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

Effective Date:

Approval Date: 59

any programmatic changes to the hawk-i program is presented to the grassroots outreach coordinators who are required to work specifically with any tribes in their areas.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d). See the response for 9.9.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- Projected amount to be spent on health services; Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and Assumptions on which the budget is based, including cost per child and expected enrollment. Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

9.10.1-DS Please include a separate budget line to indicate the cost of providing dental-only supplemental coverage.

SCHIP Budget Plan FFY 10 IOWA - for supplemental dental

Federal Fiscal Year Costs Enhanced FMAP rate 74.46% Benefit Costs

Population 1 - hawk-i - Iowa's stand alone program

Insurance payments $0 Managed care $62,228,537 per member/per month rate @ # of eligibles $194 Fee for Service $0 per member/per month rate @ # of eligibles n/a Benefit Costs subtotal population 1 $62,228,537 Population 2 - Supplemental Dental

Insurance payments $3,170,827 per member/per month rate @ # of eligibles $26 Benefit Costs subtotal population 2 $3,170,827