Page 2

Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestatio n Accepted with Post- Eligibility Verificatio n (Y/N) Electron ic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonabl e Explanatio n from the Individual (Y/N) Paper Documentati on Required from the Individual (Y/N) Comments Citizenship ** NO NO YES N/A N/A N/A YES Immigration Status ** NO NO YES N/A N/A N/A YES Household Composition YES NO NO N/A N/A NO NO Pregnancy *** YES NO NO N/A N/A NO NO Caretaker Relative YES NO NO N/A N/A NO NO Medicare NO NO YES N/A N/A NO NO MN does not accept paper documentation of Medicare enrollment. If we are unable to verify Medicare enrollment electronically through the Federal Data Hub (SSA), we will assist the individual in resolving discrepancies with the SSA. Once the discrepancy has been resolved, we will initiate an attempt to re-verify the Medicare enrollment through the Federal Data Hub (SSA). If unable to resolve the discrepancy, we will allow eligibility to continue, if otherwise eligible, as long as the individual is cooperating with SSA to resolve the discrepancy. Application for Other Benefits YES NO NO N/A N/A NO NO 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