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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 Incarceration status NO NO YES N/A N/A YES YES If attestation is different from the hub, reasonable explanation is requested. Release papers will be requested if data match indicates they are incarcerated but individual claims they are not incarcerated. If HI verifies that the individual is incarcerated, the individual would be suspended from Medicaid. HI allows 15 days to provide proof of current (date of match) incarceration status after all available agency data sources are exhausted. Other insurance coverage NO NO YES N/A N/A YES YES If CHIP eligible and applicant indicates no TPL, but TPL is identified through electronic sources, then state requests reasonable explanation and/or paper documentation. HI is using multiple data sources prior to reaching out to the individual. This is CHIP Specific. * States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment. If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at or below the applicable income standard, the State must determine the applicant eligible or ineligible for Medicaid/CHIP. (NOTE: this option is prepopulated for the state and is not an option that can be changed). ** States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available. *** States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 3