Information Collection Request

Medicaid State Plan Base Plan Pages (CMS-179)

ICR 202409-0938-017 · OMB 0938-0193 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-179 4.31, 4.32, 4.33, and 4.34 Form Modified Available
Form CMS-179 4.19(d) Form Modified Repair queued
Form CMS-179 4.19(c) Form Modified Repair queued
Form CMS-179 Attachment 4.19 B, Supplement 1 Form Modified Repair queued
Form CMS-179 Attachment 4.19-B, Section 24 Form Modified Available
Form CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, 7, 8a, 8b, 8c, 9b, 11, 12, 14, and 15 Form Modified Available
Form CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, 5a, 6, 7, 8, 8a, 8b, 8c, 9b, 10, 11, 12, 13, 14, and 15 Form Modified Available
Form CMS-179 4.19(b): Attachment 4.19 B Form Modified Repair queued
Form CMS-179 Attachment 2.2 A and Supplements 1 - 3 Form Modified Available
Form CMS-179 4.19 (k)(1) Form Modified Repair queued
Form CMS-179 4.19(i) Form Modified Repair queued
Form CMS-179 4.19(h) Form Modified Available
Form CMS-179 4.19(g) Form Modified Repair queued
Form CMS-179 4.19(f) Form Modified Repair queued
Form CMS-179 4.19(e) Form Modified Repair queued
Form CMS-179 4.19(a) Form Modified Repair queued
Form CMS-179 2.1 - 2.7 (Territory) Form Modified Repair queued
Form CMS-179 2.1 - 2.7 (State) Form Modified Repair queued
Form CMS-179 Transmittal and Notice of Approval of State Plan Material Form and Instruction Modified Available
Form CMS-179 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction Modified Repair queued
CMS-179 - Supporting Statement A (2024 Version 4).docx Supporting Statement A Uploaded 2024-09-16 Repair queued
CMS-179 - Supporting Statement A (2024 Version 4).docx Supporting Statement A Uploaded 2024-09-16 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.31, 4.32, 4.33, and 4.34
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(d)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(c)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form ModifiedAttachment 4.19 B, Supplement 1
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form ModifiedAttachment 4.19-B, Section 24
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified(Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, 7, 8a, 8b, 8c, 9b, 11, 12, 14, and 15
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified(State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, 5a, 6, 7, 8, 8a, 8b, 8c, 9b, 10, 11, 12, 13, 14, and 15
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(b): Attachment 4.19 B
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form ModifiedAttachment 2.2 A and Supplements 1 - 3
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19 (k)(1)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(i)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(h)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(g)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(f)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(e)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified4.19(a)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified2.1 - 2.7 (Territory)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form Modified2.1 - 2.7 (State)
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction ModifiedTransmittal and Notice of Approval of State Plan Material
7877 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2028 36 Months From Approved 03/31/2025
1,120 0 1,120
22,400 0 22,400
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
State Plan Under Title XIX of the Social Security Act (Base plan pages) CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179, CMS-179 ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,120 1,120 0 0 0 0
Annual Time Burden (Hours) 22,400 22,400 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No