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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Montana 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 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 For the Medicaid expansion component, post-enrollment paper documentation is requested to verify if the applicant has other coverage for TPL purposes. 2. Applicant does not have access to affordable ESI N/A 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): YES NO NO NO The parent or guardian providing insurance loses TriCare coverage. 5b. Waiting period exception #2 (describe): YES NO NO NO The parent or guardian providing the insurance is fired, terminated, or laid off 5c. Waiting period exception #3 (describe): YES NO NO NO The parent or guardian providing the insurance can no longer work due to a disability 5d. Waiting period exception #4 (describe): YES NO NO NO The parent or guardian providing the insurance has a lapse in insurance coverage due to new employment 5e. Waiting period exception #5 (describe): YES NO NO NO The parent or guardian providing the insurance had insurance coverage that ended because the stepparent, who provided the coverage, and the parent divorced MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 11