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

ARKANSAS Effective Date: July 1, 2003

Approval Date: 39

SCHIP Budget Plan Template

State Fiscal Year 2005 (July 1, 2004 – June 30, 2005)

Fiscal Year Costs Enhanced FMAP rate 82.31% 1 Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles $ 17,496.00 Fee for Service $ 3,259,854.72 Total Benefit Costs $ 3,277,350.72 2 (Offsetting beneficiary cost sharing payments)

Net Benefit Costs

Administration Costs

Outreach $ 49,100.00 Reporting $ 49,100.00 Quality Assurance $ 25,000.00 Assessment $ 28,300.00 Eligibility $ 176,235.08 Other

Total Administration Costs $ 327,735.08 10% Administrative Cost Ceiling $ 360,508.58

Federal Share (multiplied by SCHIP-FMAP rate) $ 2,967,556.42 State Share $ 637,529.38 TOTAL PROGRAM COSTS $ 3,605,085.802

See Attachments I and J for supporting documentation.

1This is a weighted percentage (i.e., July-September 2004 are at 82.27% and October 2004 through June 2005 are at 82.32%).

2These program estimates are only for the coverage of unborn children.