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Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestation Accepted with Post-Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Caretaker Relative YES NO NO N/A N/A NO NO Medicare NO YES YES N/A N/A NO YES Post enrollment checks automatically validate enrolled population against TPL and MMA Application for Other Benefits YES NO NO N/A N/A NO NO Applicants must avail themselves of other potential benefits including Medicare and SSI. For the majority of cases, the State accepts self-attestation without additional verification. However if the state is made aware of inconsistencies though the course of other verifications or reported information, the State has systems in place that can perform verification. In such cases additional information including paper documentation maybe be requested if it were to affect eligibility.

Other: (Please describe any other eligibility factors in the space below) * States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment. If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at or below the applicable income standard, the State must determine the applicant eligible or ineligible for Medicaid/CHIP. (NOTE: this option is prepopulated for the state and is not an option that can be changed). ** States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available. *** States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 2