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Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentatio n Required from the Individual (Y/N) Non- Applicab le (N/A) Comments 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A 5g. Waiting period exception #7 (describe): N/A 5h. Waiting period exception #8 (describe): N/A 5i. Waiting period exception #9 (describe): N/A 5j. Waiting period exception #10 (describe): N/A 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) Lockout (max. 90 days) for failure to pay family contribution NO NO YES NO Uses data from MCHP Premium Accounts Receivable system. Paper documentation would not be necessary; generally, payments missing from the system would have to be resubmitted to correct this element of eligibility. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 11