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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

October 1, 2009 4 Approval Date: November 19, 2010 Effective date: Original State Plan – February 1, 1998 Amendment 1 – Establishment of ALL Kids: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS: October 1, 1999 Amendment 3 – Disregards: June 1, 2001 Amendment 4 - Compliance: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding: October 27, 2009 Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): October 1, 2009; Addendum on Dental Benefits Under Title XXI: October 1, 1998

Implementation date: Original State Plan – February 1, 1998 Amendment 1 – Establishment of ALL Kids: October 1, 1998 Amendment 2 – Establishment of ALL Kids PLUS: October 1, 1999 Amendment 3 – Disregards: June 1, 2001 Amendment 4 - Compliance: August 24, 2001 Amendment 5 – Waiting List, Cost Sharing, Benefit Changes: October 1, 2003 Amendment 6 – Discontinuance of the Waiting List and other Clean-Up changes

November 23, 2004 Amendment 7 – Raise the upper income eligibility limit to 300% of FPL and

other minor changes: October 1, 2009 Amendment 8 – Include a private foundation grant as an additional source of state funding: October 27, 2009

Amendment 9 – Establishment of a Prospective Payment System for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): August 25, 2010; Addendum on Dental Benefits Under Title XXI: October 1, 1998