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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 14 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 5c. Waiting period exception #3 (describe): NO NO NO YES Reason: Employer no longer provides coverage State has not identified a data source. Paper verification will be required 5d. Waiting period exception #4 (describe): NO NO NO YES Reason: Financial hardship, defined as health insurance costs exceeding 10% of HH gross monthly income or the premium paid for coverage of the child exceeds 5% of gross family income. State has not identified a data source. Paper verification will be required 5e. Waiting period exception #5 (describe): NO NO NO YES N/A Reason: Divorce of Policy Holder (Parent) State has not identified a data source. Paper verification will be required 5f. Waiting period exception #6 (describe): NO NO NO YES N/A Reason: Child has special health care needs State has not identified a data source. Paper verification will be required 5g. Waiting period exception #7 (describe): NO NO YES YES N/A Reason: Child's parent is determined eligible for APTC because ESI is determined it is not affordable The FFM will be consulted, however paper verification may be required if this cannot be substantiated through phone contact with a navigator or the FFM. 5h. Waiting period exception #8 (describe): N/A 5i. Waiting period exception #9 (describe): N/A 5j. Waiting period exception #10 (describe): N/A