Page 3

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 Residency YES NO NO N/A N/A NO NO Age (Date of Birth) YES NO NO N/A N/A NO NO Social Security Number ** NO NO YES N/A N/A N/A YES Self-attestation will be accepted for an individuals who are not eligible to receive a SSN, individuals who may only be issued a SSN for a valid non-work reason, or individuals who refuse to obtain a SSN because of a well-established religious objection(s ). State will request paper documentation if unable to resolve through the FDSH or other data source. Citizenship ** NO NO YES N/A N/A N/A YES a 90-day reasonable opportunity period to permit the State to check vital statistics or the individual to provide other documentation of citizenship and furnish Medicaid or CHIP during that time period to an otherwise eligible individual. The reasonable opportunity period will be extended beyond 90 days Immigration Status ** NO NO YES N/A N/A N/A YES DE uses uses SAVE Step 1 through FDSH VLP service. If immigration status is not confirmed at Step 1, DE completes the SAVE process through its existing SAVE interface. See Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 3