Page 15

Official source

MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 15 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 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) Delinquent Premium NO NO YES NO Interface with the premium billing agent will automatically set a deliquency indicator and prevent enrollment in CHIP if unforgiven delinquent premiums exist for the family. This is applicable for a maximum of 90 days.

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Page 15

Official source

MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 15 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 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) Delinquent Premium NO NO YES NO Interface with the premium billing agent will automatically set a deliquency indicator and prevent enrollment in CHIP if unforgiven delinquent premiums exist for the family. This is applicable for a maximum of 90 days.