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Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestation Accepted with Post- Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Age (Date of Birth) NO YES YES N/A N/A YES YES Reasonable explanation/paper documentation requested when there is an inconsistency between the attestation and information from the data source that affects eligibility. If SSA cannot confirm the SSN, which means they cant verify citizenship, the reasonable opportunity period will be triggered to verify citizenship. What is provided to prove citizenship will serve the purpose of verifying age/DOB as well. Social Security Number ** NO NO YES N/A N/A N/A YES If an SSN is not verifiable via an electronic data source, paper documentation will be required. For example, if an individual does not have a number for religious reasons, the individual will have to provide documented proof of their good cause. Citizenship ** NO NO YES N/A N/A N/A YES Immigration Status ** NO NO YES N/A N/A N/A YES Household Composition YES NO NO N/A N/A NO NO Pregnancy *** YES NO NO N/A N/A NO NO Caretaker Relative YES NO NO N/A N/A NO NO Medicare NO YES YES N/A N/A NO NO When an inconsistency is identified between the attested information and the data source, state will use the data from SSA and auto populate the Medicare fields. Application for Other Benefits YES NO NO N/A N/A NO NO Other: (Please describe any other eligibility factors in the space below) * States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment. If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at or below the applicable income standard, the State must determine the applicant eligible or ineligible for Medicaid/CHIP. (NOTE: this option is prepopulated for the state and is not an option that can be changed). MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 2