Page 8

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 5. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES NO YES YES NO NO NO YES YES NO Arizona will have an integrated eligiblity determination system in July 2017 which will include Medicaid, CHIP, SNAP and TANF. If the eligibility factor has been verified for SNAP or TANF, will not reverify. For citizenship and immigration status will only use the verification if it meets the same standards as Medicaid. Will only use for SSN if the SSN has been verified with SSA. 6. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES YES NO NO NO YES YES NO Arizona will have an integrated eligiblity determination system in July 2017 which will include Medicaid, CHIP, SNAP and TANF. If the eligibility factor has been verified for SNAP or TANF, will not reverify. For citizenship and immigration status will only use the verification if it meets the same standards as Medicaid. Will only use for SSN if the SSN has been verified with SSA. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 8