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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Louisiana Last updated 10/30/2019 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 NO NO YES NO Must be Applied Effective September 1, 2016, Louisiana has a contract approved with the vendor, HMS, to collect insurance information on active enrollees and to update MMIS and eligibility systems. 2. Applicant does not have access to affordable ESI N/A Not applicable to Louisiana 3. When child has had coverage (as applicable to states' waiting period) NO NO YES NO This only applies to separate CHIP population. 4. Access to public employee coverage NO NO YES NO Use of Louisiana Department of Employment and Training. The Work Number if available. Office of Group Benefits (OGB) listing of employers (PDF format). As a safeguard, OGB will match the individual's employer with their employer roll and not accept enrollment if public employee coverage is available. Notification will be issued to enrollee as to ineligibility. Louisiana has elected not to cover children of state employees with title XXI funds. 5a. Waiting period exception #1 (describe): NO NO YES NO Lost insurance due to death of parent. Clear through SSA. 5b. Waiting period exception #2 (describe): NO NO YES NO Lost insurance due to divorce of parent. Request proof from applicant/ enrollee. 5c. Waiting period exception #3 (describe): NO NO YES YES COBRA ended. Request proof from applicant/ enrollee. 5d. Waiting period exception #4 (describe): NO NO YES YES Lifetime maximum reached. Request proof from applicant/ enrollee or insurance carrier. 5e. Waiting period exception #5 (describe): NO NO YES YES Lay-off or business closure. Department of Employment and Training, the Work Number. Request proof from applicant/ enrollee. 5f. Waiting period exception #6 (describe): NO NO YES YES Changed employment. Department of Employment and Training, the Work Number. Request proof from applicant/ enrollee. 5g. Waiting period exception #7 (describe): NO NO YES YES Employer no longer provides dependent coverage. Contact employer. Request proof from applicant/ enrollee. 5h. Waiting period exception #8 (describe): NO NO YES NO Monthly family premium exceeds 9.5 percent of gross income. Internal calculation based on available data. 5i. Waiting period exception #9 (describe): NO NO YES NO The premium paid by the family for coverage of the child under the group health plan exceeded five percent of household income; Internal calculation based on available data. 5j. Waiting period exception #10 (describe): NO NO YES YES The child's parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP through the Exchange because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B-2(c)(3)(v). Request proof from applicant/ enrollee. 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) 6a. Waiting period exception #11 (describe) NO NO YES YES The child has special health care needs; Request proof from applicant/enrollee. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10