Form Cms-179 - Transmittal And Notice Of Approval Of State Plan Material (Page 2 of 2) in pdf

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Block 9 - Page No.(s) of the Superseded Plan Section or Attachment (if Applicable) - Enter the page number(s)

(including the transmittal sheet number) that is being superseded.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.

Form Cms-179 - Transmittal And Notice Of Approval Of State Plan Material Page 2

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