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Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification (Y/N) Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments 5b. Waiting period exception Lost other government funded coverage. This will be verified electonically through the State's #2 (describe): NO NO YES YES eligibility determination system. Paper documentation will be required only when electronic data is not available (e.g. loss of coverage in another state). The government entity will be called directly to resolve and only in rare instances paper documentation is needed. 5c. Waiting period exception #3 (describe): YES NO NO NO Chronically or seriously ill 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A 5g. Waiting period exception #7 (describe): N/A 5h. Waiting period exception #8 (describe): N/A 5i. Waiting period exception #9 (describe): N/A 5j. Waiting period exception #10 (describe): N/A 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12