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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 Documentatio n Required from the Individual (Y/N) Non- Applicabl e (N/A) Comments 4. Access to public employee coverage NO YES NO YES Paper documentation required only if discrepancy State does not have an ability to perform verification through a data source. However, if on the application, it is found that the child's parent is a State employee, then that would be used in determining if the individual has access to public employee coverage. 5a. Waiting period exception #1 (describe): YES NO NO NO Loss of employment other than voluntary termination 5b. Waiting period exception #2 (describe): YES NO NO NO Death of the parent who was responsible for the insurance coverage 5c. Waiting period exception #3 (describe): YES NO NO NO Change to new employment that does not provide an option for dependent coverage 5d. Waiting period exception #4 (describe): YES NO NO NO Change of address that results in no employer-sponsored coverage 5e. Waiting period exception #5 (describe): YES NO NO NO Discontinuation of health benefits to all employees of the applicants employer 5f. Waiting period exception #6 (describe): YES NO NO NO Expiration of coverage periods established by COBRA 5g. Waiting period exception #7 (describe): YES NO NO NO Self-Employment 5h. Waiting period exception #8 (describe): YES NO NO NO Termination of health benefits due to long-term disability 5i. Waiting period exception #9 (describe): NO YES NO YES Termination of dependent coverage due to extreme economic hardship on the part of the employee or employer 5j. Waiting period exception #10 (describe): YES YES NO YES Extreme financial hardship related to cost of premiums, deductibles, and/or co-payments MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 10