Page 10

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 Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 13. Other: (Please describe additional electronic data sources in the space provided below) 12. PARIS* YES NO NO NO YES NO NO NO NO NO YES YES NO NO YES Quarterly When change in residency is reported by PARIS and for VA benefits Existing information in State Eligibility Determination Systems YES NO NO NO NO NO NO YES YES NO NO NO YES YES NO We will have data from previous applications, non-MAGI Medicaid eligibility such as ABD populations, Medicaid Buy-In program, Breast & Cervical Cancer Treatment Program, etc. If a case already exists and a new application is being made, we will compare the previous data to the new application for inconsistencies in household composition, relationships, etc. * 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