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

Effective Date:

39 Approval Date: premium for title XXI funded coverage notifying them of the premium increase. Effective November 1, 2004, the premium increases will be implemented as members come up for renewal. At that time, they will be notified of the exact amount of their new premium.

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. SCHIP Budget Plan

Current FFY Budget Budget Increase For Requested SPA

Current B SPA B Incre Federal Fiscal Year

FFY 2005 FFY 2005 FFY 2 State's enhanced FMAP rate

.7542

Benefit Costs

Insurance payments

Managed care

per member/per month rate @ # of eligibles

Fee for Service

$ 31,480,176 $ - $ 31,48 Total Benefit Costs

$ 31,480,176 $ -

$ 31,48 (Offsetting beneficiary cost sharing payments)

$ 783,504 $ -

$ -78 Net Benefit Costs

$ 30,696,672 $

$ 30,69

Administration Costs

Personnel

General administration

$ 1,100,000 $ $ 1,10 Contractors/Brokers

Claims Processing

Outreach/marketing costs

Other: Health Service Initiatives

$ 2,100,000

$ 2,10 Total Administration Costs

$ 3,200,000 $

$ 3,20 10% Administrative Cap

$ 3,410,741

$ 3,41