DEPARTMENT OF HEALTH AND HUMAN SERVICES |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CENTERS FOR MEDICARE & MEDICAID SERVICES |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Age Groups |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State____________ FY _______ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
<1 |
1 - 2 * |
3 - 5 |
6 - 9 |
10 - 14 |
15 - 18 |
19-20 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1. Total Individuals |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Eligible for EPSDT |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2a. State Periodicity |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Schedule |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2b. Number of Years |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
in Age Group |
|
|
1 |
2 |
3 |
4 |
5 |
4 |
2 |
|
|
|
|
|
|
|
|
|
|
2c. Annualized State |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Periodicity Schedule |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3a. Total Months |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
of Eligibility |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
3b. Average Period |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
of Eligibility |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
4. Expected Number of |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Screenings per |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Eligible |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5. Expected Number |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
of Screenings |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6. Total Screens |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Received |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
7. Screening Ratio |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
* Includes 12-month visit |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Note: "CN" = Categorically Needy, "MN" = Medically Needy |
|
|
|
|
|
|
OMB control number: 0938-0354 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Page 2 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Age Groups |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
State____________ FY _______ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
<1 |
1 - 2 * |
3 - 5 |
6 - 9 |
10 - 14 |
15-18 |
19-20 |
|
|
|
|
|
|
|
|
|
|
8. Total Eligibles Who |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Should Receive at |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Least One Initial or |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Periodic Screen |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
9. Total Eligibles |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Receiving at Least |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
One Initial or |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Periodic Screen |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
10. PARTICIPANT RATIO |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
11. Total Eligibles |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Referred for |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Corrective Treatment |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
12a. Total Eligibles |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Receiving Any Dental |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Services |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
12b. Total Eligibles |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Receiving Preventive |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Dental Services |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
12c. Total Eligibles |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Receiving Dental |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Treatment Services |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
13. Total Eligibles Enrolled |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
in Managed Care |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
14. Total number of |
CN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Screening Blood |
MN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Lead Tests |
Total |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
* Includes 12-month visit |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Note: "CN" = Categorically Needy, "MN" = Medically Needy |
|
|
|
|
|
|
OMB control number: 0938-0354 |
|
|
|
|
|
|
|
|
|
|
|
|