Page 3

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 Caretaker Relative YES NO YES N/A N/A NO NO Self-attestation will be accepted in many cases, however, Oklahoma has internal systems checks in place to review all applications. If, during the regular application review, it is discovered that a member is on another case as a caretaker relative, then we will request a reasonable explanation from the member. All measures to obtain the information electronically will be exhausted prior to paper documentation being requested from the member. Medicare NO YES YES N/A N/A YES YES If inconsistencies are discovered between what the person has reported and electronic data sources, then paper documentation may be requested. 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). ** 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