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MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 8 MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Texas Date Submitted: (mm/dd/yyyy) Section C . Additional Factors of Eligibility for Separate CHIP Eligibility Factor Self-Attestation Accepted without Additional Verification Self-Attestation Accepted with Post-Enrollment Verification (Y/N) Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments 1. Applicant does not have other coverage YES NO NO NO Must be Applied Data provided by claims administrator is used to verify insurance at the end of the child eligibility period. This process only applies to individuals for which the data is available. 2. Applicant does not have access to affordable ESI YES NO NO NO 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): YES NO NO NO A parent's employment was terminated due to layoff, reduction in force or the closure of a business 5b. Waiting period exception #2 (describe): YES NO NO NO The loss of Medicaid eligibility (due to income, resources or the child ages out of Medicaid) 5c. Waiting period exception #3 (describe): YES NO NO NO Dependent coverage was terminated by an employer 5d. Waiting period exception #4 (describe): YES NO NO NO A parent's insurance benefit under the Consolidated Omnibus Budget Reconciliation Act of 1984 was terminated 5e. Waiting period exception #5 (describe): YES NO NO NO A parent's marital status has changed resulting in the loss of coverage 5f. Waiting period exception #6 (describe): YES NO NO NO The child is no longer covered by the Texas Employee Retirement System 5g. Waiting period exception #7 (describe): YES NO NO NO A loss of CHIP eligibility from another state 5h. Waiting period exception #8 (describe): YES NO NO NO The health insurance coverage costs 10% or more of the family's net income 5i. Waiting period exception #9 (describe): YES NO NO NO Other circumstances similar to those described that result in an involuntary loss of insurance coverage 5j. Waiting period exception #10 (describe): YES NO NO NO The Health and Human Services Commission (HHSC) determines that good cause exists based on information provided by the applicant or information otherwise obtained by HHSC. 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) N/A 07/22/2019