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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 Medicare NO NO YES N/A N/A NO YES Only request paper documentation if information from data source is inconsistent with attestation. Application for Other Benefits YES NO YES N/A N/A NO YES Differs from initial application to renewal. At initial application, attestation of application for other benefits is accepted if it is not directly contradicted by positive information that no such application is on file. At renewal, continued attestation that application was made and is still pending unless data sources do not indicate receipt of benefits. In such cases we would ask for paper documentation. Additional data sources will be added over time. Other: (Please describe any other eligibility factors in the space below) Former foster care status NO NO YES N/A N/A NO YES If not previously verified as a foster child on the date the individual aged out of foster care, manual verification is provided by the children's services worker. * 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