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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 43 - 9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42 CFR 457.140) • Planned use of funds, including - o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and o 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. Response: Benefit Costs Insurance Payments Total projected costs for the SCHIP 1 and SCHIP 2 populations. Federal Fiscal Year (FFY) 2009 expenditures include actual expenditures of the one quarter available and projected expenditures of the three quarters not yet available. Based on the last year of historical expenditures, the State expects a 2% annual trend. Member months are calculated from the CMS 64.21E Line 1, per CMS instructions. FFY 2009 member months include actual member months of the one quarter available and projected member months of the three quarters not yet available. Based on the last year of historical expenditures, the State expects member months to grow approximately .50% annually.

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Page 85

Official source

Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 43 - 9.10 Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42 CFR 457.140) • Planned use of funds, including - o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and o 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. Response: Benefit Costs Insurance Payments Total projected costs for the SCHIP 1 and SCHIP 2 populations. Federal Fiscal Year (FFY) 2009 expenditures include actual expenditures of the one quarter available and projected expenditures of the three quarters not yet available. Based on the last year of historical expenditures, the State expects a 2% annual trend. Member months are calculated from the CMS 64.21E Line 1, per CMS instructions. FFY 2009 member months include actual member months of the one quarter available and projected member months of the three quarters not yet available. Based on the last year of historical expenditures, the State expects member months to grow approximately .50% annually.