Form CMS-179 Transmittal and Notice of Approval of State Plan Materia

FORM APPROVED
OMB No. 0938-0193

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

2. STATE

1. TRANSMITTAL NUMBER

TRANSMITTAL AND NOTICE OF APPROVAL OF
STATE PLAN MATERIAL
FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES
TO: REGIONAL ADMINISTRATOR
CENTERS FOR MEDICARE & MEDICAID SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL
SECURITY ACT (MEDICAID)
4. PROPOSED EFFECTIVE DATE

5. TYPE OF PLAN MATERIAL (Check One)
NEW STATE PLAN

AMENDMENT TO BE CONSIDERED AS NEW PLAN

✔

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION

7. FEDERAL BUDGET IMPACT
a. FFY__________________ $ __________________
b. FFY__________________ $ __________________

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION
OR ATTACHMENT (If Applicable)

10. SUBJECT OF AMENDMENT

11. GOVERNOR’S REVIEW (Check One)
GOVERNOR’S OFFICE REPORTED NO COMMENT
COMMENTS OF GOVERNOR’S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
12. SIGNATURE OF STATE AGENCY OFFICIAL

✔

OTHER, AS SPECIFIED:

16. RETURN TO

13. TYPED NAME
14. TITLE
15. DATE SUBMITTED

17. DATE RECEIVED

FOR REGIONAL OFFICE USE ONLY
18. DATE APPROVED

PLAN APPROVED - ONE COPY ATTACHED
19. EFFECTIVE DATE OF APPROVED MATERIAL
20. SIGNATURE OF REGIONAL OFFICIAL
21. TYPED NAME

22. TITLE

23. REMARKS

FORM CMS-179 (07/92)

Instructions on Back

INSTRUCTIONS FOR COMPLETING FORM CMS-179
Use Form CMS-179 to transmit State plan material to the regional office for approval. A separate typed transmittal
form should be completed for each plan/amendment submitted.
Block 1 - Transmittal Number - Enter the State Plan Amendment transmittal number. Assign consecutive numbers on
a calendar year basis (e.g., 92-001, 92-002, etc.).
Block 2 - State - Type the name of the State submitting the plan material.
Block 3 - Program Identification - Title XIX of the Social Security Act (Medicaid).
Block 4 - Proposed Effective Date - Enter the proposed effective date of material.
Block 5 - Type of Plan Material - Check the appropriate box.
Block 6 - Federal Statute/Regulation Citation - Enter the appropriate statutory/regulatory citation.
Block 7 - Federal Budget Impact - 7(a) - Enter 1st Federal Fiscal Year (FFY) impacted by the SPA & estimated Federal
share of the cost of the SPA (in thousands) for 1st FFY. 7(b) - Enter 2nd FFY impacted by the SPA & estimated
Federal share of the cost for 2nd FFY. See SMM section 13026.
Block 8 - Page No.(s) of Plan Section or Attachment - Enter the page number(s) of plan material transmitted.
If additional space is needed, use bond paper.
Block 9 - Page No.(s) of the Superseded Plan Section or Attachment (if Applicable) - Enter the page number(s)
(including the transmittal sheet number) that is being superseded. If additional space is needed, use bond paper.
Block 10 - Subject of Amendment - Briefly describe plan material being transmitted.
Block 11 - Governor’s Review - Check the appropriate box. See SMM section 13026 B.
Block 12 - Signature of State Agency Official - Authorized State official signs this block.
Block 13 - Typed Name - Type name of State official who signed block 12.
Block 14 - Title - Type title of State official who signed block 12.
Block 15 - Date Submitted - Enter the date you mail plan material to RO.
Block 16 - Return To - Type the name and address of State official to whom this form should be returned.
Block 17–23 (FOR REGIONAL OFFICE USE ONLY).
Block 17 - Date Received - Enter the date plan material is received in RO. See ROM section 6003.2.
Block 18 - Date Approved - Enter the date RO approved the plan material.
Block 19 - Effective Date of Approved Material - Enter the date the plan material becomes effective. If more than
one effective date, list each provision and its effective date in Block 23 or attach a sheet.
Block 20 - Signature of Regional Official - Approving RO official signs this block.
Block 21 - Typed Name - Type approving official’s name.
Block 22 - Title - Type approving official’s title.
Block 23 - Remarks - Use this block to reference pen and ink changes, a partial approval, more than one effective
date, etc. If additional space is needed, use bond paper.
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 number for this information collection is 0938-0193. The time required to complete this information collection is estimated to average 1 hour per response, including the
time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21224-1850.