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CMS 416 Reporting Instructions - Medicaid

Instructions for Completing Form CMS-416: Annual Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Participation Re port Effective for the Reporting period federal fiscal year 2020 (October 1, 2019 through September 30, 2020), with submission of Form CMS-416 by April 1, 2021. PRA 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.

B. Reporting Requirement -- Each state that supervises or administers a medical assistance program under Title XIX of the Social Security Act must report annually on form CMS-416. These data must include services reimbursed directly by the state under fee-for- service, or through managed care, prospective payment, or other payment arrangement or

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