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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 N/A 5a. Waiting period exception #1 (describe): NO NO NO YES Exception: Employer cancellation of entire group plan. Paper documentation only requested when applicant disagrees with electronic data source match or customer reports the information and there is no electronic data source match 5b. Waiting period exception #2 (describe): NO NO NO YES Exception: Loss of Eligibility due to parent’s layoff from employer: Paper documentation requested or verified with electronic data report or HMS Insurance associates. 5c. Waiting period exception #3 (describe): NO NO NO YES Exception: Employment Termination: Paper documentation requested. 5d. Waiting period exception #4 (describe): NO NO NO YES Exception: Leave of absence without pay or reduction of work hours: Paper documentation requested, electronic data report, HMS 5e. Waiting period exception #5 (describe): NO NO NO YES Exception: Cancellation of private health insurance due to cost share exceeding 5% of the annual income : Paper documentation requested 5f. Waiting period exception #6 (describe): NO NO NO YES Exception: Cancellation of individual policy to due meeting lifetime caps: Paper verification requested 5g. Waiting period exception #7 (describe): NO NO NO YES Exception: Cancellation of COBRA or individual policy: Paper documentation requested. 5h. Waiting period exception #8 (describe): NO NO NO YES Exception: Resignation of parent from employment : Paper documentation requested. 5i. Waiting period exception #9 (describe): NO NO NO YES Exception: A child born during the two month waiting period. 5j. Waiting period exception #10 NO NO NO YES Exception: Has special health care needs 5k. Waiting period exception #11 NO NO NO YES Exception: Lost coverage due to the death or divorce of a parent 5. Waiting period exception #12 (describe): NO NO NO YES Exception: The employer stopped offering coverage of dependents MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 13