Page 53

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

Effective Date: August 24, 2001

Approval Date: 53 Treatment $23,353 $373,647 $432,963 Mental Health $4,787 $76,584 $88,742 All Other $1,323 $21,168 $24,529

Total Services $148,650 $2,378,400 $2,755,971

Administration

Personal Services $11,727 $187,629 $217,416 Outreach $2,147 $34,355 $39,808 Data Collection $1,487 $23,784 $27,560 Computer Services $1,156 $18,499 $21,435 Total Administration $16,517 $264,267 $306,219 Total Budget $165,167 $2,642,667 $3,062,190 Federal Share $128,995 $2,056,523 $2,331,858 State Share $36,172 $586,144 $730,332

M-SCHIP THREE YEAR BUDGET PROJECTION

Federal Fiscal Year Budget Estimates-- - M-SCHIP FFY 2000 FFY 2001 FFY 2002 Medical Services Purchased

Physician $746,133 $884,348 $982,069 Inpatient Hospital $747,471 $885,934 $983,830 Outpatient Hospital $426,266 $505,229 $561,056 Prescription Drugs $389,127 $461,209 $512,173 Preventive Services (EPSDT)

Screening $13,049 $15,466 $17,175 Dental and Orthodontic $224,844 $266,494 $295,942 Optometric $135,843 $161,007 $178,798 Treatment $525,639 $623,009 $691,852 Mental Health $107,738 $127,695 $141,805 All Other $29,778 $35,295 $39,195

Total Services $3,345,887 $3,965,687 $4,403,896