|
State Plan Under Title XIX of the Social Security Act (Base plan pages) |
|
|
| |
|
No
|
Modified |
| |
|
Required to Obtain or Retain Benefits
|
| |
|
|
| Document Type |
Form No. |
Form Name |
Instrument File |
URL |
Available Electronically? |
Can Be Submitted Electronically? |
Electronic Capability |
| Form and Instruction |
CMS-179 |
Transmittal and Notice of Approval of State Plan Material
|
CMS 179 Transmittal Form and Instructions (2021 e-version 1).pdf
|
|
Yes |
Yes |
Fillable Fileable |
| Form |
CMS-179 |
2.1 - 2.7 (State)
|
Exhibit A 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
2.1 - 2.7 (Territory)
|
Exhibit A1 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(a)
|
Exhibit AA 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(e)
|
Exhibit AB 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(f)
|
Exhibit AC 508 (2021 version n1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(g)
|
Exhibit AD 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(h)
|
Exhibit AE 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(i)
|
Exhibit AF 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19 (k)(1)
|
Exhibit AG 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
Attachment 2.2 A and Supplements 1 - 3
|
Exhibit D and E 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(b): Attachment 4.19 B
|
Exhibit DP 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| 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
|
Exhibit F and G 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
(Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, 7, 8a, 8b, 8c, 9b, 11, 12, 14, and 15
|
Exhibit H and J 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
Attachment 4.19-B, Section 24
|
Exhibit N 508 (2021 version1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
Attachment 4.19 B, Supplement 1
|
Exhibit O 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(c)
|
Exhibit P 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.19(d)
|
Exhibit Y (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
| Form |
CMS-179 |
4.31, 4.32, 4.33, and 4.34
|
Exhibits R S T U 508 (2021 version 1).pdf
|
|
Yes |
Yes |
Fillable Printable |
|
Health
|
Health Care Services
|
|
|
|
|
|
|
56
|
0
|
| |
|
|
State, Local, and Tribal Governments
|
|
| |
|
100
%
|
| |
Requested |
Program Change Due to New Statute |
Program Change Due to Agency Discretion |
Change Due to Adjustment in Agency Estimate |
Change Due to Potential Violation of the PRA |
Previously Approved |
| Annual Number of Responses for this IC |
1,120 |
0 |
0 |
0 |
0 |
1,120 |
| Annual IC Time Burden (Hours) |
22,400 |
0 |
0 |
0 |
0 |
22,400 |
| Annual IC Cost Burden (Dollars) |
0 |
0 |
0 |
0 |
0 |
0 |
| Title |
Document |
Date Uploaded |
| No associated records found |
|
