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Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestatio n Accepted with Post- Eligibility Verificatio n (Y/N) Electron ic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibili ty Standard for Income Ask for a Reasonabl e Explanatio n from the Individual (Y/N) Paper Documentati on Required from the Individual (Y/N) Comments Medicare NO YES YES N/A N/A YES YES Paper documentation required only if data source is unavailable or there is an inconsistency between the attestation and the data source Application for Other Benefits NO YES YES N/A N/A YES YES Paper documentation required only if electronic data source is unavailable or there is an inconsistency between the attestation and the data source. 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). ** States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available. *** States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 3