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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 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 NO NO NO NO NO NO NO YES NO NO YES Quarterly To identify other coverage / benefits in other states. State workers compensation YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Quarterly To identify other insurance coverage. Dept. of Defense Enrollment Eligibility Reporting (DEERS) YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Annually To identify other insurance coverage. If not available through Federal Hub State Department of Public Safety YES NO NO NO NO NO NO NO NO NO NO YES YES YES YES Other (specify in comments) Monthly interface for incarceration status to check for any change or updates. Hawaii Youth Correctional Facility YES NO NO NO NO NO NO NO NO NO NO YES YES YES YES Other (specify in comments) Monthly interface for incarceration status to check for any change or updates. * 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 9