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Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments Department of Revenue, Permanent Fund Dividend YES NO NO NO NO NO NO NO NO NO NO NO YES YES YES Other (specify in comments) PFD interface can be used to verify residency if a discrepancy is found. Dept of Labor YES NO NO NO NO NO NO NO NO NO YES NO YES YES YES Other (specify in comments) Checked post enrollment to verify changes. State Administered Supplementary Payment Program YES YES YES YES NO NO NO YES NO NO YES NO YES YES NO Check at application, recertification and report of change only if there is a discrepancy in state eligibility database. Only used at renewal/post enrollment if there's been a change in immigrations status or 5 yr. bar. Only use for SSN if verified with SSA first. Only use for citizenship and immigration status if verified in accordance with Medicaid/CHIP rules. * Under 42 CFR 435.945(d), all State Medicaid eligibility systems must conduct a match with PARIS for Interstate benefit information. If used for other purposes, please indicate in Section D. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 10