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Electronic Data Source

To Be

Used (Y/N) Social Security mber Nu ip Citizensh Immigration Status Residency B Age/DO Pregnancy Household Composition Caretaker Relative Medicare ion Applicat her for ot 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)

* 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 8