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

Effective Date:

Approval Date: 61

SCHIP Budget Plan FFY 10 IOWA - for supplemental dental

Tobacco settlement

Other (specify) [500] 4. In the table below, enter 1) number of eligibles used to determine per member per month costs for the current year; and, 2) per member per month cost rounded to a whole number. If you have SCHIP enrollees in a fee for service program, per member per month cost will be the average cost per month to provide services to these enrollees.

2010 # of eligibles $ PMPM Insurance payments -

$ - Managed Care 28,170 $ 194 Fee for Service 14,989 $ 173 Supplemental dental insurance payments 6,440 $ 26