| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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| CENTERS FOR MEDICARE & MEDICAID SERVICES |
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| FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT |
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Age Groups |
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| State____________ FY _______ |
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Total |
<1 |
1 - 2 * |
3 - 5 |
6 - 9 |
10 - 14 |
15 - 18 |
19-20 |
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| 1. Total Individuals |
CN |
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| Eligible for EPSDT |
MN |
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Total |
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| 2a. State Periodicity |
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| Schedule |
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| 2b. Number of Years |
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| in Age Group |
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1 |
2 |
3 |
4 |
5 |
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2 |
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| 2c. Annualized State |
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| Periodicity Schedule |
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| 3a. Total Months |
CN |
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| of Eligibility |
MN |
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Total |
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| 3b. Average Period |
CN |
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| of Eligibility |
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Total |
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| 4. Expected Number of |
CN |
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| Screenings per |
MN |
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| Eligible |
Total |
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| 5. Expected Number |
CN |
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| of Screenings |
MN |
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Total |
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| 6. Total Screens |
CN |
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| Received |
MN |
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Total |
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| 7. SCREENING Ratio |
CN |
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MN |
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Total |
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| * Includes 12-month visit |
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| Note: "CN" = Categorically Needy, "MN" = Medically Needy |
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Page 2 |
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Age Groups |
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| State____________ FY _______ |
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Total |
<1 |
1 - 2 * |
3 - 5 |
6 - 9 |
10 - 14 |
15-18 |
19-20 |
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| 8. Total Eligibles Who |
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| Should Receive at |
CN |
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| Least One Initial or |
MN |
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| Periodic Screen |
Total |
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| 9. Total Eligibles |
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| Receiving at Least |
CN |
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| One Initial or |
MN |
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| Periodic Screen |
Total |
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| 10. PARTICIPANT RATIO |
CN |
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MN |
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Total |
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| 11. Total Eligibles |
CN |
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| Referred for |
MN |
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| Corrective Treatment |
Total |
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| 12a. Total Eligibles |
CN |
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| Receiving Any Dental |
MN |
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| Services |
Total |
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| 12b. Total Eligibles |
CN |
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| Receiving Preventive |
MN |
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| Dental Services |
Total |
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| 12c. Total Eligibles |
CN |
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| Receiving Dental |
MN |
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| Treatment Services |
Total |
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| 12d. Total Eligibles |
CN |
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| Receiving Dental |
MN |
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| Diagnostic Services |
Total |
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| 12e. Total Eligibles Receiving |
CN |
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| Oral Health Services |
MN |
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| By a Non-Dentist |
Total |
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| 12f. Total Eligibles |
CN |
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| Receiving Any Dental |
MN |
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| Or Oral Health Service |
Total |
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| * Includes 12-month visit |
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| Note: "CN" = Categorically Needy, "MN" = Medically Needy |
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Page 3 |
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Age Groups |
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| State____________ FY _______ |
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Total |
<1 |
1 - 2 * |
3 - 5 |
6 - 9 |
10 - 14 |
15-18 |
19-20 |
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| 13. Total Eligibles Enrolled |
CN |
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| in Managed Care |
MN |
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Total |
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| 14. Total number of |
CN |
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| Screening Blood |
MN |
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| Lead Tests |
Total |
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| * Includes 12-month visit |
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| Note: "CN" = Categorically Needy, "MN" = Medically Needy |
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