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

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

FORM APPROVED
OMB No. 0938-0193

TRANSMITTAL AND NOTICE OF APPROVAL OF
STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES
TO: CENTER DIRECTOR
CENTERS FOR MEDICAID & CHIP SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES

1. TRANSMITTAL NUMBER

2. STATE

3. PROGRAM IDENTIFICATION: TITLE ___ OF THE SOCIAL
SECURITY ACT
4. PROPOSED EFFECTIVE DATE

5. FEDERAL STATUTE/REGULATION CITATION

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars)
a. FFY
$
b. FFY
$

7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION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

9. SUBJECT OF AMENDMENT

10. GOVERNOR’S REVIEW (Check One)
OTHER, AS SPECIFIED:

GOVERNOR’S OFFICE REPORTED NO COMMENT
COMMENTS OF GOVERNOR’S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
11. SIGNATURE OF STATE AGENCY OFFICIAL

15. RETURN TO

12. TYPED NAME
13. TITLE
14. DATE SUBMITTED

16. DATE RECEIVED

FOR REGIONAL OFFICE USE ONLY
17. DATE APPROVED

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

21. TITLE OF APPROVING OFFICIAL

22. 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 Center for Medicaid & CHIP Services for approval. Submit a separate
typed transmittal form with each plan/amendment.
Block 1 - Transmittal Number - Enter the State Plan Amendment transmittal number. Assign consecutive numbers on a calendar year basis
with the first two digits being the two-digit year (e.g., 21-0001, 21-0002, etc.). Because states have different state fiscal years, a calendar
year is required for consistency.
Block 2 - State - Enter the two-letter abbreviation code of the State/District/Territory submitting the plan material.
Block 3 - Program Identification - Enter the applicable Title of the Social Security Act (Title XIX Medicaid or Title XXI CHIP).
Block 4 - Proposed Effective Date - Enter the proposed effective date of material. The effective date of a new plan may not be earlier than
the first day of the calendar quarter in which an approvable plan is submitted. With respect to expenditures for assistance under such
plan, the effective date may not be earlier than the first day on which the plan is in operation on a statewide basis or earlier than the day
following publication of notice of changes.
Block 5 - Federal Statute/Regulation Citation - Enter the appropriate statutory/regulatory citation.
Block 6 - Federal Budget Impact - 6(a) - IN WHOLE DOLLARS, NOT IN THOUSANDS, Enter 1st Federal Fiscal Year (FFY) impacted by
the SPA & estimated Federal share of the cost of the SPA for 1st FFY.
The first FFY should be the FFY inclusive of the earliest effective
date of any amended payment language; 6 (b) - Enter 2nd FFY impacted by the SPA & estimated Federal share of the cost for 2nd FFY.
In general, the estimates should include any amount not currently approved in the state’s plan for assistance.
Block 7 - Page No.(s) of Plan Section or Attachment - Enter the page number(s) of plan material amended and transmitted. If additional
space is needed, use bond paper. New pages should be included in Block 7, but not in Block 8.
Block 8 - Page No.(s) of the Superseded Plan Section or Attachment (if Applicable) - Enter the page number(s) (including the transmittal
number) that is being superseded. If additional space is needed, use bond paper. Deleted pages should be included in Block 8, but not
in Block 7.
Block 9 - Subject of Amendment - Briefly describe plan material being transmitted.
Block 10 - Governor’s Review - Check the appropriate box. See SMM section 13026 A.
Block 11 - Signature of State Agency Official - Authorized State official signs this block.
Block 12 - Typed Name - Type name of State official who signed block 11.
Block 13 - Title - Type title of State official who signed block 11.
Block 14 - Date Submitted - Enter the date that the state transmits plan material to CMCS. Unless the state officially withdraws this SPA and
then resubmits it, this date should not be revised. Documentation of version revisions will be maintained in the CMCS administrative
record.
Block 15 - Return To - Type the name and address of State official to whom this form should be returned.
Block 16–22 (FOR CMCS USE ONLY).
Block 16 - Date Received - Enter the date plan material is received by CMCS. This is the date that the submission is received by CMCS via
the subscribed submission process.
Block 17 - Date Approved - Enter the date CMCS approved the plan material.
Block 18 - 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 22 or attach a sheet.
Block 19 - Signature of Approving Official - Approving official signs this block.
Block 20 - Typed Name of Approving Official - Type approving official’s name.
Block 21 - Title of Approving Official - Type approving official’s title.
Block 22 - Remarks - Use this block to reference and explain agreed to changes and strike-throughs to the original CMS-179 as submitted, 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.