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

Effective Date:

Approval Date: 60

SCHIP Budget Plan FFY 10 IOWA - for supplemental dental Population 3 - expanded Medicaid

Managed care $0 per member/per month rate @ # of eligibles n/a Fee for Service $31,076,850 per member/per month rate @ # of eligibles $173 Benefit Costs subtotal popuation 3 $31,076,850 Population 4 LPRs

43 children added over a 18 month period

hawk- i (28 children added over an 18 month period) $9,079 Expanded Medicaid (15 children added over an 18 month period) $4,889 Benefit costs subtotal Population 4 $13,968 Total Benefit Costs $96,490,182 (Offsetting beneficiary cost sharing payments) -$2,036,930 Net Benefit Costs $94,453,252 Administration Costs

Personnel $459,188 General administration $518,781 Contractors/Brokers (e.g., enrollment contractors) $4,042,002 Claims Processing $2,077,540 Outreach/marketing costs $1,243,970 Other (cost allocation) $920,000 Total Administration Costs $9,261,481 10% Administrative Cost Ceiling $10,494,806

Federal Share (multiplied by enh-FMAP rate) $77,225,990 State Share $26,488,743 TOTAL PROGRAM COSTS $103,714,733 NOTE 1: The Federal Fiscal Year (FFY) runs from October 1st through September 30th. 2. What were the sources of non-Federal funding used for State match during the reporting period? XX State appropriations

County/local funds

Employer contributions

Foundation grants

Private donations