Page 2

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 Citizenship ** NO NO YES N/A N/A N/A YES if verification cannot be obtained or resolved through federal hub, will go to RI Dept of Health Vital Statistics when link to data source is available, then paper documentation Immigration Status ** NO NO YES N/A N/A N/A YES will require paper documentation only if verification cannot be obtained or resolved through federal hub 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 NO YES N/A N/A NO NO If a discrepancy is found, the State will go with the data source and notify individual if the change affects their benefits. Application for Other Benefits NO YES YES N/A NO YES State is using post-enrollment verification process for this eligibility factor. Application for Other Benefits will not hold up the eligibility process while the individual is applying for benefits. State will only request paper documentation if there is a discrepancy between the attestation and 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 2