Page 2
Effective Date:
Approval Date:
Updated and amended effective August 24, 2001
2
MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM
(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))
State/Territory: Commonwealth of Pennsylvania ________________ (Name of State/Territory)
As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))
________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)
submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.
The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):
Name: M. Diane Koken
Position/Title: Insurance Commissioner, PA Insurance Department Name: George L. Hoover
Position/Title: Deputy Commissioner, Children’s Health Insurance Program and adultBasic Coverage Program
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, N2-14-26, Baltimore, Maryland 21244.