Form CMS-416 Annual EPSDT Participation Report

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

Form_CMS_416_2016_version [rev 02-23-2107 by OSORA PRA)

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

OMB: 0938-0354

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
State Code

Fiscal
Year
Age Group
<1

Totals

Age Group
6-9

Age Group
10-14

Age Group
15-18

Age Group
19-20

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

2a. State Periodicity Schedule

0

0

0

0

0

0

0

2b. Number of Years in Age Group

1

2

3

4

5

4

2

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

0.00
0
0
0
0.00
0.00
0.00
0.00
0.00
0.00
0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

1b. Total Individuals eligible for
EPSDT for 90 Continous Days
1c. Total Individuals Eligible under
a CHIP Medicaid Expansion

0
0
0
0
0
0
0
0
0

Age Group
3-5

0
0
0
0
0
0
0
0
0

1a. Total individuals
eligible for EPSDT

CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:

Age Group
1-2

2c. Annualized State
Periodicity Schedule
3a. Total Months of
Eligibility
3b. Average Period of
Eligibility
4. Expected Number of
Screenings per
Eligible
5. Expected Number of
Screenings
6. Total Screens
Received
7. SCREENING RATIO
8. Total Eligibles Who
Should Receive at Least
One Initial or Periodic Screen

CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:

* Includes 12-month visit
Note: "CN" = Categorically Needy, "MN"= Medically Needy

0
0
0
0.00
0.00
0.00

0
0
0
0
0
0
0.00
0.00
0.00
0
0
0

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
State Code

Fiscal
Year
Age Group
<1

Totals
9. Total Eligibles Receiving at least
One Initial or Periodic
Screen
10. PARTICIPANT RATIO
11. Total Eligibles Referred for
Corrective Treatment
12a. Total Eligibles Receiving
Any Dental Services
12b. Total Eligibles Receiving
Preventive Dental Services
12c. Total Eligibles Receiving
Dental Treatment Services
12d. Total Eligibles Receiving a
Sealant on a Permanent Molar
Tooth
12e. Total Eligibles Reciving Dental
Diagnostic Services
12f. Total Eligibles Receiving Oral
Health Services provided by a
Non-Dentist provider
12g. Total Eligibles Reciving Any
Dental Or Oral Health Service
13. Total Eligibles Enrolled in
Managed Care
14a. Total Number of Screening
Blood Lead Tests

CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:
CN:
MN:
Total:

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Age Group
1-2

Age Group
3-5

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Enter X For Method I

14b. Methodology used for calculating
the Total Number of Screening Blood
Lead Tests

CPT Code 83655
within certain
diagnoses codes
(Method I)

Age Group
6-9

Enter X For Method II

HEDIS (Method II)

0

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0

Age Group
10-14

Age Group
15-18

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Age Group
19-20

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0.00
0.00
0.00
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

Enter X For Method III

Combination
Methodology
(Method III)

0

Note: "CN"=Categorically Needy, "MN"= Medically Needy
* Includes 12-month visit
Note: "CN" = Categorically Needy, "MN"= Medically Needy

2 of 3
10/18/2016 10:00 AM

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
State Code

Fiscal
Year
Totals

Age Group
<1

Age Group
1-2

Age Group
3-5

Age Group
6-9

Age Group
10-14

Age Group
15-18

Age Group
19-20

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 (Expires: TBD). 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: C7-26-05, Baltimore, Maryland 21244-1850.

* Includes 12-month visit
Note: "CN" = Categorically Needy, "MN"= Medically Needy

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File Type	application/pdf
Author	Kimberly Perrault
File Modified	2017-02-23
File Created	2016-10-18