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

Forms and Documents

Document Name	Status
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form	Modified
Response to 60-day comments on CMS-416 instructions.doc Supplementary Document	2013-12-09
PRA Crosswalk 2014 CMS-416 instructions.pdf Supplementary Document	2013-12-09
CMS-416 - Supporting Statement A [rev 12-06-2013 by OSORA PRA].rtf Supporting Statement A	2013-12-09

IC Document Collections

IC ID	Document Title	Status
7986	Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form	Modified

ICR Details

OMB Control No: 0938-0354	ICR Reference No: 201312-0938-009
Status: Historical Active	Previous ICR Reference No: 201009-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: 21096
Title: Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/2014
	Date Received in OIRA: 12/10/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved	02/28/2014
Responses	56	0	56
Time Burden (Hours)	1,568	0	1,568
Cost Burden (Dollars)	0	0	15,000

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 101 - 239 6403 Name of Law: EPSDT Defined
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 48687	08/09/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 73546	12/06/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 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

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ICR Summary of Burden

	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)	0	15,000	0	0	-15,000	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $57,114

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/10/2013

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