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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 Documentati on Required from the Individual (Y/N) Non- Applicab le (N/A) Comments 5c. Waiting period exception #3 (describe): NO YES YES YES By a household member who is actively engaged in farming in a county which was declared a federal disaster area within the last 12 months. This information is available in the Vision tables 5d. Waiting period exception #4 (describe): NO YES YES YES By a parent or caretaker quitting a job with health insurance coverage to take a job without health insurance coverage 5e. Waiting period exception #5 (describe): NO YES YES YES By a parent or caretaker quitting a job with health insurance coverage to start a new job with a waiting period for health care coverage 5f. Waiting period exception #6 (describe): NO YES YES YES If the child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a qualified health plan (QHP) because the employer sponsored insurance (ESI) in which the family was enrolled is determined unaffordable 5g. Waiting period exception #7 (describe): NO YES YES YES If the premium paid by the family for coverage of the child under the group health plan exceeded 5% of household income 5h. Waiting period exception #8 (describe): NO YES YES YES If the cost of family coverage that includes the child exceeds 9.5% of the household income 5i. Waiting period exception #9 (describe): NO YES YES YES By the employer who stopped offering coverage of dependents (or any coverage) under an employer- sponsored health insurance plan 5j. Waiting period exception #10 (describe): NO YES YES YES When the child has special health care needs 5k. Waiting period exception #11 (describe): NO YES YES YES Due to the death or divorce of a parent 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 10