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• Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees. • Include a separate budget line to indicate the cost of providing coverage to pregnant women. • States must include a separate budget line item to indicate the cost of providing coverage to premium assistance children. • Include a separate budget line to indicate the cost of providing dental-only supplemental coverage. • Include a separate budget line to indicate the cost of implementing Express Lane Eligibility. • Provide a 1-year projected budget for all targeted low-income children covered under the state plan using the attached form. Additionally, provide the following: - Total 1-year cost of adding prenatal coverage - Estimate of unborn children covered in year 1

CHIP Budget Projections

STATE: CA FFY Budget FFY Budget Federal Fiscal Year 2013 2014 State’s enhanced FMAP rate 65.00% 65.00%

Benefit Costs

Insurance payments - - Managed care $1,309,760,269 $1,161,016,067 per member/per month rate $119.15 $119.07 Fee for Service $547,879,132 $483,378,754 Total Benefit Costs $1,857,639,520 $1,644,394,940 (Offsetting beneficiary cost sharing payments) (92,585,780) (68,784,114) Net Benefit Costs $1,765,053,739 $1,575,610,826 Cost of Proposed SPA Changes – Benefit - -

Administration Costs

Personnel - - General administration $94,422,201 $43,414,158 Contractors/Brokers - - Claims Processing - - Outreach/marketing costs - - Health Services Initiatives - -