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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 Documentatio n Required from the Individual (Y/N) Non- Applicabl e (N/A) Comments 5f. Waiting period exception #6 (describe): YES NO NO NO The parent or guardian providing the insurance had coverage through the Insure Montana Program 5g. Waiting period exception #7 (describe): YES NO NO NO The parent or guardian providing the insurance dies. 5h. Waiting period exception #8 (describe): YES NO NO NO The parent or guardian providing the insurance paid more than 50% of the insurance premium 5i. Waiting period exception #9 (describe): YES NO NO NO The parent or guardian providing the insurance has insurance coverage that is not accessible (e.g. coverage is through an HMO in another state) 5j. Waiting period exception #10 (describe): YES NO NO NO The parent or guardian providing insurance had coverage through the MT Health Insurance Premium Payment Program. 5k. Waiting period exception #11 YES NO NO NO the parent or guardian providing the insurance has an annual aggregate amount of health insurance premiums and cost sharing expenses imposed for coverage of the family of a child which exceeds 5% of the family's income. 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12