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Eligibility Factor Self-Attestation Accepted without Additional Verification (Y/N) Self-Attestation Accepted with Post-Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Residency YES NO NO N/A N/A NO NO Age (Date of Birth) NO NO YES N/A N/A YES YES If there is an inconsistancy with the electronic data source that effects eligibility, Reasonable Explanation/Paper Documentation is required. Social Security Number ** NO NO YES N/A N/A N/A YES If not verified, request explanation or paper documentation. Citizenship ** NO NO YES N/A N/A N/A YES A reasonable opportunity period (ROP) of 90 days will be allowed to provide satisfactory verification, if none received, benefits will be terminated. §42 CFR 435.407(k) Immigration Status ** NO NO YES N/A N/A N/A YES Hawaii uses the Hub's VLP service for all steps of SAVE Household Composition YES NO NO N/A N/A YES NO Pregnancy *** YES NO NO N/A N/A NO NO Caretaker Relative YES NO NO N/A N/A YES NO Medicare NO NO YES N/A N/A YES YES If electronic data source indicates that recipient has Medicare, but applicant does not indicate Medicare, request additional information from individual. Application for Other Benefits YES NO NO N/A N/A NO NO Other: (Please describe any other eligibility factors in the space below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 2