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

Effective Date:

October 1, 2009 59 Approval Date: November 19, 2010 Based on actuarial analysis the State does not anticipate any notable budgetary impact for FY2010 resulting from transitioning to PPS due to the relatively small percent of program claims expenditures attributable to FQHCs and RHCs. However, the State expects PPS expenditures to be higher than what was projected for fee for service expenditures to FQHCs and RHCs based on this analysis. For FY 2010, fee for service expenditures to FQHCs and RHCs are estimated to be between $402,000 - $431,000 with approximately 2,613- 2,750 medical visits and 719-757 dental visits. Replacing the cost of each visit with PPS rates, total projected expenditures become $459,000 - $483,000, resulting in approximately $52,000 – $56,000 more dollars.

It is estimated 55,000 members will utilize dental services during FY2010.

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1. X The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2. X The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. X The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Section 10.3-D X Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website.