View Information Collection Request (ICR) Package

OMB Control No: 0938-0354	ICR Reference No: 202002-0938-015
Status: Historical Active	Previous ICR Reference No: 201702-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report (CMS-416)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/04/2020
	Date Received in OIRA: 02/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2023	36 Months From Approved	06/30/2020
Responses	56	0	112
Time Burden (Hours)	1,512	0	1,778
Cost Burden (Dollars)	0	0	0

Abstract: 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.

Authorizing Statute(s): PL: Pub.L. 101 - 239 6403 Name of Law: EPSDT Defined

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 58390	10/31/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 4992	01/28/2020
Did the Agency receive public comments on this ICR? Yes

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Annual Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) Participation Report	CMS-416
Training Modules

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	56	112	-56
Annual Time Burden (Hours)	1,512	1,778	-266
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: 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.

Annual Cost to Federal Government: $147,862

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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