| 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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| 1a. Total Individuals |
CN |
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| Eligible for EPSDT |
MN |
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Total |
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| 1b. Total Individuals |
CN |
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| Eligible for EPSDT for |
MN |
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| 90 Continous Days |
Total |
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| 1c. Total Individuals |
CN |
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| Eligible under a CHIP |
MN |
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| Medicaid Expansion |
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 |
4 |
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 |
MN |
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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 a Sealant on |
MN |
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| a Permanent Molar |
Total |
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| 12e. Total Eligibles |
CN |
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| Receiving Dental |
MN |
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| Diagnostic Services |
Total |
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| 12f. Total Eligibles |
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| Receiving Oral Health |
CN |
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| Services |
MN |
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| By a Non-Dentist |
Total |
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| 12g. 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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| Disclosure Statement - According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0354. The time required to complete this information collection is estimated to average 28 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop: C4-26-05, Baltimore, Maryland 21244-1850. |
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