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

Effective Date:

3 Approval Date:

part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Date Plan Submitted:

May 19, 1998 Date Plan Approved:

August 7, 1998 Effective Date:

July 1, 1998 (Title XIX expansion)

August 1, 1998 (Title XXI)

Amendment #1: Cover birth-18 185%-200%; no AI/AN cost sharing Date Submitted:

January 5, 2000 Date Approved:

March 1, 2001 Date Effective:

October 1, 1999

Amendment #2: Hospice Date Submitted:

April 5, 2001 Date Approved:

June 6, 2001 Date Effective:

March 30, 2001

Amendment #3: Compliance Date Submitted:

June 28, 2002 Date Approved:

September 19, 2002

Amendment #4: Public health initiatives Date Submitted:

January 9, 2003 Date Approved:

April 16, 2003 Date Effective:

July 1, 2002

Amendment #5: Increase premiums for separate child health program Date Submitted:

October 6, 2004 Date Approved:

January 5, 2005 Date Effective:

November 1, 2004

Amendment #6: DirigoChoice Date Submitted:

June 29, 2005 Date Approved

September 22, 2005 Date Effective:

January 1, 2005