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59 Effective Date: July 1, 2009

Approval Date: • Planned use of funds, including: o Projected amount to be spent on health services; o Projected amount to be spent on administrative costs, such as

outreach, child health initiatives, and evaluation; and o 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.

Washington State SCHIP Budget Plan Federal Fiscal Year Costs Federal Fiscal Year Costs Enhanced FMAP rate 65.08% 65.00% Benefit Costs FFY 2010 FFY 2011 Insurance Payments - - Managed Care – Children (200-300%FPL) PM/PM $106 $119 • 17,293 FFY10 eligibles; 19,188 FFY11 eligibles $22,015,372 $27,508,684 • 179 FFY10 eligibles; 181 FFY11 eligibles [Section 214, Title XXI] (1) $227,881 $259,489 • 3,876 FFY10 eligibles; 4,564 FFY11 eligibles [Section 214, Title XIX](1) (2) $4,934,458 $6,543,133 Fee for Service - Children (200-300%FPL) PM/PM $155 $156 • 3,023 FFY10 eligibles; 3,349 FFY11 eligibles $5,622,054 $6,282,188 • 31 FFY10 eligibles; 32 FFY11 eligibles [Section 214, Title XXI](1) • 677 FFY10 eligibles; 797 FFY11 eligibles [Section 214, Title XIX] (1) (2)

$57,653

$1,259,058

$60,027

$1,495,044 Fee for Service - Unborn Child (185%FPL) PM/PM $188 $190 • 7,377 FFY10 eligibles; 7,378 FFY11 eligibles $16,601,616 $16,814,763 133% Medicaid Children (FMAP to EFMAP Federal Only)(3) $10,450,000 $24,575,000 Total Benefit Costs $61,168,093 $83,540,205 (Total offsetting beneficiary cost sharing payments) ($3,811,611) ($4,297,723) Net Benefit Costs $57,356,482 $79,242,482 Administration Costs(4)