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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 11. Commercial database: (Please describe any commercial databases in the space below) HEALTH MANAGEMENT SYSTEM (HMS YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Monthly This data source is only used for the CHIP program. It shows whether the individual has other insurance coverage. 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) The State will use PARIS to provide information about health benefits provided by the VA, TriCare, and Department of Defense, benefits from another state health agency, and duplicate benefits. Third Party Administrator (TPA) YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Other (specify in comments) Used as a data source to verify other coverage, for CHIP purposes. State receives this data when changes are made. Public Employees Insurance Agency (PEIA) YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Monthly Used as a data source to verify other coverage, for CHIP purposes. FACTS YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Other (specify in comments) This post enrollment match will occur daily. Families and Children Tracking System (FACTS) is used to confirm eligibility for the former foster children coverage group. FACTS provides confirmation that the individual was in Foster Care. * 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 12