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

Effective Date: August 24, 2001

Approval Date: 55 Personal Services $275,680 $500,478 $564,834 Outreach $50,477 91,637 $103,420 Data Collection $34,945 $63,441 $71,599 Computer Services $27,180 $49,343 $55,688 Total Administration $388,282 $704,899 $795,541 Total Budget $3,882,819 $7,048,986 $7,955,408 Federal Share $3,032,482 $5,485,521 $6,058,043 State Share $850,337 $1,563,465 $1,897,365

∃ Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. ∃ Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750) 10.1.1. X The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2. X The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3. X The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Section 11. Program Integrity (Section 2101(a))

Γ Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue to Section 12.

11.1 X The state assures that services are provided in an effective and efficient manner