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

Effective Date:

Approval Date: 52

SCHIP Budget STATE: FFY Budget Federal Fiscal Year 2010 State's enhanced FMAP rate (FF) 72.39% vs (GF) 27.61%

Benefit Costs

Insurance payments

Managed care (See Note 1) $ 4,865,000 per member/per month rate

Fee for Service (See Note 1) 51,973,000 Total Benefit Costs $56,838,000 (Offsetting beneficiary cost sharing payments) 0 Net Benefit Costs $56,838,000

Administration Costs

Personnel $3,772,423 General administration $160,654 Contractors/Brokers 0 Claims Processing $1,155,923 Outreach/marketing costs (included with General Admin) Other 0 Total Administration Costs $5,089,000 10% Administrative Cap $6,315,333

Federal Share $45,716,698 State Share $17,436,635 Total Costs of Approved SCHIP Plan $63,153,333 The Source of State Share Funds: Legislative Appropriation

NOTE 1: “Managed Care” costs include “capitation payments” only. “Carved-out Services” costs such as those for dental services and pharmaceuticals provided to children enrolled in Managed Care are included with “Fee-for-Service” benefit cost total.

NOTE 2: Expected enrollment:

2010 Estimate:

24,080

Additional per Impact Statement 5,430

TOTAL EXPECTED ENROLLMENT 29,510