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

Medicaid State Plan Base Plan Pages (CMS-179)

OMB: 0938-0193

IC ID: 7877

⚠️ Notice: This information collection may be referencing outdated material.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

2024-09-16 - Extension without change of a currently approved collection

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 Transmittal Form and Instructions (2021 e-version 1).pdf Form and Instruction
CMS-179 Transmittal and Notice of Approval of State Plan Materia CMS 179 Transmittal Form and Instructions (2021 e-version 1).pdf Form and Instruction
CMS-179 2.1 - 2.7 (State) Exhibit A 508 (rev OSORA PRA).pdf Form
CMS-179 2.1 - 2.7 (State) Exhibit A 508 (rev OSORA PRA).pdf Form
CMS-179 2.1 - 2.7 (Territory) Exhibit A1 508 (rev OSORA PRA).pdf Form
CMS-179 2.1 - 2.7 (Territory) Exhibit A1 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(a) Exhibit AA 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(a) Exhibit AA 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(e) Exhibit AB 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(e) Exhibit AB 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(f) Exhibit AC 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(f) Exhibit AC 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(g) Exhibit AD 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(g) Exhibit AD 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(h) Exhibit AE 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(h) Exhibit AE 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(i) Exhibit AF 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(i) Exhibit AF 508 (rev OSORA PRA).pdf Form
CMS-179 4.19 (k)(1) Exhibit AG 508 (rev OSORA PRA).pdf Form
CMS-179 4.19 (k)(1) Exhibit AG 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 2.2 A and Supplements 1 - 3 Exhibit D and E 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 2.2 A and Supplements 1 - 3 Exhibit D and E 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(b): Attachment 4.19 B Exhibit DP 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(b): Attachment 4.19 B Exhibit DP 508 (rev OSORA PRA).pdf Form
CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, Exhibit F and G 508 (rev OSORA PRA).pdf Form
CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5, Exhibit F and G 508 (rev OSORA PRA).pdf Form
CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, Exhibit H and J 508 (rev OSORA PRA).pdf Form
CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4, Exhibit H and J 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 4.19-B, Section 24 Exhibit N 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 4.19-B, Section 24 Exhibit N 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 4.19 B, Supplement 1 Exhibit O 508 (rev OSORA PRA).pdf Form
CMS-179 Attachment 4.19 B, Supplement 1 Exhibit O 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(c) Exhibit P 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(c) Exhibit P 508 (rev OSORA PRA).pdf Form
CMS-179 4.19(d) Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf Form
CMS-179 4.19(d) Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf Form
CMS-179 4.31, 4.32, 4.33, and 4.34 Exhibits R S T U 508 (rev OSORA PRA).pdf Form
CMS-179 4.31, 4.32, 4.33, and 4.34 Exhibits R S T U 508 (rev OSORA PRA).pdf Form
CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf CROSSWALK: Transmittal and Notice of Approval of State Plan Material IC Document
CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf CROSSWALK: Transmittal and Notice of Approval of State Plan Material IC Document

Information Collection (IC) Details

View Information Collection (IC)

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	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 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	2.1 - 2.7 (Territory)	Exhibit A1 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(a)	Exhibit AA 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(e)	Exhibit AB 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(f)	Exhibit AC 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(g)	Exhibit AD 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(h)	Exhibit AE 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(i)	Exhibit AF 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19 (k)(1)	Exhibit AG 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	Attachment 2.2 A and Supplements 1 - 3	Exhibit D and E 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(b): Attachment 4.19 B	Exhibit DP 508 (rev OSORA PRA).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 (rev OSORA PRA).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 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	Attachment 4.19-B, Section 24	Exhibit N 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	Attachment 4.19 B, Supplement 1	Exhibit O 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(c)	Exhibit P 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.19(d)	Exhibit Y Revision 4-9-15 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable
Form	CMS-179	4.31, 4.32, 4.33, and 4.34	Exhibits R S T U 508 (rev OSORA PRA).pdf	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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
CROSSWALK: Transmittal and Notice of Approval of State Plan Material	CMS 179 Transmittal Form and Instructions (2021 e-version 1) CROSSWALK.pdf	08/25/2021

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