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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 1 MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Colorado 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 State asks applicants if they are covered by other coverage. Information is accepted through self-attestation and individual is deemed ineligible for CHP+ if they have other coverage. This process is the same for our title XXI Medicaid Expansion. 2. Applicant does not have access to affordable ESI N/A

3. When child has had coverage (as applicable to states' waiting period) NO NO NO NO Colorado's waiting period has been eliminated and SPA was approved as of early August 2013. 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A