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

Effective Date: August 24, 2001

Approval Date: 54

Administration

Personal Services $263,953 $312,849 $347,418 Outreach $48,329 $57,282 $63,612 Data Collection $33,459 $39,657 $44,039 Computer Services $26,024 $30,844 $34,253 Total Administration $371,765 $440,632 $489,322 Total Budget $3,717,652 $4,406,319 $4,893,218 Federal Share $2,903,486 $3,428,997 $3,726,186 State Share $814,166 $977,322 $1,167,032

TOTAL SOUTH DAKOTA SCHIP THREE YEAR BUDGET PROJECTION

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

Physician $779,282 $1,414,731 $1,596,650 Inpatient Hospital $780,680 $1,417,269 $1,599,514 Outpatient Hospital $445,204 $808,237 $912,167 Prescription Drugs $406,415 $737,817 $832,693 Preventive Services (EPSDT)

Screening $13,629 $24,742 $27,923 Dental and Orthodontic $234,833 $426,323 $481,143 Optometric $141,878 $257,570 $290,691 Treatment $548,992 $996,656 $124,815 Mental Health $112,524 $204,280 $230,548 All Other $31,101 $56,462 $63,723

Total Services $3,494,537 $6,344,087 $7,159,867

Administration