Page 10

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Hawaii 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 NO YES YES Must be Applied Refer to information that is captured in Section B2 and Section A for CHIP details. 2. Applicant does not have access to affordable ESI NO NO YES YES Refer to information that is captured in Section B2 and Section A for CHIP details. 3. When child has had coverage (as applicable to states' waiting period) N/A 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A 5d. Waiting period exception #4 (describe): N/A MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10 Last Updated: April 5, 2016