EPSDT Reporting, CMS Form 416

Executive Summary

Link to EPSDT resources, including CMS Form 416 (2011)

Early and Periodic Screening, Diagnostic, and Treatment
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.
Early Assessing and identifying problems early
Periodic Checking children’s health at periodic, age-appropriate intervals
Screening Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
Diagnosis Performing diagnostic tests to follow up when a risk is identified, and
Treatment Control, correct or reduce health problems found.
EPSDT Services
States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services:
Screening Services
  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate immunizations (according to the Advisory Committee on Immunization Practices)
  • Laboratory tests (including lead toxicity screening
  • Health Education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)
Vision Services
At a minimum, diagnosis and treatment for defects in vision, including eyeglasses. Vision services must be provided according to a distinct periodicity schedule developed by the state and at other intervals as medically necessary.
Dental Services
At a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services. Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health.
Hearing Services
At a minimum, hearing services include diagnosis and treatment for defects in hearing, including hearing aids.
Other Necessary Health Care Services
States are required to provide any additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in a state?s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.
Diagnostic Services
When a screening examination indicates the need for further evaluation of an individual’s health, diagnostic services must be provided. Necessary referrals should be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation. States should develop quality assurance procedures to assure that comprehensive care is provided.
Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.
State Program Guidelines
State Medicaid agencies are required to:
  • Inform all Medicaid-eligible individuals under age 21 that EPSDT services are available and of the need for age-appropriate immunizations;
  • Provide or arrange for the provision of screening services for all children;
  • Arrange (directly or through referral) for corrective treatment as determined by child health screenings; and
  • Report EPSDT performance information annually via Form CMS-416.
Periodicity Schedule
Periodicity schedules for periodic screening, vision, and hearing services must be provided at intervals that meet reasonable standards of medical practice. States must consult with recognized medical organizations involved in child health care in developing their schedules. Alternatively, states may elect to use a nationally recognized pediatric periodicity schedule (i.e., Bright Futures). A separate dental periodicity schedule is also required.
Lead Screening
CMS has updated its Medicaid lead screening policy for children eligible for EPSDT services.  For more information, see the June 2012 Informational Bulletin.  CMS recognizes that lead poisoning continues to be a problem for a small share of low-income children.  To improve screening of children most at risk for lead exposure, CMS is aligning Medicaid lead screening policy with current recommendations of the Centers for Disease Control and Prevention (CDC).  The new policy encourages a targeted screening approach in States that have sufficient data to support this action.  We have developed materials to assist States with the process of determining their lead screening approach going forward.  CMS and CDC have developed guidance and process for States that want to request to move to a targeted screening approach.  Interested States should send requests and supporting documentation to the EPSDT mailbox at [email protected], with the subject line: “Request for Use of Targeted Lead Screening.”
The Form CMS-416 is used by CMS to collect basic information on State Medicaid and CHIP programs to assess the effectiveness of EPSDT.  See Form CMS-416 instructions .  States must provide CMS with the following information:
  1. Number of children provided child health screening services
  2. Number of children referred for corrective treatment
  3. Number of children receiving dental services
  4. State?s results in attaining goals set under section 1905(r) of the Social Security Act.
  • CMS 416 Instructions (06/2011 version)
  • Electronic Form 416 (Excel)
  • CMS Form 416 (PDF; 01/2011 version)
  • 2011 National Data (as of 12/20/12; CO data now included; missing data from 3 states)
  • 2011 State Data (as of 12/20/12; CO data now included; missing data from 3 states)
  • 2010 National Data (as of 11/13/12; updated KS, MO, and RI data)
  • 2010 State Data (as of 11/13/12; updated KS, MO, and RI data)
  • 2009 National Data (as of 6/18/12; OR data now included)
  • 2009 State Data (as of 6/18/12; OR data now included)
  • 2008 National Data
  • 2008 State Data
  • 1995 to 2007 National Data
  • 1995 to 1997 State Data
National EPSDT Improvement Workgroup
In December 2010, CMS convened a National EPSDT Improvement Workgroup that included state representatives, children?s health providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, and data analysis. The members of the group will help CMS identify the most critical areas for improvement of EPSDT. The group, which meets periodically throughout the year, will also discuss steps that the federal government might undertake in partnership with states and others to both increase the number of children accessing services, and improve the quality of the data reporting that enables a better understanding how effective HHS is putting EPSDT to work for children.

Related Content