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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 For CHIP, if attestation of income puts premium (cost sharing) in a lower band than the data source, premium is assigned based on data source and the applicant will be given an opportunity to provide further verification in order to lower the premium. If verification is submitted, then we would redetermine the premium amount and eligibility. If ineligible for CHIP, refer to FFM or Medicaid program is applicable. 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 14