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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: North Carolina Date Submitted: (mm/dd/yyyy) 05/26/2016 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 Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments 1. Applicant does not have MMIS; Vendor searches and updates MMIS. Paper documentation is requested when there is other coverage NO YES YES YES Must be Applied an inconsistancy between individual's attestation and electronic data source and effects eligibility. Medicaid Expansion Component - same process as above. 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 Children of State employees and teachers are eligible for coverage under Title XXI because the coverage NO YES YES YES State of North Carolina does not subsidize or contribute to the cost of dependent health insurance. The state employee must pay 100% of the health insurance premium costs for any dependents covered under the State Employee PPO health plan. MMIS; Vendor searches and updates MMIS. Paper documentation is requested when there is an inconsistancy between individual's attestation and electronic data source and effects eligibility. 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 9