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

ICR 201507-0938-009

OMB: 0938-0354

Federal Form Document

Forms and Documents
ICR Details
0938-0354 201507-0938-009
Historical Active 201312-0938-009
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
No material or nonsubstantive change to a currently approved collection   No
Approved without change 08/18/2015
Retrieve Notice of Action (NOA) 07/14/2015
  Inventory as of this Action Requested Previously Approved
02/28/2017 02/28/2017 02/28/2017
112 0 56
1,834 0 1,568
0 0 0

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.

PL: Pub.L. 101 - 239 6403 Name of Law: EPSDT Defined

Not associated with rulemaking

  78 FR 48687 08/09/2013
78 FR 73546 12/06/2013

  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 112 56 0 56 0 0
Annual Time Burden (Hours) 1,834 1,568 0 266 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
This package sets out nonsubstantive changes. This package does not involve any changes to form CMS-416 or to the instructions for completing the form or to the burden for completing the form. Rather, CMS is requesting approval to offer to states and their contractors a set of online training modules related to reporting on the dental lines of the CMS-416 form. Using the modules is entirely voluntary. They are intended to support states and their contractors to more accurately and completely report dental data to CMS. The modules would add 266 hours (aggregate).

Mitch Bryman 410 786-5258 [email protected]


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.

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