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

Effective Date: August 24, 2001

Approval Date: 52 A three year CHIP-NM budget is presented. FFY2000 budget amounts are estimated using three months of FFY 2000 from July to September of 2000. Estimates for FFY2001 and FFY2002 represent a full year of operation. This budget assumes 600 clients for FFY 2000, 2,400 clients for FFY 2001, and 2,700 for FFY 2002.

The CHIP-NM service budget is based upon funds appropriated by the South Dakota Legislature. This appropriation was based on an average cost of $991 per eligible child per year. Amounts were then allocated to service categories using utilization figures from currently eligible M-SCHIP children from July, 1999 through April, 2000. Administrative costs for CHIP-NM are calculated at 10% of the allowable service and administration costs. The percentages allocated to administrative categories reflect the best estimates of actual anticipated expenditures by the State.

Recognizing that South Dakota currently operates a M-SCHIP program, an updated 3 year budget for M-SCHIP is also presented for all of FFY 2000, FFY 2001, and FFY 2002. This budget is based on 3,839 clients for FFY 2000, 3,839 clients for FFY 2001, and 4,139 clients for FFY 2002. The average cost per client for FFY 2000 and FFY 2001 is $1,033 per child, per year based on actual costs from July-April of SFY 2000. Amounts have been allocated to service categories using utilization figures from the same time period. Administrative costs are estimated at 10% of the allowable expenditures for services and administration. These costs are based upon current state estimates of anticipated expenditures.

A total SCHIP budget for South Dakota for the three federal fiscal years is also presented. This budget is the sum of the anticipated expenditures for CHIP-NM and M-SCHIP in South Dakota.

CHIP-NM THREE YEAR BUDGET PROJECTION

Federal Fiscal Year Budget Estimates --- CHIP-NM FFY 2000 FFY 2001 FFY 2002 Medical Services Purchased

Physician $33,149 $530,383 $614,582 Inpatient Hospital $33,208 $531,335 $615,684 Outpatient Hospital $18,938 $303,008 $351,111 Prescription Drugs $17,288 $276,608 $320,519 Preventive Services (EPSDT)

Screening $580 $9,276 $10,748 Dental and Orthodontic $9,989 $159,828 $185,201 Optometric $6,035 $96,563 $111,892