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

ICR 201702-0938-010

OMB: 0938-0354

Federal Form Document

ICR Details
0938-0354 201702-0938-010
Historical Active 201507-0938-009
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Revision of a currently approved collection   No
Approved without change 06/12/2017
Retrieve Notice of Action (NOA) 02/24/2017
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
112 0 112
1,778 0 1,834
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

  81 FR 75406 10/31/2016
82 FR 11037 02/17/2017

  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 112 112 0 0 0 0
Annual Time Burden (Hours) 1,778 1,834 0 -56 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
Miscellaneous Actions
Training Videos The modules, which were initially interactive online tools, have been converted to YouTube videos, reducing the state burden to a state agency for one (1) person to complete all six (6) videos from 4.75 hours to 2.75 hours. Using the videos is entirely voluntary. They are intended to support states and their contractors to more accurately and completely report dental data to CMS. Overall, the videos decrease the burden of hours from 266 hours (aggregate) for completing the modules to 154 hours (aggregate) viewing time. CMS-416 (Form) The changes to the Form CMS-416 include adding a line to provide the methodology for reporting Line 14 and adding the expiration date in the PRA disclaimer. We have adjusted our per response burden by adding 0.5 hr/response for reporting and 0.5 hr/response for recordkeeping. In aggregate, we adjust our estimate from 1,568 hr to 1,624 hr. CMS-416 (Instructions) Misc clarifications (see Supporting Statement 15 and Crosswalk for details).

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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