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.
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.
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.
Form CMS-416 Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report
CMS-416 - Supporting Statement A (2020 version 3).docx
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report