Form CMS-416 Annual EPSDT Participation Report

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

CMS416clean 020620 with updated PRA disclosure.xlsx

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

OMB: 0938-0354

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FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
State Code Fiscal Year







ex. AL 20XX







CMS Generated Reporting of State Form CMS-416 Data Using T-MSIS
Enter X if your state gives CMS permission to generate the data for this form on behalf of your state using information reported in T-MSIS.








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
1a. Total Individuals
Eligible for EPSDT
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
1b. Total Individuals Eligible for
EPSDT for 90 Continuous Days
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
1c. Total Individuals Eligible under
a CHIP Medicaid Expansion
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
2a. State Periodicity Schedule








2b. Number of Years in Age Group

1 2 3 4 5 4 2
2c. Annualized State
Periodicity Schedule


0.00 0.00 0.00 0.00 0.00 0.00 0.00
3a. Total Months of
Eligibility
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
3b. Average Period of
Eligibility
CN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
MN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Total: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
4. Expected Number of
Screenings per Eligible
CN:
0.00 0.00 0.00 0.00 0.00 0.00 0.00
MN:
0.00 0.00 0.00 0.00 0.00 0.00 0.00
Total:
0.00 0.00 0.00 0.00 0.00 0.00 0.00
5. Expected Number of
Screenings
CN: 0 0 0 0 0 0 0 0
MN: 0 0 0 0 0 0 0 0
Total: 0 0 0 0 0 0 0 0
6. Total Screens
Received
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
7. SCREENING RATIO CN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
MN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Total: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
8. Total Eligibles Who
Should Receive at Least
One Initial or Periodic Screen
CN: 0 0 0 0 0 0 0 0
MN: 0 0 0 0 0 0 0 0
Total: 0 0 0 0 0 0 0 0
FORM CMS-416: ANNUAL EPSDT PARTICIPATION REPORT
State Code Fiscal Year







ex. AL 20XX









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
9. Total Eligibles Receiving at Least
One Initial or Periodic Screen
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
10. PARTICIPANT RATIO CN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
MN: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Total: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
11. Total Eligibles Referred for
Corrective Treatment
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12a. Total Eligibles Receiving
Any Dental Services
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12b. Total Eligibles Receiving
Preventive Dental Services
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12c. Total Eligibles Receiving
Dental Treatment Services
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12d. Total Eligibles Receiving a
Sealant on a Permanent Molar
Tooth
CN: 0






MN: 0






Total: 0


0 0

12e. Total Eligibles Receiving Dental
Diagnostic Services
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12f. Total Eligibles Receiving Oral
Health Services provided by a
Non-Dentist Provider
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
12g. Total Eligibles Receiving Any
Preventive Dental or Oral
Health Service
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
13. Total Eligibles Enrolled in
Managed Care
CN: 0






MN: 0






Total: 0 0 0 0 0 0 0 0
14a. Total Number of Screening
Blood Lead Tests
CN: 0






MN: 0






Total: 0 0 0 0



14b. Methodology used to
Calculate the Total Number of
Screening Blood Lead Tests


Enter X for Method I
Enter X for Method II
Enter X for Method III


CPT Code 83655 within certain diagnosis codes (Method I)
HEDIS (Method II)
Combination Methodology (Method III)












Note: "CN"=Categorically Needy, "MN"= Medically Needy
Disclosure Statement - Annual completion of the Form CMS-416 is mandatory for states pursuant to section 1902(a)(43)(D) of the Social Security Act which requires states to annually report on the provision of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 (expiration date June 30, 2023). The time required to complete this information collection is estimated to average 29 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: C4-26-05, Baltimore, Maryland 21244-1850.

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