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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Minnesota Section C . Additional Factors of Eligibility for Separate CHIP 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- Applicabl e (N/A) Comments 1. Applicant does not have other coverage YES NO NO NO Must be Applied Medicaid Expansion also accepts self-attestation without additional verification. 2. Applicant does not have access to affordable ESI N/A 3. When child has had coverage (as applicable to states' waiting period) N/A 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): N/A No waiting period 5b. Waiting period exception #2 (describe): N/A No waiting period 5c. Waiting period exception #3 (describe): N/A No waiting period 5d. Waiting period exception #4 (describe): N/A No waiting period 5e. Waiting period exception #5 (describe): N/A No waiting period 5f. Waiting period exception #6 (describe): N/A No waiting period MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 7