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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 5d. Waiting period exception #4 (describe): YES NO NO NO A change in employment, including involuntary separation, resulted in the child's loss of employer-sponsored insurance (other than the full premium payment by the parent under COBRA). 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. 5e. Waiting period exception #5 (describe): YES NO NO NO The child has special health care needs. Paper documentation would only be requested if conflicting information was known to the agency. 5f. Waiting period exception #6 (describe): YES NO NO NO The child lost coverage due to the death or divorce of a parent. 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. 5g. Waiting period exception #7 (describe): YES NO NO NO Coverage is for a specific illness, body part or school-related activities (e.g., Student accidental plans, cancer policy, vision policy). 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. 5h. Waiting period exception #8 (describe): YES NO NO NO Coverage was provided by Indian Health Services, Tribal Health, COBRA, or another insurance affordability program. 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. 5i. Waiting period exception #9 (describe): N/A 5j. Waiting period exception #10 (describe): N/A 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12