Form CMS-416 Annual EPSDT Participation Report

FORM CMS 416: ANNUAL EPSDT
PARTICIPATION REPORT

Age Group
<1
1a. Total individuals eligible for EPSDT
(CN)
1a. Total individuals eligible for EPSDT
(MN)
1b. Total Individuals Eligible for EPSDT for
90 Continous Days (CN)
1b. Total Individuals Eligible for EPSDT for
90 Continous Days (MN)
1c. Total Individuals Eligible under a CHIP
Medicaid Expansion (CN)
1c. Total Individuals Eligible under a CHIP
Medicaid Expansion (MN)
2a. State Periodicity Schedule
3a. Total Months of Eligibility (CN)
3a. Total Months of Eligibility (MN)
6. Total Screens Received (CN)
6. Total Screens Received (MN)
9. Total Eligibles Receiving at least One
Initial or Periodic Screen (CN)
9. Total Eligibles Receiving at least One
Initial or Periodic Screen (MN)
11. Total Eligibles Referred for Corrective
Treatment (CN)

Age Group
1-2

Age Group
3-5

Age Group
6-9

Age Group
10-14

Age Group
15-18

Age Group
19-20

11. Total Eligibles Referred for Corrective
Treatment (MN)
12a. Total Eligibles Receiving Any Dental
Services (CN)
12a. Total Eligibles Receiving Any Dental
Services (MN)
12b. Total Eligibles Receiving Preventive
Dental Services (CN)
12b. Total Eligibles Receiving Preventive
Dental Services (MN)
12c. Total Eligibles Receiving Dental
Treatment Services (CN)
12c. Total Eligibles Receiving Dental
Treatment Services (MN)
12d. Total Eligibles Receiving a Sealant on
a Permanent Molar Tooth (CN)
12d. Total Eligibles Receiving a Sealant on
a Permanent MolarTooth (MN)
12e. Total Eligibles Receiving Dental
Diagnostic Services (CN)
12e. Total Eligibles Receiving Dental
Diagnostic Services (MN)
12f. Total Eligibles Reciving Oral Health
Services provided by a Non-Dentist
provider (CN)
12f. Total Eligibles Reciving Oral Health
Services provided by a Non-Dentist
provider (MN)
12g. Total Eligibles Receiving Any Dental or
Oral Health Services (CN)
12g. Total Eligibles Receiving Any Dental or
Oral Health Services (MN)
13. Total Eligibles Enrolled in Managed
Care (CN)

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

13. Total Eligibles Enrolled in Managed
Care (MN)
14. Total Number of Screening Blood Lead
Tests (CN)
14. Total Number of Screening Blood Lead
Tests (MN)

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field

Do not enter data
in this field