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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 5a. Waiting period exception #1 (describe): YES NO NO NO Exception 1: Voluntary termination of COBRA coverage. We take customer statement on the voluntary termination of coverage reason. 5b. Waiting period exception #2 (describe): YES NO NO NO Exception 2: Voluntary termination of HIP Utah (Health Insurance Pool) coverage. We take customer statement on the voluntary termination of coverage reason. 5c. Waiting period exception #3 (describe): YES NO NO NO Exception 3: Voluntary termination of coverage by non-custodial parent. We take customer statement on the voluntary termination of coverage reason. 5d. Waiting period exception #4 (describe): NO NO YES NO Exception 4: Voluntary termination of UPP reimbursed employer-sponsored coverage. We verify the end date for UPP in our eREP eligibility system. Paper documentation would never be necessary, as the eRep eligibility system is the primary source of information. 5e. Waiting period exception #5 (describe): NO NO NO YES Exception 5: Voluntary termination of insurance that does not provide coverage in Utah. We obtain verification from the customer to verify that the coverage is not provided in Utah and when it ended. 5f. Waiting period exception #6 (describe): YES NO NO NO Exception 6: Voluntary termination of limited health insurance plan. We take the customer statement on the voluntary termination. 5g. Waiting period exception #7 (describe): NO NO YES NO Exception 7: ORS forces enrollment under NMSN (National Medical Support Notice). Then, because the cost of insurance exceeds 5% of the gross monthly income, ORS reverses the forced enrollment and the child is terminated from the TPL of the custodial parent. We verify this with ORS. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 15