State Plan Under Title XIX of the Social Security Act (Base plan pages)

State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0193 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-179 State Plan Under Title XIX of the Social Security Act (Base plan pages) Form and Instruction
CMS-179 Transmittal and Notice of Approval of State Plan Materia CMS 179 Form (e-version).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	State Plan Under Title XIX of the Social Security Act (Base plan pages)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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 (e-version)	CMS 179 Form (e-version).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,120	1,120
Annual IC Time Burden (Hours)	22,400	22,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.