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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Maine Date Submitted: (mm/dd/yyyy) 05/05/2020 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 Source: Maine's eligibility system, HMS. If attestation is inconsistent with source, obtain other coverage verification. NO YES YES YES Must be Applied 2. Applicant does not have access to affordable ESI YES NO NO NO N/A 3. When child has had coverage (as applicable to YES NO NO NO states' waiting period) 4. Access to public employee coverage YES NO NO NO Maine has elected to cover children of state employees. 5a. Waiting period exception #1 (describe): NO YES YES YES Exception reason: Individual who dropped coverage does not reside with the child. Source: Maine's eligibility system. 5b. Waiting period exception #2 (describe): NO NO NO YES Exception reason: Family (employee) pays 50% or more of the cost of the child's coverage. Will try and call the employer first before asking for paper. No electronic data source to obtain this information. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 15