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DocuSign Envelope ID: 9B3FAF99-0D78-49C7-B41E-F53AE7922E72 5

Self-Attestation of Household Income/Resources Electronic Data Source Reasonably Compatible Case Action Source of Income/Resource Used to Determine Eligibility Above Threshold for applicable household size Above Threshold for applicable household size Yes If both amounts are above the FPL or resource limit, it is always reasonably compatible regardless of the difference between the two amounts. If a/b is ineligible due to excess income, then determine if the a/b is medically needy and able to meet a deductible. If the a/b is ineligible due to excess resources, allow rebuttal/spend down of resources if applicable. Applicant’s income/resource self-attestation.

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Official source

DocuSign Envelope ID: 9B3FAF99-0D78-49C7-B41E-F53AE7922E72 5

Self-Attestation of Household Income/Resources Electronic Data Source Reasonably Compatible Case Action Source of Income/Resource Used to Determine Eligibility Above Threshold for applicable household size Above Threshold for applicable household size Yes If both amounts are above the FPL or resource limit, it is always reasonably compatible regardless of the difference between the two amounts. If a/b is ineligible due to excess income, then determine if the a/b is medically needy and able to meet a deductible. If the a/b is ineligible due to excess resources, allow rebuttal/spend down of resources if applicable. Applicant’s income/resource self-attestation.