Page 10

MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10 MAGI-BASED ELIGIBILITY VERIFICATION PLAN Program: Medicaid & CHIP State: Nebraska Last updated by Nebraska 09/04/2019 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 other coverage YES NO YES YES Must be Applied Nebraska does interface with Blue Cross Blue Sheild of Nebraska. If the applicant or beneficiary has BCBS of Nebraska it would be verified through an electronic data source. If Nebraska is unable to verify electronically or the applicant/beneficiary has other health insurance paper documentation is required. (e.g. if individual is covered through other insurance carriers) These verification procedures also apply to the state Medicaid Expansion component, according to title XXI. The state will require paper documentation only if they cannot validate that individual has other coverage through electronic data source. 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 coverage N/A 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A