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MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Wyoming 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 FFE/Federal Hub data. Will use an electronic data source if inconsistencies are identified (i.e. if an individual has already enrolled in CHIP, state would utilize an electronic data source to resolve any discrepencies). 2. Applicant does not have access to affordable ESI NO NO YES YES Paper documentation will be requested when electronic sources (FFE/Hub) are not available and/or inconsistencies are identified. State does use an electronic data source but may request paper documentation if data source is unavailable or unreliable. 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO Paper documentation will be requested when electronic sources (FFE/Hub) are not available or conflicting information is present. An electronic data source will be used if inconsistencies are identified. 4. Access to public employee coverage YES NO NO NO Public employee coverage is defined as access to the insurance plan available to employees of the State of Wyoming. 5a. Waiting period exception #1 (describe): NO NO YES YES The premium paid by the family for coverage of the child under the group health plan exceeded 5% of household income. Electronic data sources include the FFE and Federal Data Hub. Paper documentation may be requested if inconsistencies are found. 5b. Waiting period exception #2 (describe): NO NO YES YES The cost of family coverage that includes the child exceeds 9.5% of household income. Electronic data sources include the FFE and Federal Data Hub. Paper documentation may be requested if inconsistencies are found. 5c. Waiting period exception #3 (describe): YES NO NO NO The employer stopped offering coverage of dependents or the insurance plan is no longer accessible under an employer-sponsered health insurance plan. Paper documentation would only be requested if conflicting information was known to the agency and eletronic data sources did not rectify the conflict. Electronic data sources include the FFE and Federal Data Hub. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 11