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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: California Effective Date: (mm/dd/yyyy) 7/11/23 Section C . Additional Factors of Eligibility for Separate CHIP 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 1. Applicant does not have other coverage YES NO NO NO Must be Applied For the majority of cases, the State will accept self-attestation. If the State finds an inconsistency with Social Security Administration (SSA) data or MEDS data during client indexing, then the State will reach out for a reasonable explanation and/or request paper documentation from individual. This process will be utilized to determine eligibility for California's Title XXI Expansion coverage group. 2. Applicant does not have access to affordable ESI YES NO NO NO For the majority of cases, the State will accept self-attestation. If the State finds an inconsistency with Social Security Administration (SSA) data or MEDS data during client indexing, then the State will reach out for a reasonable explanation and/or request paper documentation from individual. 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage YES NO NO NO 5a. Waiting period exception #1 (describe): YES NO NO NO Description: Loss of employment due to factors other than voluntary termination 5b. Waiting period exception #2 (describe): YES NO NO NO Description: Change to a new employer that does not provide an option for dependent coverage 5c. Waiting period exception #3 (describe): YES NO NO NO Description: Change of address so that no employer sponsored covered is available 5d. Waiting period exception #4 (describe): YES NO NO NO Description: Discontinuance of health benefits to all employees of the applicant's employer 5e. Waiting period exception #5 (describe): YES NO NO NO Description: Expiration of COBRA coverage period 5f. Waiting period exception #6 (describe): YES NO NO NO Description: Coverage provided pursuant to an exemption authorized under subdivision (I) of Section 1367 of the Health and Safety Code 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) N/A MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 8