Page 57

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

Effective Date:

Approval Date: September 19, 2002 57 Budget For Federal Fiscal Years 2001, 2002, and 2003

Federal Fiscal Year 2001 Federal Fiscal Year 2002

Federal Fiscal Year 2003

Benefit Costs

Estimated average enrollees 59,908 65,841 68,676 Estimated cost per member per month $79.21 $83.01 $83.01

Insurance payments

Managed care $2,804,255 $3,100,000 $3,300,000

Fee for Service 54,142,479 62,482,000 65,106,100

Total Benefit Costs 56,946,734 65,582,000 68,406,100

(Offsetting beneficiary cost sharing payments) (1,046,305) (1,100,000) (1,200,000)

Net Benefit Costs 55,900,429 64,482,000 67,206,100

Administration Costs

Personnel $2,232,869 $1,875,312 $1,969,914

General administration 1,047,418 879,692 924,068

Other Indirect Costs 991,820 832,996 875,017

Total Administration Costs 4,272,107 3,588,000 3,769,000

10% Administrative Cost Ceiling 4,272,107 3,588,000 3,769,000

Federal Share (multiplied by enhanced FMAP rate) 39,112,148 44,245,500 46,133,815

State Share 21,060,388 23,824,500 24,841,285

TOTAL PROGRAM COSTS $60,172,536 $68,070,000 $70,975,100