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

Effective Date:

Approval Date: 62 Eligibility Enrollment and Outreach 20,883,925 Other Administration 5,624,944 Subtotal 26,508,869

Total Administration Costs 26,508,869 10% Administrative Cost Ceiling (benefits-cost share)/9) 117,765,931 Federal Share (multiplied by EFMAP rate) 786,446,587 State Share 299,955,661 TOTAL PROGRAM COSTS 1,086,402,248

Notes: The Federal Fiscal Year (FFY) runs from October 1st through September 30th. Members per Month and PMPM assumptions are derived from the June Update 2007 forecast which includes HB 109. Client Service cost include Perinates, Vaccines, and Dental.

Average Federally funded SCHIP Members per Month: FY 2008 - 335,969 (excludes Perinates). The PMPM assumptions are $103.06 for premiums, and $0.49 for vaccines and $25.36 for Prescription Drugs

Average Federally-funded SCHIP Perinate Members per Month: FY 2008 - 95,480 The PMPM assumptions are $451.85 for premiums, and $29.17 for Prescription Drugs

The State's funding sources include State Tobacco Funds, General Revenues, rebates, and cost sharing.

Assumptions:

Benefit costs represent payments to health providers for providing health care services to CHIP enrollees. These cost estimates are based upon the yearly mean average of enrollees and the average cost per enrollee per month. Administration costs represent the cost of eligibility determination and enrollment services, outreach, quality assurance efforts by the agency, audits, and actuarial work.

Funding Sources The funding source for the state share for state fiscal years 2002 and beyond includes appropriated state funds and may include other public funds certified or transferred from public agencies consistent with applicable federal law and regulations.

Sources of state share for state fiscal year 2002 and beyond also include bona-fide donations consistent with Section 2107(e)(1)(C) of the Social Security Act, Section 1903(w) of the Act, and other applicable federal law and regulations. The following provides background on the donors, donor sources of revenue and donor funding flow for the one project that involves bona-fide donations: the Community Health Workers Project (approved in correlation with the compliance SPA amendment). Documentation for additional donors will be submitted to CMS for approval. The State assures compliance with the definition of bona-fide donations described in 42CFR