Skip to Main Content

Breadcrumb

  1. HFS
  2. Agency Information
  3. Early and Periodic Screening, Diagnosis and Treatment Services for Children Illinois’ CMS-416 Reporting

Early and Periodic Screening, Diagnosis and Treatment Services for Children Illinois’ CMS-416 Reporting 

 

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) initiative is a comprehensive federal-state program that provides initial and periodic examinations and medically necessary follow-up to low-income children under age 21 who are enrolled in Medicaid. The EPSDT program includes medical, dental, vision, and hearing services.

Annually, states report on EPSDT services to the federal Centers for Medicare and Medicaid Services (CMS) using Form CMS-416. CMS requires states to complete Form CMS-416 based on guidance it provides to ensure consistency in reporting.  The CMS-416 report includes basic information on participation of children in Medicaid. Each state reports on the number of children by age group who are provided child health screening services, referred for corrective treatment, and who received dental services.

For federal fiscal year 2013 (October 1, 2012 through September 30, 2013) reporting, Illinois used the version of the CMS guidance that was finalized in June 2011.

Illinois’ CMS-416 report for federal fiscal year 2013 and the federal guidance for completing the report follow.

FORM CMS-416: Annual EPSDT Participation Report

State Code IL Fiscal Year
2013
Totals Age Group
< 1
Age Group
1-2
Age Group
3-5
Age Group
6-9
Age Group
10-14
Age Group
15-18
Age Group
19-20
1a.  Total individuals
eligible for EPSDT
CN: 1,679,803 69,905 171,414 291,921 376,024 403,587 280,969 85,983
MN: 7,093 23 380 1,049 1,811 2,279 1,433 118
Total:   1,686,896 69,928 171,794 292,970 377,835 405,866 282,402 86,101
1b.  Total Individuals eligible for
EPSDT for 90 Continous Days
CN: 1,617,909 55,931 166,180 285,721 367,297 394,247 273,581 74,952
MN: 6,128 19 341 929 1,559 1,962 1,225 93
Total: 1,624,037 55,950 166,521 286,650 368,856 396,209 274,806 75,045
1c. Total Individuals Eligible under
a CHIP Medicaid Expansion
CN: 14,530 0 0 482 3,395 3,809 2,878 3,966
MN: 0 0 0 0 0 0 0 0
Total:   14,530 0 0 482 3,395 3,809 2,878 3,966
2a. State Periodicity Schedule     6 4 3 2 3 2 1
2b. Number of Years in Age Group     1 2 3 4 5 4 2
2c. Annualized State
Periodicity Schedule
    6.00 2.00 1.00 0.50 0.60 0.50 0.50
3a. Total Months of
Eligibility
CN: 18,258,376 414,180 1,883,207 3,311,420 4,265,007 4,579,132 3,150,428 655,002
MN: 62,194 102 3,176 9,415 15,925 20,001 12,840 735
Total:   18,320,570 414,282 1,886,383 3,320,835 4,280,932 4,599,133 3,163,268 655,737
3b. Average Period of
Eligibility
CN: 0.94 0.62 0.94 0.97 0.97 0.97 0.96 0.73
MN: 0.85 0.45 0.78 0.84 0.85 0.85 0.87 0.66
Total:   0.94 0.62 0.94 0.97 0.97 0.97 0.96 0.73
4.   Expected Number of
Screenings per
Eligible
CN:   3.72 1.88 0.97 0.49 0.58 0.48 0.37
MN:   2.70 1.56 0.84 0.43 0.51 0.44 0.33
Total:     3.72 1.88 0.97 0.49 0.58 0.48 0.37
5.   Expected Number of
Screenings
CN: 1,365,320 208,063 312,418 277,149 179,976 228,663 131,319 27,732
MN: 3,604 51 532 780 670 1,001 539 31
Total:   1,368,924 208,114 312,950 277,929 180,646 229,664 131,858 27,763
6.   Total Screens
Received
CN: 1,443,460 210,515 343,039 286,491 180,794 270,852 133,776 17,993
MN: 2,062 19 316 444 326 668 282 7
Total:   1,445,522 210,534 343,355 286,935 181,120 271,520 134,058 18,000
7.   SCREENING RATIO CN: 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.65
MN: 0.57 0.37 0.59 0.57 0.49 0.67 0.52 0.23
Total:   1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.65
8.  Total Eligibles Who
Should Receive at Least
One Initial or Periodic Screen
CN: 1,066,950 55,931 166,180 277,149 179,976 228,663 131,319 27,732
MN: 3,381 19 341 780 670 1,001 539 31
Total:   1,070,331 55,950 166,521 277,929 180,646 229,664 131,858 27,763
9.  Total Eligibles Receiving at least
One Initial or Periodic
Screen
CN: 779,638 47,958 125,428 177,606 132,756 183,399 94,498 17,993
MN: 1,503 9 155 319 275 515 223 7
Total:   781,141 47,967 125,583 177,925 133,031 183,914 94,721 18,000
10. PARTICIPANT RATIO CN: 0.73 0.86 0.75 0.64 0.74 0.80 0.72 0.65
MN: 0.44 0.47 0.45 0.41 0.41 0.51 0.41 0.23
Total:   0.73 0.86 0.75 0.64 0.74 0.80 0.72 0.65
11. Total Eligibles Referred for
Corrective Treatment
CN: 315,409 23,654 33,545 65,709 65,637 89,206 34,965 2,693
MN: 447 12 46 87 77 167 58 0
Total:   315,856 23,666 33,591 65,796 65,714 89,373 35,023 2,693
12a. Total Eligibles Receiving
Any Dental Services
CN: 865,802 2,173 53,998 191,869 255,327 237,325 118,329 6,781
MN: 2,460 1 68 402 747 859 380 3
Total:   868,262 2,174 54,066 192,271 256,074 238,184 118,709 6,784
12b. Total Eligibles Receiving
Preventive Dental Services
CN: 816,633 1,697 49,566 183,209 246,126 225,673 105,427 4,935
MN: 2,265 1 61 375 703 786 337 2
Total:   818,898 1,698 49,627 183,584 246,829 226,459 105,764 4,937
12c. Total Eligibles Receiving
Dental Treatment Services
CN: 332,199 52 4,217 57,726 108,538 98,229 59,494 3,943
MN: 921 0 3 93 310 345 169 1
Total:   333,120 52 4,220 57,819 108,848 98,574 59,663 3,944
12d. Total Eligibles Receiving a
Sealant on a Permanent Molar   
Tooth
CN: 152,070       82391 69679    
MN: 464       230 234    
Total:   152,534       82,621 69,913    
12e. Total Eligibles Reciving Dental
Diagnostic Services
CN: 820,233 2,127 52,665 184,711 243,138 223,519 108,328 5,745
MN: 2,262 1 67 385 685 777 345 2
Total:   822,495 2,128 52,732 185,096 243,823 224,296 108,673 5,747
 12f. Total Eligibles Receiving Oral
Health Services provided by a
Non-Dentist Provider
CN: 21,558 3,769 17,499 289 1 0 0 0
MN: 34 7 26 1 0 0 0 0
Total:   21,592 3,776 17,525 290 1 0 0 0
12g. Total Eligibles Reciving Any
Dental Or Oral Health Service
CN: 882,977 5,859 67,319 192,037 255,327 237,325 118,329 6,781
MN: 2,491 8 91 403 747 859 380 3
Total:   885,468 5,867 67,410 192,440 256,074 238,184 118,709 6,784
13.  Total Eligibles Enrolled in
Managed Care
CN: 223,068 9,278 26,587 42,762 50,302 49,348 32,133 12,658
MN: 93 0 8 13 20 36 13 3
Total:   223,161 9,278 26,595 42,775 50,322 49,384 32,146 12,661
14.  Total Number of Screening
Blood Lead Tests
CN: 435,710 53,516 179,289 202,905        
MN: 530 69 201 260        
Total:   436,240 53,585 179,490 203,165        

* Includes 12-month visit
Note: "CN"=Categorically Needy, "MN"= Medically Needy

2700.4 Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Report (Form CMS-416)

  1. Purpose -- The annual EPSDT report (form CMS-416) provides basic information on participation in the Medicaid child health program. The information is used to assess the effectiveness of State EPSDT programs in terms of the number of children (by age group and basis of Medicaid eligibility) who are provided child health screening services, referred for corrective treatment, and receiving dental services. Child health screening services are defined for purposes of reporting on this form as initial or periodic screens required to be provided according to a state’s screening periodicity schedule.

The completed report demonstrates the State’s attainment of its participation and screening goals. Participant and screening goals are two different standards against which EPSDT participation is measured on the form CMS-416. From the completed reports, trend patterns and projections are developed for the nation and for individual states or geographic areas, from which decisions and recommendations can be made to ensure that eligible children are given the best possible health care. The information is also used to respond to congressional and public inquiries.

  1. 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. This data must include services provided under both fee-for-service and capitated managed care arrangements. Each State is required to collect encounter data (or other data as necessary) from managed care entities in sufficient detail to provide the information required by this report. You may contact your CMS regional office EPSDT specialist if you need technical assistance in completing this form.
  2. Effective Date -- The form CMS-416 effective date was April 1, 1990. The first full fiscal year for which the form was effective began October 1, 1990. This version of the form must be used effective fiscal year 2010 for data due on or after April 1, 2011.
  3. Submittal Procedure -– States should submit the annual form CMS–416 and your State periodicity schedule electronically to the CMS central office via the EPSDT mailbox at EPSDT@cms.hhs.gov not later than April 1 of the year following the end of the Federal fiscal year being reported. The electronic form and instructions are available on the CMS website. States may not modify the electronic form. It must be submitted as downloaded. A “hard copy” submittal to CMS is no longer required.
  4. Detailed Instructions – Enter your State name and the federal fiscal year as directed below. For each of the following line items, report total counts by the age groups indicated and by whether categorically and medically needy. In cases where calculations are necessary, perform separate calculations for the total column and each age group. You must enter a number in each line and column of data requested even if the number is “0.” Report age based upon the child’s age as of September 30.

State -- Enter the name of your State using two character State code in upper case format.

Fiscal Year -- Enter the Federal fiscal year (FY) being reported in YYYY format. Note: The Federal fiscal year is from October 1 through September 30.

Line 1a -- Total Individuals Eligible for EPSDT-- Enter the total unduplicated number of individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (CHIP) Medicaid expansion program determined to be eligible for EPSDT services, distributed by age (based on age as of September 30) and by basis of eligibility. “Unduplicated” means that an eligible person is reported only once although he/she may have had more than one period of eligibility during the year. Include all individuals regardless of whether the services are provided under fee-for-service arrangements or managed care arrangements. States should determine the basis of eligibility consistent with the instructions for form CMS-2082. Medicaid-eligible individuals under age 21 are considered eligible for EPSDT services regardless of whether they have been informed about the availability of EPSDT services or whether they accept EPSDT services at the time of informing. Individuals for whom third-party liability is available should also be counted in the number.

Do not include in this count the following groups of individuals:

  1. medically needy individuals under the age of 21 if you do not provide EPSDT services for the medically needy population;
  2. individuals eligible for Medicaid only under a §1115 waiver as part of an expanded population for which the full complement of EPSDT services is not available;
  3. undocumented aliens who are eligible only for emergency Medicaid services;
  4. children in separate State CHIP programs; or
  5. other groups of individuals under age 21 who are eligible only for limited services as part of their Medicaid eligibility (i.e., pregnancy-related services).

Line 1b -- Total Individuals Eligible for EPSDT for 90 Continuous Days -- Enter the total unduplicated number of individuals under the age of 21 from line 1a who have been continuously enrolled in Medicaid or a CHIP Medicaid expansion program for at least 90 days in the Federal fiscal year and determined to be eligible for EPSDT services, distributed by age and by basis of eligibility. For example, if a child was enrolled from August 1st to September 30th and October 1st to November 30, the child would not be considered eligible for 90 continuous days in the Federal fiscal year.

Line 1c -– Total Individuals Eligible for EPSDT under a CHIP Medicaid Expansion Program – Enter the number of individuals included in line 1b who are under the age of 21 and eligible for EPSDT services as part of a CHIP Medicaid expansion program. For children who have been eligible for EPSDT under both Medicaid and a CHIP Medicaid expansion program during the report year, include the child on this line if they are enrolled in CHIP as of September 30.

Line 2a -- State Periodicity Schedule -- Enter the number of initial or periodic general health screenings required to be provided to individuals within the age group specified according to the State’s periodicity schedule. (Example: If your State periodicity schedule requires screening at 12, 18 and 24 months, the number 3 should be entered in the 1-2 age group column.) Make no entry in the total column.

Note: Use the State’s most recent periodicity schedule and attach a copy to the completed report for submittal to CMS.

Line 2b -- Number of Years in Age Group -- Make no entries on this line. This is a fixed number reflecting the number of years included in each age group.

Line 2c -- Annualized State Periodicity Schedule -- Divide line 2a by the number in line 2b. Enter the quotient. This is the number of screenings expected to be received by an individual in each age group in one year. Make no entry in the total column.

Line 3a -- Total Months of Eligibility -- Enter the total months of eligibility for the individuals in each age group in line 1b during the reporting year. A child should only be counted once in the age group the child is in as of September 30. Include the total months of eligibility in the age category where the child is reported, even if the child had months of eligibility in two age categories during the reporting period. For example, if a child was eligible 12 months, from October 1st through September 30th, but turned age 3 on August 1st, all 12 months of eligibility would be counted in the age 3-5 category.

Line 3b -- Average Period of Eligibility -- Divide line 3a by the number in line 1b. Divide that number by 12 and enter the quotient. This number represents the portion of the year that individuals remain Medicaid eligible during the reporting year.

Line 4 -- Expected Number of Screenings per Eligible -- Multiply line 2c by line 3b. Enter the product. This number reflects the expected number of initial or periodic screenings per child per year based on the number required by the State-specific periodicity schedule and the average period of eligibility. Make no entries in the total column.

Line 5 -- Expected Number of Screenings -- Multiply line 4 by line 1b. Enter the product. This reflects the total number of initial or periodic screenings expected to be provided to the eligible individuals in Line 1b.

Line 6 -- Total Screens Received -- Enter the total number of initial or periodic screens furnished to eligible individuals on line 1b under either fee-for-service or managed care arrangements.

Note: States may use the CPT codes listed below as a proxy for reporting these initial or periodic screens. Use of these proxy codes is for reporting purposes only. States must continue to ensure that all five age-appropriate elements of an EPSDT screen, as defined by law, are provided to EPSDT recipients.

This number should not reflect sick visits or episodic visits provided to children unless an initial or periodic screen was also performed during the visit. However, it may reflect a screen outside of the normal State periodicity schedule that is used as a "catch-up" EPSDT screening. (A catch­up EPSDT screening is defined as a complete screening that is provided to bring a child up-to-date with the State's screening periodicity schedule. For example, a child who did not receive a periodic screen at age five visits a provider at age 5 years and 4 months. The provider may use that visit to provide a complete age appropriate screening and the screening may be counted on the CMS-416.) Report all screening data in the age category reflecting the child’s age at the end of the federal fiscal year even if the child received services in two age categories. For example, if a child turned age 3 on September 1st, but had a 30-month well-child visit in March, the 30-month visit would be counted in the age 3-5 category. Use the codes below or other documentation of such services furnished under capitated arrangements. The codes to be used to document the receipt of an initial or periodic screen are as follows:

CPT-4 codes: Preventive Medicine Services *

  • 99381 New Patient under one year
  • 99382 New Patient (ages 1-4 years)
  • 99383 New Patient (ages 5-11 years)
  • 99384 New Patient (ages 12-17 years)
  • 99385 New Patient (ages 18-39 years)
  • 99391 Established patient under one year
  • 99392 Established patient (ages 1-4 years)
  • 99393 Established patient (ages 5-11years)
  • 99394 Established patient (ages 12-17 years)
  • 99395 Established patient (ages 18-39 years)
  • 99460 Initial hospital or birthing center care for normal newborn infant
  • 99461 Initial care in other than a hospital or birthing center for normal newborn infant
  • 99463 Initial hospital or birthing center care of normal newborn infant (admitted/
    discharged same date)

*These CPT codes do not require use of a “V” code.

or

CPT-4 codes: Evaluation and Management Codes **

99202-99205 New Patient
99213-99215 Established Patient

** These CPT-4 codes must be used in conjunction with codes V20-V20.2, V20.3, V20.31 and V20.32 and/or V70.0 and/or V70.3-70.9.

Line 7 -- Screening Ratio -- Divide the actual number of initial and periodic screening services received (line 6) by the expected number of initial and periodic screening services (line 5). This ratio indicates the extent to which EPSDT eligibles receive the number of initial and periodic screening services required by the State's periodicity schedule, prorated by the proportion of the year for which they are Medicaid eligible.

Note: In calculating Line 7, if the number exceeds 100 percent, enter 1.0 in this field.

Line 8 -- Total Eligibles Who Should Receive at Least One Initial or Periodic Screen -- The number of persons who should receive at least one initial or periodic screen is dependent on each State's periodicity schedule. Use the following calculations:

  1. Look at the number entered in line 4 of this form. If that number is greater than 1, use the number 1. If the number on line 4 is less than or equal to 1, use the number in line 4. (This procedure will eliminate situations where more than one visit is expected in any age group in a year.).
  2. Multiply the number from calculation 1 above by the number in line 1b of the form. Enter the product on line 8.

Line 9 -- Total Eligibles Receiving at Least One Initial or Periodic Screen -- Enter the unduplicated count of individuals from line 1b, including those enrolled in managed care arrangements, who received at least one documented initial or periodic screen during the year. Refer to codes in line 6.

Line 10 -- Participant Ratio -- Divide line 9 by line 8. Enter the quotient. This ratio indicates the extent to which eligibles are receiving any initial and periodic screening services during the year.

Note: In calculating Line 10, if this number exceeds 100 percent, enter 1.0 in this field.

Line 11 -- Total Eligibles Referred for Corrective Treatment -- Enter the unduplicated number of individuals on line 1b, including those in managed care arrangements, who, as the result of at least one health problem identified during an initial or periodic screening service, including vision and hearing screenings, were referred for another appointment with the screening provider or referred to another provider for further needed diagnostic or treatment services. This element does not include correction of health problems during the course of a screening examination.

Line 12a -- Total Eligibles Receiving Any Dental Services -- Enter the unduplicated number of children receiving at least one dental service by or under the supervision of a dentist as defined by HCPCS codes D0100 - D9999 (CDT codes D0100 - D9999).

Line 12b -- Total Eligibles Receiving Preventive Dental Services -- Enter the unduplicated number of children receiving at least one preventive dental service by or under the supervision of a dentist as defined by HCPCS codes D1000 - D1999 -(CDT codes D1000 - D1999).

Line 12c -- Total Eligibles Receiving Dental Treatment Services -- Enter the unduplicated number of children receiving at least one treatment service by or under the supervision of a dentist, as defined by HCPCS codes D2000 - D9999 (CDT codes D2000 - 09999).

Line 12d -– Total Eligibles Receiving a Sealant on a Permanent Molar Tooth -- Enter the unduplicated number of children in the age categories of 6-9 and 10-14 who received a sealant on a permanent molar tooth regardless of whether the sealant was provided by a dentist or a non-dentist, as defined by HCPCS code D1351 (CDT code D1351).

Line 12e -– Total Eligibles Receiving Diagnostic Dental Services -– Enter the unduplicated number of children receiving at least one diagnostic dental service by or under the supervision of a dentist, as defined by HCPCS codes D0120 – D0180 (CDT codes D0120 – D0180).

12f -– Total Eligibles Receiving Oral Health Services Provided by a Non-Dentist Provider -- Enter the unduplicated number of children receiving at least one oral health service as defined by a HCPCS or CDT code furnished by a licensed practitioner that is not a dentist. For example, a pediatrician that applies a fluoride varnish or an independently practicing dental hygienist not under the supervision of a dentist furnishing a prophylaxis. These are only examples and are not intended to limit your reporting. NOTE: Due to the variance in State Practice Acts some States may not have data to report on this line.

12g -– Total Eligibles Receiving any Dental or Oral Health Service -- Enter the unduplicated number of children who received a dental service by or under the supervision of a dentist or an oral health service by a non-dentist. A child should only be counted once on this line even if the child received a dental service and an oral health service.

NOTES FOR LINE 12 DATA: For purposes of reporting the information on dental services in Lines 12a – 12g, use the total eligible individuals from line 1b. “Unduplicated” means that a child may only be counted once for each line of dental or oral health data. However, a child may be counted on two or more lines. For example, a child is counted once on line 12a for receiving any dental service, counted again on line 12c for receiving a dental treatment service and, if applicable, counted again on line 12f for receiving an oral health service by a non-dentist. These numbers should reflect services provided under both fee-for-service and managed care arrangements and through any other private health plans that contract with the State. We refer to “dental services” when referring to services provided by or under the supervision of a dentist. We refer to “oral health services” when the service is not provided by or under the supervision of a dentist.

Line 13 -- Total Eligibles Enrolled in Managed Care -- This number is reported for informational purposes only. This number represents all individuals eligible for EPSDT services in your State who are enrolled in any type of managed care arrangement at any time during the reporting year. It includes any capitated arrangements such as health maintenance organizations or individuals assigned to a primary care provider or primary care case manager regardless of whether reimbursement is fee-for-service or capitated. Include these individuals in the total number of eligibles on line 1a and b, as appropriate; include the number of initial or periodic screenings provided to these individuals in lines 6 and 8 for purposes of determining the State's screening and participation rates. The number of individuals referred for corrective treatment and receiving dental services are reflected in lines 11 and 12, respectively.

Line 14 -- Total Number of Screening Blood Lead Tests -- Enter the total number of screening blood lead tests furnished to eligible individuals from line 1a under fee-for-service or managed care arrangements. Follow-up blood tests performed on individuals who have been diagnosed with or are being treated for lead poisoning should not be counted. You may use one of two methods, or a combination of these methods, to calculate the number of blood lead screenings provided:

  1. Count the number of times CPT code 83655 (“lead”) for a blood lead test is reported within certain ICD-9-CM codes (see Note below); or
  2. You may include data collected from use of the HEDIS® 1 measure developed by the National Committee for Quality Assurance to report blood lead screenings if your State had elected to use this performance measure.

NOTE: On a claim, CPT code 83655 is the procedure code used to identify that a blood lead test was performed. CPT code 83655, when accompanied on the claim by a diagnosis code of V15.86 (exposure to lead) or V82.5) (special screening for other conditions such as a screening for heavy metal poisoning) may be used to identify a person receiving a screening blood lead test. However, a claim in which the procedure code 83655 is accompanied by a diagnosis code of 984(.0-.9) (toxic effect of lead and its compounds) or e861.5 (accidental poisoning by lead paints) would generally indicate that the person receiving the blood lead test had already been diagnosed or was being treated for lead poisoning and should not be counted.

  1. Disclosure Statement - 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. The valid OMB control number for this information collection is 0938-0354. The time required to complete this information collection is estimated to average 28 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop: C4-26-05, Baltimore, Maryland 21244-1850.

1 Health Effectiveness Data and Information Set