Page 11

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 4. Access to public employee coverage YES NO NO NO 5a. Waiting period exception #1 (describe): YES NO NO NO death of parent 5b. Waiting period exception #2 (describe): YES NO NO NO disability of parent 5c. Waiting period exception #3 (describe): YES NO NO NO termination of employment 5d. Waiting period exception #4 (describe): YES NO NO NO change to a new employer who does not cover dependents 5e. Waiting period exception #5 (describe): YES NO NO NO change of address so that employer-sponsored coverage is not available - the provider service network is not available within the county in which the family resides 5f. Waiting period exception #6 (describe): YES NO NO NO expiration of the coverage periods established by COBRA 5g. Waiting period exception #7 (describe): YES NO NO NO employer terminating health coverage as a benefit for all employees MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 11