Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)

ICR 200908-0938-014

OMB: 0938-0354

Federal Form Document

ICR Details
0938-0354 200908-0938-014
Historical Active 200903-0938-002
HHS/CMS
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Revision of a currently approved collection   No
Emergency 09/21/2009
Approved without change 10/09/2009
Retrieve Notice of Action (NOA) 08/31/2009
  Inventory as of this Action Requested Previously Approved
04/30/2010 6 Months From Approved 04/30/2012
56 0 56
1,568 0 1,568
15,000 0 15,000

States are required to submit an annual report on the provision of EPSDT services to CMS pursuant to section 1902(a)(43)(D) of the Social Security Act. These reports provide CMS with data necessary to assess the effectiveness of State EPSDT programs, to determine a state's results in achieving its participation goal, and to respond to inquiries. Respondents are State Medicaid agencies. The data is due April 1 of every year so States need to have the form and instructions as soon as possible in order to report timely.
See attached emergency justification.

PL: Pub.L. 101 - 239 6403 Name of Law: EPSDT Defined
  
None

Not associated with rulemaking

74 FR 39702 08/07/2009
No

1
IC Title Form No. Form Name
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report CMS-416 Annual EPSDT Participation Report

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 56 56 0 0 0 0
Annual Time Burden (Hours) 1,568 1,568 0 0 0 0
Annual Cost Burden (Dollars) 15,000 15,000 0 0 0 0
No
No

$55,760
No
No
Uncollected
Uncollected
No
Uncollected
Melissa Musotto 4107866962

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/31/2009


© 2024 OMB.report | Privacy Policy