Supporting Statement Part A
Annual Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Participation Report (CMS-416/OMB# 0938-0354)
and Supporting Statutory Language
Contained in 1902(a)(43)(D) of the Social Security Act

Background

Section 1902 (a)(43)(D) of the Social Security Act  (the Act) requires States to report annually by age group and basis of Medicaid eligibility for medical assistance, information relating to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services provided under the State plan.  The Centers for Medicare & Medicaid Services (CMS) is responsible for administering the EPSDT benefit, in partnership with states, and uses the annual reports to evaluate the benefit’s effectiveness in meeting the health care needs of Medicaid eligible children.  The report also is used to provide data to the Congress and the public on the use of health care services by Medicaid children.

Section 2700.4 of the State Medicaid Manual (SMM) contains form CMS-416, instructions for completion of the form, and the required PRA disclosure statement.

A.	Justification

1.	Need and Legal Basis

The authority for requiring states to submit the EPSDT annual report is section 1902 (a) (43)(D) of the Act.  This is a national report that CMS is required to produce and publish on a yearly basis.  This report is compiled with the data submitted to CMS by each state on their yearly CMS-416 report.  The information is used to assess the effectiveness of state EPSDT programs, including the provision of required dental services to eligible children. CMS has experienced that reporting by states on the form CMS-416 can be uneven and inaccurate. CMS regularly receives inquiries from staff responsible for reporting the data. Those inquiries often evidence confusion about how to interpret the instructions. It is important that the data CMS receives from the states on the form CMS-416 be complete and accurate, and that the instructions be followed consistently across all states. To this end, CMS has developed these modules to provide an opportunity for more in-depth training about the instructions as well as context around the EPSDT benefit and the importance of the data CMS collects. 

2.	Information Users

States submit the CMS-416: Annual EPSDT Participation Report to CMS’ Center for Medicaid and CHIP Services (CMCS).  The baseline data collected is used to assess the effectiveness of state EPSDT programs in reaching eligible children, by age group and basis of Medicaid eligibility, who are provided initial and periodic child health screening services, referred for corrective treatment, and receiving dental, hearing, and vision services.  This assessment is coupled with the state’s results in attaining the participation goals set for the state.  The information gathered from this report, permits federal and state managers to evaluate the effectiveness of the EPSDT law on the basic aspects of the program.

3.	Information Technology

CMS developed a uniform electronic form by which states must report the required data.  All states and territories use a Medicaid Management Information Systems (MMIS) from which the data is extracted, based on programing according to the CMS-416 instructions. The state extracts the data and inputs it into the electronic CMS form, and then submits the report via email to the CMS EPSDT mailbox.

The six (6) training modules reside online and rest on an Adobe Captivate platform. They appear to the user as Powerpoint slides and are interactive, with embedded exercises. 

4.	Duplicate Information

CMCS is the only CMS component collecting this EPSDT data. Therefore, there is no duplication.

5.	Small Business

This collection of information does not involve small businesses or other small entities.

6.	Less Frequent Collection

Section 1902 (a)(43)(D) of the Act requires the annual reporting by states of the EPSDT data.  Less frequent collection does not provide adequate/current data necessary for response to Congressional and public inquiries.

7.	Special Circumstances

No special circumstances exist which require completion of this section of the supporting statement.

8.	Federal Register/Outside Consultations

Federal Register

Not applicable, this is a nonsubstantial change request which does not require public comment or the publication of any Federal Register notices.

Outside Consultations

There are no changes to the form CMS-416 or to the instructions for completing the form. The training modules merely supplement the instructions. 

CMS has beta-tested the modules with three (3) states. CMS has also presented the concept behind the modules to, and solicited feedback from, the CMS Oral Health Technical Advisory Group (OTAG). The OTAG members represent states, territories, dental consultants, and dental associations, and all represented parties are welcome to listen to the discussion and consult with respective OTAG members.

9.	Payments or Gifts

There is no provision for any payment or gift to respondents associated with this reporting requirement.

10.	Confidentiality

Because no personal identifying information is collected in the report, there is no issue of confidentiality with respect to the data submitted by the state.  The data collected on the report is available for public review.

11.	Sensitive Questions

There are no questions of a sensitive nature in this data collection.

12.	Estimate of Hour Burden and Cost to Respondents

Wages

The following costs are based on the U.S. Bureau of Labor Statistics’ May 2014 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes/current/oes_nat.htm). 
Occupation Title	Occupation Code	Mean Hourly Wage	Fringe Benefit (at 100%)	Adjusted Hourly Wage	
Computer and Information Analyst	15-1120	$42.25	$42.25	$84.50	

We are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.

Burden

Training Modules (added)

There are six (6) modules covering the following topics:

•	Module 1:Overview of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit (see http://www.eventvideostream.com/mathematica/ohi/module_1/OHI_Form_CMS_416_Training_Module_1.htm)

•	Module 2: Form CMS-416 Overview (see http://www.eventvideostream.com/mathematica/ohi/module_2/OHI_Form_CMS_416_Training_Module_2.htm)

•	Module 3: Form CMS-416 Specifications – Lines 1a and 1b (see http://www.eventvideostream.com/mathematica/ohi/module_3/OHI_Form_CMS_416_Training_Module_3.htm)

•	Module 4: Form CMS-416 Specifications – Lines 12a through 12e (see http://www.eventvideostream.com/mathematica/ohi/module_4/OHI_Form_CMS_416_Training_Module_4.htm)

•	Module 5: Form CMS-416 Specifications – Lines 12f and 12g (see http://www.eventvideostream.com/mathematica/ohi/module_5/OHI_Form_CMS_416_Training_Module_5.htm)

•	Module 6: Using Form CMS-416 Dental Data (see http://www.eventvideostream.com/mathematica/ohi/module_6/OHI_Form_CMS_416_Training_Module_6.htm)

The modules range in size from 13 slides to 31 slides. The content is largely based on the form CMS-416 instructions, which are not changed or modified in any way by the modules.

Using the modules is entirely voluntary. They are intended to support states and their contractors to more accurately and completely report dental data to CMS using the form CMS-416.

Learning Time Burden

The estimate of burden includes time for one individual to complete all six (6) of the training modules in a learning mode, including performing the embedded exercises.  The estimate was derived from the three (3) states that beta-tested the modules.  This is a one-time burden per staff member. It is unknowable how many, if any, staff members each state or contractor might ask to complete the training modules. Thus the burden is expressed in terms of one individual per state.  

1 individual for Module 1 = .5 hour 
1 individual for Module 2 = 1 hour 
1 individual for Module 3 = .75 hour 
1 individual for Module 4 = 1 hour 
1 individual for Module 5 = .75 hour 
1 individual for Module 6 = .75 hour 
TOTAL                                4.75 hours (1 Person)
TOTAL 		         266 hours (4.75 hours per person x 56 states and territories)

The estimate of cost to a state agency for one (1) person to complete the training is $401.38 (4.75 hours x $84.50 adjusted hourly wage from the above table). 

Total estimated cost to 50 states, the District of Columbia, and the territories is $22,477.28 ($401.38 per person x 56)

Form CMS-416 (No Changes)

The estimate of burden includes time for reviewing instructions, searching/gathering data, and completing the form.  The estimate was derived from a sample of states and has not changed.  It has been updated to correct the amount of salary for a GS 12, step 1 that is used in the calculation.

Record Keeping Burden
56 State entities x 1 report annually x 9 hours	=	504

Reporting Burden
56 State entities x 1 report annually x 19 hours	=	1,064

TOTAL ANNUAL BURDEN HOURS	1,568

The estimate of annualized cost to state governments is $13,548 (25 percent of the total costs ($54,190).  The State employee hourly wage figure is computed as 80 percent of a GS-12 step 1, annual salary, plus 20 percent retirement/insurance.  The State cost is computed as follows:

$74,872 x 80 percent = $59,898 + 11,980 (20% retirement/insurance) =
$71,878 divided by 2,080 hours per year = $34.56 per hour.

$34.56 per hour x 1,568 hours per year = $54,190 per year.

$54,190 x 25 percent (state share) = $13,548.

13.	Total Costs as a Result of Training for Data Collection

There are no costs to states to use this set of training modules. States will be able to access the modules using their existing systems. 

14.	Federal Costs

There is no cost to the federal government to deploy the modules or to support states to use them. 

With regard to CMS-416, the estimate of annualized cost to the Federal Government is $57,114 which is computed as follows:

	75 percent (Federal share) of the states’ total costs	=		$40,643
	Data entry, analysis, and inquiry responses		=	+ 16,471
	(GS-13/8 x .15 FTE)			
	Total Federal Costs			$ 57,114

15.	Changes in Burden and/Program Changes

This package sets out nonsubstantive changes. 

This package does not involve any changes to form CMS-416 or to the instructions for completing the form or to the burden for completing the form. 

Rather, CMS is requesting approval to offer to states and their contractors a set of online training modules related to reporting on the dental lines of the CMS-416 form. Using the modules is entirely voluntary. They are intended to support states and their contractors to more accurately and completely report dental data to CMS.

The modules would add 266 hours (aggregate).

16.	Publication and Tabulation Data

The modules are currently housed on an Adobe Captivate web platform hosted by a CMS contractor, Mathematica Policy Research, Inc.  

The modules will be made available after OMB approval.

17.	Display of Expiration Date

CMS requests approval to not display the expiration date for OMB approval. 

18.	Exception to Certification Statement

Not applicable. There are exceptions.

B.	Collections of Information Employing Statistical Methods

CMS does not intend to collect information employing statistical methods.