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

Effective Date:

Approval Date: 41 Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/Marketing Costs

Healthy Schools (Health Services Initiatives) $100,000 $410,000 Other

Total Administration Costs $961,321 $1,288,548 10% Administrative Cap $1,172,563 $1,343,381 Federal Title XXI Share $9,089,461 $10,507,848 State Share $2,424,931 $2,871,128 TOTAL COSTS OF APPROVED SCHIP PLAN $11,514,392 $13,378,977

Average Monthly Eligibles 7,139 8,021

Average PMPM Cost (Prior to Offsets) $126.02 $131.32