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

Effective Date:

Approval Date: 40 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.

State match for CHIP participants with family incomes between 150% and 185% FPL is collected through a state-imposed premium tax on insurance policies sold within the State. A portion of these funds is dedicated to CHIP funding via Idaho statute. The premium tax that funds this portion of the program is imposed on all entities that sell insurance (not just health insurance) in Idaho. Less than 85 percent of the premium tax burden falls on health care providers. The premium tax collections from health insurance are treated the same as premium tax collections from other types of insurance. Therefore, this premium tax does not meet the definition of a “health-care related tax” as defined in 42 CFR §433.55.

State match for CHIP participants with family incomes between 133% and 150% FPL is appropriated from the state General Fund.

Benefit Costs FFY06 FFY07 Insurance payments, PCCM (PMPM x # eligibles) $9,176,418 $10,743,319 Insurance payments, Fee for Service (PMPM x # eligibles) $1,619,367 $1,895,880 Total Benefit Costs $10,795,786 $12,639,199 (Offsetting beneficiary cost sharing payments) ($242,715) ($548,770) Net Benefit Costs $10,553,071 $12,090,429

Administration Costs

Personnel $638,000 $650,760 General Administration $223,321 $227,788