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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CH Florida State: 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 Documentatio n Required from the Individual (Y/N) Non- Applicabl e (N/A) Comments 1. Applicant does not have other coverage YES NO NO NO Must be Applied These verification procedures do not apply to title XXI Medicaid Expansion population. For Medicaid self attestation will be accepted. 2. Applicant does not have access to affordable ESI N/A 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage NO NO YES NO Perform a file match against Florida employee system for state employee coverage for reporting purposes only but does not affect eligibility. 5a. Waiting period exception #1 (describe): YES NO NO NO cost greater than 5% of income 5b. Waiting period exception #2 (describe): YES NO NO NO lost employment 5c. Waiting period exception #3 (describe): YES NO NO NO death of insurance carrier 5d. Waiting period exception #4 (describe): YES NO NO NO employer cancelled coverage MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10