Form Cms-179 - Transmittal And Notice Of Approval Of State Plan Material
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1
2FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0193
CENTERS FOR MEDICARE & MEDICAID SERVICES
2. STATE
1. TRANSMITTAL NUMBER
TRANSMITTAL AND NOTICE OF APPROVAL OF
STATE PLAN MATERIAL
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL
FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES
SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR
4. PROPOSED EFFECTIVE DATE
CENTERS FOR MEDICARE & MEDICAID SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES
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 PAGE NUMBER OF THE SUPERSEDED PLAN SECTION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)
OTHER, AS SPECIFIED
GOVERNOR’S OFFICE REPORTED NO COMMENT
COMMENTS OF GOVERNOR’S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
16. RETURN TO
12. SIGNATURE OF STATE AGENCY OFFICIAL
13. TYPED NAME
14. TITLE
15. DATE SUBMITTED
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED
18. DATE APPROVED
PLAN APPROVED - ONE COPY ATTACHED
19.
EFFECTIVE DA
TE OF APPROVED MATERIAL
20. SIGNATURE OF REGIONAL OFFICIAL
21. TYPED NAME
22. TITLE
23. REMARKS
FORM CMS-179 (07/92)
Instructions on Back
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