Page 52
Model Application Template for the State Children’s Health Insurance Program
Effective Date:
Approval Date: 9-5 9.10. Provide a 1- 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: 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.
CHIP Budget STATE: FFY Budget Federal Fiscal Year 2010 State's enhanced FMAP rate
Benefit Costs
Insurance payments
Managed care $704,776,000 per member/per month rate $170 Fee for Service
Total Benefit Costs $704,776,000 (Offsetting beneficiary cost sharing payments) ($27,124,000) Net Benefit Costs $677,652,000
Administration Costs
Personnel $1,971,000 General administration $3,313,000 Contractors/Brokers
Claims Processing
Outreach/marketing costs $7,277,000 Other
Total Administration Costs $12,561,000 10% Administrative Cap $75,294,667
Federal Share $448,638,450 State Share $241,574,550 Total Costs of Approved SCHIP Plan $690,213,000 The Source of State Share Funds: