT ONLY ENTITLED TO RESTRICTED BENEFITS BASED ON ALIEN STATUS (INCLUDING ILLEGAL ENTRANTS AND LEGAL ENTRANTS DURING THE 5-YEAR WAITING PERIOD).
3	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH BUT ONLY ENTITLED TO RESTRICTED BENEFITS BASED ON MEDICAID DUAL ELIGIBILITY STATUS (E.G. QMB ONLY OR SLMB ONLY).
4	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH BUT ONLY ENTITLED TO RESTRICTED BENEFITS FOR PREGNANCY-RELATED SERVICES.
5	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH BUT ONLY ENTITLED TO RESTRICTED BENEFITS FOR REASONS OTHER THAN ALIEN, DUAL ELIGIBILITY OR PREGNANCY-RELATED STATUS (E.G. RESTRICTED BENEFITS BASED UPON SUBSTANCE ABUSE, MEDICALLY NEEDY OR OTHER CRITERIA).
6	INDIVIDUAL IS ELIGIBLE FOR MEDICAID, BUT ONLY ENTITLED TO RECEIVE FAMILY PLANNING SERVICES (BEGINNING IN 2001)
7	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND ENTITLED TO MEDICAID BENEFITS UNDER AN ALTERNATIVE PACKAGE OF BENCHMARK-EQUIVALENT COVERAGE.
8	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND ENTITLED TO BENEFITS UNDER A "MONEY FOLLOWS THE PERSON" (MFP) REBALANCING DEMONSTRATION, AS ENACTED BY THE DEFICIT REDUCTION ACT OF 2005, TO ALLOW STATES TO DEVELOP COMMUNITY BASED LONG TERM CARE OPPORTUNITIES.
9	INDIVIDUAL'S BENEFIT RESTRICTIONS ARE UNKNOWN.
A	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND ENTITLED TO BENEFITS UNDER THE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES DEMONSTRATION GRANT PROGRAM (PRTF), AS ENACTED BY THE DEFICIT REDUCTION ACT OF 2005. PRTF GRANTS ASSIST STATES TO HELP PROVIDE COMMUNITY ALTERNATIVES TO PSYCHIATRIC RESIDENT TREATMENT FACILITIES FOR CHILDREN.
B	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND ENTITLED TO MEDICAID BENEFITS USING A HEALTH OPPORTUNITY ACCOUNT (HOA).
C	INDIVIDUAL IS ELIGIBLE FOR SEPARATE CHIP DENTAL COVERAGE (SUPPLEMENTAL DENTAL WRAPAROUND BENEFIT TO EMPLOYER-SPONSORED INSURANCE).
W	INDIVIDUAL IS ONLY ELIGIBLE FOR MEDICAID HEALTH INSURANCE PREMIUM PAYMENT ASSISTANCE (NO ADDITIONAL TITLE XIX or XXI FFS OR MANAGED CARE WRAPAROUND SERVICES) IN MASSACHUSETTS, NEW JERSEY, OKLAHOMA, OR VERMONT.
X	INDIVIDUAL IS ELIGIBLE FOR MEDICAID DURING THE MONTH BUT ONLY ENTITLED TO RECEIVE PRESCRIPTION DRUG BENEFITS (BEGINNING IN 2003)
Y	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND MEDICARE DURING THE MONTH BUT ONLY ENTITLED TO RECEIVE PRESCRIPTION DRUG BENEFITS AND RESTRICTED BENEFITS BASED ON MEDICAID DUAL ELIGIBILITY STATUS (E.G. QMB ONLY, SLMB ONLY, OR QDWI OR QI). (BEGINNING IN 2003)
Z	INDIVIDUAL IS ELIGIBLE FOR MEDICAID AND MEDICARE DURING THE MONTH BUT ONLY ENTITLED TO RECEIVE PRESCRIPTION DRUG BENEFITS. THE EDB LINK FOUND THAT THE INDIVIDUAL WAS ALSO ELIGIBLE FOR MEDICARE, BUT THE MEDICAID PROGRAM WAS NOT PAYING RESTRICTED BENEFITS BASED ON MEDICAID DUAL ELIGIBILITY STATUS (E.G. QMB ONLY, SLMB ONLY, QDWI OR QI). (BEGINNING IN 2003)