DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
 
 
                  SMDL #04-007 
 
 
            December 3, 2004 
 
 
Dear State Medicaid Director:  
 
The purpose of this letter is to inform you of a change to the reporting specifications for 
the Medicaid Statistical Information System (MSIS).  This change is effective with the 
first quarterly tape submittals for Federal fiscal year (FFY) 2006 (the October - 
December 2005 quarter).  
 
Effective in FFY 1999, MSIS became the primary Federal reporting medium for general 
Medicaid program information, replacing the hard-copy HCFA-2082 report.  Under 
MSIS, states submit quarterly tape extracts of eligibles and claims data from their claims 
processing and administrative systems.  This change affects only the MSIS eligible tapes 
and no changes are required for the claims tape submittals.  It is documented in the 
attached MSIS Data Dictionary replacement pages and it will be available on our Web 
site at http://www.cms.hhs.gov/medicaid/msis at a later date.  
 
This change revises the reporting of the dual eligibility flag from quarterly to monthly 
beginning with the first quarterly tape submittals for FFY 2006 (the October - December 
2005 quarter).  The change from quarterly to monthly reporting of dual eligibility is 
required to provide improved program information for analysis of the dual eligibility 
population. 
 
Please forward this information, along with the attached modifications to the MSIS data 
dictionary, to the appropriate state staff.  We have an ongoing working relationship with 
the reporting staffs from the states, and look forward to providing any needed information 
or assistance to facilitate these changes.  
 
We very much appreciate your efforts to implement the dramatic improvements in 
program information represented by MSIS.  Please refer any questions or concerns  
 
 
 
 
  Page 2  State Medicaid Director 
 
regarding these MSIS changes to Roger Buchanan at (410) 786-0780 or 
rbuchanan@cms.hhs.gov.  
 
Sincerely, 
 
/s/ 
 
Dennis G. Smith 
 
Enclosure 
 
cc:  
CMS Regional Administrators 
  
CMS Associate Regional Administrators  
    for Medicaid and State Operations  
 
Kathryn Kotula  
Director, Health Policy Unit  
American Public Human Services Association  
 
Joy Wilson  
Director, Health Committee  
National Conference of State Legislatures  
 
Matt Salo  
Director of Health Legislation  
National Governors Association 
  
Brent Ewig  
Senior Director, Access Policy  
Association of State and Territorial Health Officials 
  
Jim Frogue  
Director, Health and Human Services Task Force  
American Legislative Exchange Council 
  
Trudi Matthews  
Senior Health Policy Analyst  
Council of State Governments 
 
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it 
displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-0345.  The time 
required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, 
search exiting data resources, gather the data needed, and complete and review the information collection.  If you have comments 
concerning the accuracy of the time estimate(s) or suggested for improving this form, please write to: CMS, 7500 Security Boulevard, 
Att: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.  Enclosure 
 
 
________________________________________________________________________ 
 
5.4  ELIGIBLE File - Physical Data Record Layout           
 
The following table summarizes the fields in the ELIGIBLE file record in the order in which they physically 
occur in each record (see Section 2, paragraph [e]).  Fields whose values remain fixed for an entire quarter 
are referred to as "root" fields; fields that vary monthly are listed separately for each month. 
 
 
  ELIGIBLE RECORD SUMMARY 
            DEFAULT 
- POSITION -  ERROR 
  FIELD NAME            COBOL PICTURE  START     END   TOLERANCE
 
ROOT FIELDS
 
MSIS-IDENTIFICATION-NUMBER  X(20)  01  20  0.1% 
DATE-OF-BIRTH  9(8)  21  28  0.1% 
DATE-OF-DEATH  9(8)  29  36  5.0% 
SEX-CODE  X(1)  37  37  2.0% 
RACE-ETHNICITY-CODE  9(1)  38  38  2.0% 
SOCIAL-SECURITY-NUMBER  9(9)  39  47  2.0% 
COUNTY-CODE  9(3)  48  50  5.0% 
ZIP-CODE  9(5)  51  55  5.0% 
TYPE-OF-RECORD  9(1)  56  56  2.0% 
FEDERAL-FISCAL-YEAR-QUARTER  9(5)  57  61  0.1% 
FILLER                                                                           X(2)   62  63   
HIC-NUMBER  X(12)  64  75  5.0% 
MSIS-CASE-NUMBER  X(12)  76  87  0.1% 
RACE-CODE-1  9(1)  88  88  5.0% 
RACE-CODE-2  9(1)  89  89  5.0% 
RACE-CODE-3  9(1)  90  90  5.0% 
RACE-CODE-4  9(1)  91  91  5.0% 
RACE-CODE-5  9(1)  92  92  5.0% 
ETHNICITY-CODE  9(1)  93  93  5.0% 
FILLER                                                                            X(9)    94  102   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
September 2004  23 
   
 
ELIGIBLE RECORD SUMMARY 
                   DEFAULT 
- POSITION -  ERROR 
FIELD NAME          COBOL PICTURE  START     END   TOLERANCE
MONTHLY FIELDS
 
MONTH 1: 
DAYS-OF-ELIGIBILITY  S9(2)  103  104  2.0% 
ELIGIBILITY-GROUP  X(6)  105  110  2.0% 
MAINTENANCE-ASSISTANCE-STATUS  X(1)  111  111  0.1% 
BASIS-OF-ELIGIBILITY  X(1)  112  112  0.1% 
HEALTH-INSURANCE  9(1)  113  113  5.0% 
TANF-CASH-FLAG  9(1)  114  114  2.0% 
RESTRICTED-BENEFITS-FLAG  9(1)  115  115  5.0% 
PLAN-TYPE-1  9(2)  116  117  5.0% 
PLAN-ID-1  X(12)  118  129  5.0% 
PLAN-TYPE-2  9(2)  130  131  5.0% 
PLAN-ID-2  X(12)  132  143  5.0% 
PLAN-TYPE-3  9(2)  144  145  5.0% 
PLAN-ID-3  X(12)  146  157  5.0% 
PLAN-TYPE-4  9(2)  158  159  5.0% 
PLAN-ID-4  X(12)  160  171  5.0% 
SCHIP-CODE  X(1)  172  172  5.0% 
INCOME-CODE  X(2)  173  174  5.0% 
WAIVER-TYPE-1             X(1)             175            175        5.0% 
WAIVER-ID-1         X(2)  176  177  5.0% 
WAIVER-TYPE-2  X(1)  178  178  5.0% 
WAIVER-ID-2  X(2)  179  180  5.0% 
WAIVER-TYPE-3  X(1)  181  181  5.0% 
WAIVER-ID-3            X(2)              182            183           5.0%                     
DUAL-ELIGIBLE-CODE                         X(2)             184            185         2.0%                   
FILLER              X(8)             186            193 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
September 2004  24 
 
 
  ____________________________________________________________________________________ 
 
 
ELIGIBLE RECORD SUMMARY 
DEFAULT 
- POSITION -      ERROR 
FIELD NAME          COBOL PICTURE  START     END   TOLERANCE
MONTHLY FIELDS
 
 
MONTH 2: 
DAYS-OF-ELIGIBILITY  S9(2)  194  195  2.0% 
ELIGIBILITY-GROUP  X(6)  196  201  2.0% 
MAINTENANCE-ASSISTANCE-STATUS  X(1)  202  202  0.1% 
BASIS-OF-ELIGIBILITY  X(1)  203  203  0.1% 
HEALTH-INSURANCE  9(1)  204  204  5.0% 
TANF-CASH-FLAG  9(1)  205  205  2.0% 
RESTRICTED-BENEFITS-FLAG  9(1)  206  206  5.0% 
PLAN-TYPE-1  9(2)  207  208  5.0% 
PLAN-ID-1  X(12)  209  220  5.0% 
PLAN-TYPE-2  9(2)  221  222  5.0% 
PLAN-ID-2  X(12)  223  234  5.0% 
PLAN-TYPE-3  9(2)  235  236  5.0% 
PLAN-ID-3  X(12)  237  248  5.0% 
PLAN-TYPE-4  9(2)  249  250  5.0% 
PLAN-ID-4  X(12)  251  262  5.0% 
SCHIP-CODE  X(1)  263  263  5.0% 
INCOME-CODE  X(2)  264  265  5.0% 
WAIVER-TYPE-1  X(1)  266  266  5.0% 
WAIVER-ID-1  X(2)  267  268  5.0% 
WAIVER-TYPE-2  X(1)  269  269  5.0% 
WAIVER-ID-2  X(2)  270  271  5.0% 
WAIVER-TYPE-3  X(1)  272  272  5.0% 
WAIVER-ID-3  X(2)  273  274  5.0% 
DUAL-ELIGIBLE-CODE  X(2)  275  276  2.0% 
FILLER  X(8)  277  284 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
September 2004  24.1 
 
 
  ______________________________________________________________________________________ 
 
 
  ELIGIBLE RECORD SUMMARY 
 
DEFAULT 
- POSITION -     ERROR 
FIELD NAME          COBOL PICTURE  START     END   TOLERANCE
 
MONTH 3: 
DAYS-OF-ELIGIBILITY  S9(2)  285  286  2.0% 
ELIGIBILITY-GROUP  X(6)  287  292  2.0% 
MAINTENANCE-ASSISTANCE-STATUS  X(1)  293  293  0.1% 
BASIS-OF-ELIGIBILITY  X(1)  294  294  0.1% 
HEALTH-INSURANCE  9(1)  295  295  5.0% 
TANF-CASH-FLAG  9(1)  296  296  2.0% 
RESTRICTED-BENEFITS-FLAG  9(1)  297  297  5.0% 
PLAN-TYPE-1  9(2)  298  299  5.0% 
PLAN-ID-1  X(12)  300  311  5.0% 
PLAN-TYPE-2  9(2)  312  313  5.0% 
PLAN-ID-2  X(12)  314  325  5.0% 
PLAN-TYPE-3  9(2)  326  327  5.0% 
PLAN-ID-3  X(12)  328  339  5.0% 
PLAN-TYPE-4  9(2)  340  341  5.0% 
PLAN-ID-4  X(12)  342  353  5.0% 
SCHIP-CODE  X(1)  354  354  5.0% 
INCOME-CODE  X(2)  355  356  5.0% 
WAIVER-TYPE-1  X(1)  357  357  5.0% 
WAIVER-ID-1  X(2)  358  359  5.0% 
WAIVER-TYPE-2  X(1)  360  360  5.0% 
WAIVER-ID-2  X(2)  361  362  5.0% 
WAIVER-TYPE-3  X(1)  363  363  5.0% 
WAIVER-ID-3  X(2)  364  365  5.0% 
DUAL-ELIGIBLE-CODE  X(2)  366  367  2.0% 
FILLER     X(8)  368  375 
 
 
The  error tolerance describes, for each field, the maximum allowable percentage of records submitted that 
may have missing, unknown, or invalid codes.  Error rates in excess of the error tolerance level for any field 
will cause the entire file to be rejected. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
September 2004  25
  ______________________________________________________________________________________ 
 
ELIGIBLE FILE
 
Data Element Name: DUAL-ELIGIBLE-CODE   
 
Definition: Monthly Field - Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) 
and eligible for some category of Medicaid benefits.  
 
Field Description: 
 
COBOL  Error  Example 
PICTURE  Tolerance  Value   
 
9(2)  2.0%  00   
 
Coding Requirements: 
 
Valid Values  Code Definition
 
00  Eligible is not a Medicare beneficiary 
01  Eligible is entitled to Medicare- QMB only 
02  Eligible is entitled to Medicare- QMB AND Medicaid coverage including RX 
  (Medicaid drug coverage criterion only applies through December 2005) 
03  Eligible is entitled to Medicare- SLMB only 
04  Eligible is entitled to Medicare- SLMB AND Medicaid coverage including RX 
  (Medicaid drug coverage criterion only applies through December 2005) 
05  Eligible is entitled to Medicare- QDWI 
06  Eligible is entitled to Medicare- Qualifying individuals 
 
08  Eligible is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB,QWDI or 
QI) with Medicaid coverage including RX (Medicaid drug coverage criterion 
only applies through December 2005) 
09  Eligible is entitled to Medicare  Other Dual Eligibles  
99  Eligible's Medicare status is unknown. 
 
00. Eligible Is Not a Medicare Beneficiary - The individual is not entitled to Medicare coverage.  
 
Medicare Dual Eligibles - The following describes the various categories of individuals who, collectively, 
are known as dual eligibles.  Medicare has two basic coverages:  Part A, which pays for hospitalization 
costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, 
and outpatient and other services.  Dual eligibles are individuals who are entitled to Medicare Part A and/or 
Part B and are eligible for some form of Medicaid benefit. 
 
01. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals 
are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that 
do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid.  Medicaid 
pays their Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and 
coinsurance for Medicare services provided by Medicare providers. 
 
02.  QMBs with Medicaid Coverage (QMB Plus).   These individuals are entitled to Medicare Part A, have 
income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility.  Through 
2005, individuals in this group qualify for one or more Medicaid benefits including prescription drug 
coverage.  Effective 2006, they qualify for one or more Medicaid benefits that do not include prescription 
drugs.  Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare 
deductibles  and  coinsurance,  and  provides  one  or  more  Medicaid  benefits.    QMB  individuals  with 
prescription drug coverage are included in this group through December 2005.  Beginning in 
January 2006, Part D provides drug coverage for these individuals, and Medicaid drug benefits are 
not required for an individual to be reported in this group.
 
 
September 2004         34 
  ______________________________________________________________________________________ 
 
ELIGIBLE FILE 
 
Data Element Name: DUAL-ELIGIBLE-CODE (continued) 
 
03. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - 
These individuals are entitled to Medicare Part A, have income of 100 -120% FPL and resources that do not 
exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.  Medicaid pays their 
Medicare Part B premiums only. 
 
04. SLMBs with  Medicaid Coverage (SLMB Plus).   These individuals are entitled to Medicare Part A, 
have income of 100-120% FPL and resources that do not exceed twice the limit for SSI eligibility.  Through 
2005, individuals in this group qualify for one or more Medicaid benefits including prescription drug 
coverage.  Effective 2006, they qualify for one or more Medicaid benefits that do not include prescription 
drugs.    Medicaid pays their Medicare Part B premiums and provides one or more Medicaid benefits.  
SLMB individuals with prescription drug coverage are included in this group through December 
2005.  Beginning in January 2006, Part D provides drug coverage for these individuals, and Medicaid 
drug benefits are not required for an individual to be reported in this group.  
 
05. Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A 
benefits due to their return to work.  They are eligible to purchase Medicare Part A benefits, have income of 
200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise 
eligible for Medicaid.  Medicaid pays the Medicare Part A premiums only. 
 
06. Qualifying Individuals (QIs) - There is an annual cap on the amount of money available, which may 
limit the number of individuals in the group.  These individuals are entitled to Medicare Part A, have income 
of 120 -135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise 
eligible for Medicaid.  Medicaid pays their Medicare Part B premiums only with 100% Federal funding. 
 
08. Other Dual Eligibles with Medicaid Coverage (Non QMB, SLMB, QDWI or QI) - These individuals are 
entitled to Medicare Part A and/or Part B and are eligible for one or more Medicaid benefits including 
prescription drug coverage.  They are not eligible for Medicaid as a QMB, SLMB, QDWI or QI.  Typically, 
these individuals need to spend down to qualify for Medicaid or fall into a Medicaid poverty group that 
exceeds the limits listed above.  Through December 2005, individuals in this group qualify for one or more 
Medicaid benefits including prescription drug coverage.  Beginning in January 2006, Part D provides 
drug coverage for these individuals, and Medicaid drug benefits are not required for an individual to 
be reported in this group. Medicaid pays for Medicaid services provided by Medicaid providers, but only to 
the extent that the Medicaid rate exceeds any Medicare payment for services covered by both Medicare and 
Medicaid.  Payment by Medicaid of Part B premiums is a state option. 
 
09. Other Dual Eligibles (e.g, Pharmacy + Waivers; states not including prescription drugs in Medicaid 
benefits for some groups)  Special dual eligible groups not included above, but approved under special 
circumstances.  This code is to be used only with specific CMS approval. 
 
Error Condition                                                                                                                  Resulting Error Code
 
1.  Value is Non-Numeric - Reset to 9-filled..........................................................................812 
 
2.  Value is 99................................................................................................................301 
 
3.  Value is < 00 OR Value is > 09 ......................................................................................203 
 
4.  Relational Field in Error................................................................................................999 
 
5.  If Value={01, 03, 05, OR 06} AND MAINTENANCE-ASSISTANCE-STATUS <>3"................503 
 
September 2004             35