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

Effective Date: 11/1/10 5

Approval Date: 12/30/10

State Plan Amendment #2: Minor revisions to performance measures in approved XXI State Plan Submitted: May 30, 2000 CMS Approved: September 11, 2000

State Plan Amendment #3: Increase enrollment cap to 19,800 Submitted: December 12, 2000 CMS Approved: March 9, 2001

State Plan Amendment #4 Compliance with final CHIP regulations and updated program descriptions Submitted: July 31, 2002 CMS Approved: April 15, 2003

State Plan Amendment #5: Asset limit increase to $10,000 Submitted: August 19, 2004 CMS Approved: November 10, 2004 Effective date: October 1, 2004

State Plan Amendment #6: Duration of eligibility period increased to 12 months Submitted: May 16, 2006 CMS Approved: August 1, 2006 Effective Date: June 1, 2006

State Plan Amendment # 7: Unborn child expansion Submitted: July 31, 2007 Approved: April 9, 2008 Effective: April 1, 2008

State Plan Amendment #8: Require SSN on application Submitted: September 13, 2007 Approved: December 12, 2007 Effective: October 1, 2007

State Plan Amendment # 9: Transition the following targeted low income children from Section 1115 demonstration to the state plan: children ages 0 through 18 above 170 percent of the FPL up to 185 percent of the FPL. Submitted: November 30, 2007 Approved: September 16, 2008Effective: November 1, 2007 State Plan Amendment # 10: This amendment expands the income