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

OMB 0938-0354

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.

The latest form for Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416) expires 2023-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form
CMS-416 - Supporting Statement A (2023 version 4).docx Supporting Statement A
Response to Public Comments.docx Supplementary Document
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report Form

All Historical Document Collections

202305-0938-017 Approved without change	Extension without change of a currently approved collection	2023-05-24
202002-0938-015 Approved without change	Revision of a currently approved collection	2020-02-27
201702-0938-010 Approved without change	Revision of a currently approved collection	2017-02-24
201507-0938-009 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-07-14
201312-0938-009 Approved without change	Revision of a currently approved collection	2013-12-10
201009-0938-018 Approved with change	Revision of a currently approved collection	2010-09-30
201003-0938-002 Approved without change	Extension without change of a currently approved collection	2010-03-24
200908-0938-014 Approved without change	Revision of a currently approved collection	2009-08-31
200903-0938-002 Approved without change	Revision of a currently approved collection	2009-03-10
200601-0938-011 Approved without change	Extension without change of a currently approved collection	2006-01-26
200209-0938-008 Approved with change	Extension without change of a currently approved collection	2002-09-26
199905-0938-009 Approved without change	Reinstatement with change of a previously approved collection	1999-05-27
199902-0938-004 Withdrawn	Extension without change of a currently approved collection	1999-02-05
199807-0938-012 Approved without change	Extension without change of a currently approved collection	1998-07-22
199706-0938-011 Approved without change	Extension without change of a currently approved collection	1997-06-25
199506-0938-003 Approved without change	Extension without change of a currently approved collection	1995-06-28
199305-0938-002 Approved without change	Revision of a currently approved collection	1993-05-13
199004-0938-002 Approved without change	Revision of a currently approved collection	1990-04-20
198707-0938-005 Approved without change	Revision of a currently approved collection	1987-07-28
198405-0938-010 Approved without change	New collection (Request for a new OMB Control Number)	1984-05-17

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-416

Annual EPSDT Participation Report

Fillable Printable

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.