Page 12

Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification 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 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