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

ICR 202002-0938-015

OMB: 0938-0354

Federal Form Document

ICR Details
0938-0354 202002-0938-015
Active 201702-0938-010
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Revision of a currently approved collection   No
Approved without change 05/04/2020
Retrieve Notice of Action (NOA) 02/27/2020
  Inventory as of this Action Requested Previously Approved
05/31/2023 36 Months From Approved 06/30/2020
56 0 112
1,512 0 1,778
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

  84 FR 58390 10/31/2019
85 FR 4992 01/28/2020

  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 56 112 0 -56 0 0
Annual Time Burden (Hours) 1,512 1,778 0 -266 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
In this 2019/2020 iteration, we propose to revise the EPSDT reporting requirements on Form CMS-416: Annual EPSDT Participation Report (EPSDT Report). We are making two changes to the Form CMS-416. A line has been added to the top of the form to give states the option to allow CMS to generate the Form CMS-416 on behalf of states using data from the CMS Transformed Medicaid Statistical Information System (T-MSIS). This option is available to states who are both current on their T-MSIS submissions to CMS and whose T-MSIS data meets internal data quality standards. In addition, CMS is modifying line 12g to capture preventive dental or oral health services. Corresponding changes have been made to the instructions. We are also proposing to revise the instructions to provide and simplify examples; clarify which lines states do not need to complete as they will be auto-calculated; clarify lines 12a-12g and coding guidance for lines 12f and 12g; and revise the instructions for line 14 to reflect lines 14a and 14b on the Form CMS-416. The new burden estimate for states is 1,512 hours. This reflects the completion and submission of the Form CMS-416 by states as well as CMS generation and state review and verification of the Form CMS-416 for states that opt to have CMS generate the form for them. This is a reduction of 112 hours (1,512 proposed hr - 1,624 active hr) from our active burden estimate for the recordkeeping and reporting. The 112 hour reduction reflects the estimated 20 percent reduction (as explained below) in the reporting burden for states who select to have CMS generate Form CMS-416 on their behalf. Section 2700.4 of the State Medicaid Manual (SMM) contains Form CMS-416, instructions for completion of the form. The reference to the six YouTube training module videos in the instructions has been removed. These videos were available as supplements to the instructions and have been removed as there was not significant state utilization.

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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