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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Georgia Date Submitted: (mm/dd/yyyy) 08/30/2016 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 Documentation Required from the Individual (Y/N) Non- Applicable (N/A) Comments 1. Applicant does not have other coverage NO YES YES YES Must be Applied Electronic Data Sources - GA MMIS, State Health Benefit Plan and Board of Regents. Paper documentation only requested when applicant disagrees with electronic data source match In general, accept self-attestation but system does automatic matches with Medicaid (MMIS) and State Health Benefit (State Board of Regents) and post-enrollment with TPL vendor other health insurance. If a customer drops his or her insurance, a waiting period is imposed. 2. Applicant does not have access to affordable ESI NO NO NO YES We will verify access to ESI to determine member exemption from the waiting period when: 1. An applicant or enrollee reports any of the following in a written or verbal statement, or indicates on his or her application or renewal that the applicant or his or her spouse or parent: a. dropped health insurance from a current employer , or c. work for an employer that stopped offering health insurance. OR 2. An applicant or enrollee provides ESI information that is inconsistent with documentation or information on file and, 3. there are no electronic matches available to verify. 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO Documents are required to determine exemption from the waiting period. Documents are requested if parent reports that the cost of insurance listed below. (5a-5l) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12