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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 13 MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Kansas Date Submitted: (mm/dd/yyyy) 04/10/2018 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 YES NO NO NO Must be Applied Self- attestation accepted unless the report is inconsistent or discrepant with other information. 2. Applicant does not have access to affordable ESI YES YES NO NO Self- attestation accepted unless the report is inconsistent or discrepant with other information. This information is used to test for the waiting period. 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO Self- attestation accepted unless the report is inconsistent or discrepant with other information. 4. Access to public employee coverage YES NO NO NO Self-attestation accepted unless the report is inconsistent or discrepant with other information. 5a. Waiting period exception #1 (describe): NO NO YES YES Reason: Loss of job providing health insurance Will search available employer/HI data bases. If verification not found, paper will be requested 5b. Waiting period exception #2 (describe): NO NO YES YES Reason: Death of Policy Holder Will search available employer/HI data bases. If verification not found, paper will be requested