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

Effective Date:

Approval Date: 61 prior public notice was provided as required in §457.65 (b) through (d).

CHIP Program changes related to the time period for payment of cost sharing obligations – This amendment increases the amount of time that enrollees have to pay the enrollment fee upon renewal of their coverage. Prior public notice was provided through: - Posting of a notice in the Texas Register regarding the submission of the SCHIP state plan amendment, including contact information to obtain a copy of the amendment.

CHIP Program Changes related to extension of coverage for Prenatal Care and Associated Health Care Services:

- Public input was sought through meetings with interested stakeholders such as the Texas Hospital Association, the Texas CHIP Coalition, and the Texas Association of Health Plans. - Eligibility and cost sharing rules were presented to members of the Medical Care Advisory Committee and the Texas Health and Human Services Commission Agency Council. - hearing was held on November 1, 2005. - Public notice was also submitted to the Texas Register.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

- 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.

SCHIP Budget Plan

Federal Fiscal Year 2008 Costs Enhanced FMAP rate (state share) 0.2761 Benefit Costs

Managed Care Premiums

Per member/per month rate times the number of eligibles 935,187,374 Fee for Service:

Prescription Drugs 135,642,986 Total Benefit Costs 1,070,830,359 (Offsetting beneficiary cost sharing payments) (10,936,980) Net Benefit Costs 1,059,893,379

Administration Costs