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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 2 Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestation Accepted with Post-Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Application for Other Benefits YES NO NO N/A N/A NO NO Other: (Please describe any other eligibility factors in the space below) Incarceration YES NO NO N/A N/A NO NO Will not preclude eligibility based on incarceration status, as it is not a factor of eligibility for Medicaid. We will use this information for claims purposes. Information for these purposes come from our existing data agreement with SSA and not through the Hub . * States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment. If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at or below the applicable income standard, the State must determine the applicant eligible or ineligible for Medicaid/CHIP. (NOTE: this option is prepopulated for the state and is not an option that can be changed). ** States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available. *** States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation.