Page 4

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

Effective Date:

Approval Date: 4 Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service act of 1912 (42 U.S.C. 290 dd-3 and 290-ee-3) as amended, relating to confidentiality of alcohol and drug abuse patients records; (h) Title VIII of the Civil Rights At of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (I) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application."

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):

Plan Submitted: May 14, 1998 Plan Approved: July 14, 1998 Plan Effective Date: October 1, 1998 1st Amendment Submitted: October 21, 1998 1st Amendment Approved: January 15, 1999 1st Amendment Effective: September 30, 1998 2nd Amendment Submitted: March 26, 1999 2nd Amendment Approved: June 23, 1999 2nd Amendment Effective: March 12, 1999 3rd Amendment Submitted: July 12, 1999 3rd Amendment Approved: September 30, 1999 3rd Amendment Effective: July 1, 1999 4th Amendment Submitted: August 3, 2000 4th Amendment Approved: October 19, 2000 a. Native American Cost Sharing Exemption Effective: May 1, 2000 b. Special Needs Children Effective: October 1, 2000 5th Amendment Submitted: November 21, 2000 5th Amendment Approved: February 16, 2001 5th Amendment Effective: January 1, 2001 6th Amendment Submitted: October 12, 2001 6th Amendment Approved: January 9, 2002 6th Amendment Effective: October 8, 2001