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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): NO NO YES NO Exception reason: Family pays over 9.5% of all family income for family coverage (including the child dropped from coverage). Source: Maine's eligibility system. 5d. Waiting period exception #4 (describe): NO NO YES YES Exception reason: The individual had good cause for terminating the insurance coverage. Source: Maine's eligibility system. 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) Child residing in a public institution or in-patient psychiatric facility YES NO NO NO MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 16