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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 Application for Other Benefits YES NO NO N/A N/A NO NO For the majority of cases, the Louisiana will accept self- attestation. If a discrepancy is discovered that effects eligibility or if third party liability is discovered as a result of routine system checks for other eligibility factors (i.e. income), the individual will be asked to provide a reasonable explanation. If the explanation is not reasonable, the individual will be asked to provide paper documentation. Other: (Please describe any other eligibility factors in the space below) TPL NO YES YES N/A N/A YES YES Louisiana has a contract approved with the vendor, HMS, to collect insurance information on active enrollees and to update MMIS and eligibility systems. Third Party Liability (TPL) is an Interface between the E&E System and Medicaid Management Information System (MMIS). This Interface will provide Third Party Liability information to the E&E System. The E&E System will use this information to update the health coverage of an individual. * 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