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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): YES NO NO NO Description: A parent in the family group died in the previous six months 5d. Waiting period exception #4 (describe): YES NO NO NO Description: The prior coverage was lost due to domestic violence 5e. Waiting period exception #5 (describe): YES NO NO NO Description: The prior coverage was lost due to becoming self-employed 5f. Waiting period exception #6 (describe): YES NO NO NO Description: The existing coverage's lifetime benefits were reduced substantially within the previous six months or prior employer-sponsored health insurance was cancelled for this reason. 5g. Waiting period exception #7 (describe): YES NO NO NO Placeholder any additional exceptions pending publication of CMS Final Rule 5h. Waiting period exception #8 (describe): 5i. Waiting period exception #9 (describe): 5j. Waiting period exception #10 (describe): 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 13