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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: West Virginia Last updated: 10/20/2016 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 NO YES YES YES Must be Applied The HMS system described in Section B2 is used. 2. Applicant does not have access to affordable ESI NO YES YES NO N/A Notices alerting CHIP that another payer exists are generated through the CHIP claims system. 3. When child has had coverage (as applicable to states' waiting period) NO YES YES YES The HMS system described in Section B2 is used. 4. Access to public employee coverage NO YES YES YES The HMS system described in Section B2 is used. 5a. Waiting period exception #1 (describe): N/A 5b. Waiting period exception #2 (describe): N/A 5c. Waiting period exception #3 (describe): N/A 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A 5g. Waiting period exception #7 (describe): N/A 5h. Waiting period exception #8 (describe): N/A 5i. Waiting period exception #9 (describe): N/A MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C- Additional Factors of Eligibility for Separate CHIP 13