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• Assumes 8,000 eligible children for every 12-month period beginning 8/22/96. • Assumes a cumulative backlog of 22,667 eligible children for the 34-month period ending 7/1/99. • Estimated monthly enrollment is projected as follows: Legal Immigrants Cost FFY 1999 920 by 10/1 $ 133,632 FFY 2000 8,520 by 10/1 $ 4,518,707 FFY 2001 17,799 by 10/1 $12,384,323 This expansion program will be 100% State-funded (requiring no federal matching Title XXI funds) unless federal matching funds are made available by Congress. DMH FOR SED SERVICES • Assumes enrollment will begin 7/99. • Assumes 3% of the average annual HFP enrollment. FFY 1999 $ 71,844 FFY 2000 $ 480,067 FFY 2001

$ 1,275,720 Only MRMIB, CCS and DMH estimate costs for this proposal. Estimated CCS costs are $137,000 total funds. The DHS estimates no additional costs for Child Health Disability Program (CHDP). MRMIB Payments to Health, Dental and Vision Plans. These health services costs are the estimated insurance premium costs as the served population grows over time. Estimated payments (or premiums) for health, dental, and vision per month are: $71.50 per enrolled child per month (PCPM) for October 1998 through June 1999 and $80.08 PCPM for the period July 1999 through September 2001. For children under age 1, estimated premiums are 230.00 PCPM. MRMIB Offsetting Premium Payments. The total health services costs are offset by a monthly premium (or contribution) payment per child paid by the family. The administrative vendor, on behalf of MRMIB collects these premiums. These premiums will be collected by the health plan. Estimated offset of premium payments per child per month is $5.00. Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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