Form CMS-416 Annual EPSDT Participation Report

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.