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 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 11. Commercial database: (Please describe any commercial databases in the space below) 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 Other (specify in comments) Semi-annually PARIS is used to verify if individual has benefits in other States. Emdeon - Third Party liability vendor YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Monthly State uses this data source for verification of third party services and payment of medical bills. * 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