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

Documents and Forms
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Form and Instruction
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Information Collection (IC) Details

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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

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

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