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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Massachusetts 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 YES YES NO Must be Applied Column D:Periodic matching with Insurance carriers to identify coverage These verification policies and procedures (for questions 1 and 2) also apply to the state Medicaid Expansion program according to title XXI. Accept self-attestation but have backup ways to check to ensure that the application info is accurate. State will follow-up with periodic data match for those who have other insurance. Plan to file an amendment to program to eliminate waiting period for CHIP (to be effective 1/1/2014). Decision will impact whether questions 3-6 apply to them. 2. Applicant does not have access to affordable ESI YES YES YES NO Column B: Yes, if applicant indicates working less than 32 hours per week Column C: Yes, if applicant indicates working 32 hours per week or more Column C: Yes, when possible 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage YES YES YES NO Column B: Yes, if applicant indicates working less than 32 hrs. per week. Column C: Yes, if applicant indicates working 32 hours per week or more Column D: Yes, when possible. 5a. Waiting period exception #1 (describe): YES NO NO NO Description: A child in the family group has special or serious health-care needs. 5b. Waiting period exception #2 (describe): YES NO NO NO Description: The prior coverage was involuntarily terminated MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12