Crosswalk CHIPRA PRA

Crosswalk Document for Changes to

Instructions and Form CMS-416

Changes to the Form CMS-416

The form CMS 416 has been revised to include the following additional information.

• Line 1 has been renumbered line 1a.

• Line 1b was added to better compare data across States and improve consistency by including only those individuals who have been eligible for EPSDT for a minimum of 90 continuous days.

• Line 1c was added to reflect new requirement of the Children’s Health Insurance Program Reconciliation Act of 2009 (CHIPRA) to specify number of children receiving EPSDT services through a CHIP Medicaid expansion program.

• Line 12d was added to meet the CHIPRA requirement to begin collecting data on the number of children in the age group including age 8, who receive a sealant on a permanent molar tooth. We also added an additional age group, children ages 10-14, in order to coordinate with Healthy People 2020 data collection.

• Line 12e was added to collect data on certain dental diagnostic services.

• Line 12f was added to collect data on the number of oral health services provided by non-dentists. Interest in collecting this data has greatly increased. This line was recommended to CMS by the Oral Health Technical Advisory Group (OTAG) and supported by other external stakeholders.

• Line 12g was added to provide a total number of children who received either a dental service or an oral health service in a given fiscal year.

Changes to the Form CMS-416 Instructions

The CMS 416 instructions have been revised to reflect the changes above by providing information for States on calculating the data for the additional lines of data (line 1b -c, 12d-g). CMS has also taken the opportunity to update the instructions in several areas based on recommendations from the OTAG and external stakeholders.

• CMS has updated section B of the instructions to strengthen the instruction that data reported on this form should include all services provided under fee for service and managed care arrangements. It also notes that States are required to collect encounter data or other data necessary from managed care entities, in sufficient detail to provide the information required by the CMS 416 report.

• Section D of the instructions was updated to include language requiring States to use the electronic submittal process for their CMS 416 data.

• CMS has revised the instructions for the new line 1b to indicate that children should be continuously eligible for at least 90 days before being included on this line.

• CMS updated the instructions for line 6 to add an example of a “catch-up” EPSDT screening that may be counted on the form.

• CMS updated the instructions for line 7 to include an additional “Note” to clarify when “V” codes are required to be used and to add additional “V” codes available for use with CPT Evaluation and Management codes.

• CMS updated a “Note” prior to the dental data lines to clarify how the dental data should be reported and to define dental services and oral health services.

• CMS has updated the instructions for line 14 to include language allowing States to count data collected through the HEDIS lead measure along with the CPT codes for lead screening. CMS also updated the “Note” to clarify which V codes were acceptable to be counted and which were not.

• CMS has made several editorial changes including changing HCFA to CMS where appropriate and other minor language edits based on comments received as part of the 60-day Federal Register process.

Change in Burden

While there will be some programming changes needed by States to report the additional data on the CMS 416, CMS does not believe this adds a significant additional burden. Based on comments received, CMS requested additional input from CMS systems staff as well as States to determine the additional burden of collecting the new data. The consensus was that while there may be some additional reprogramming necessary for the new data collected, this did not appear to be a significant burden. In order for a State’s MMIS system to be certified by CMS it must be able to run ad hoc reports. States already collect eligibility and dental screening data in their MMIS systems and should be able to run these reports without intervention by their fiscal intermediaries. Therefore we do not believe this adds any additional burden on States to report this information and we expect States to report this data with their April 2011 data submittal.

For the changes in the form and instructions that require new data to be collected for the dental diagnostic services and the services by non-dentists, there may be some programming changes needed. While the additional input we received did not indicate it would be a significant burden to collect this information, CMS will not require States to provide this information for data reported in April 2011 if States are unable to capture this data in time for reporting.