Blocks 1 to 4: identification
The State Plan Amendment transmittal number, numbered consecutively by calendar year with the two-digit year first (for example 21-0001), the state, the program and the proposed effective date.
CMS-179
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL
- Agency
- CMS
- Revision
- 09/24
- Fillable fields
- 30
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-179: Transmittal and Notice of Approval of State Plan Material
Form CMS-179, Transmittal and Notice of Approval of State Plan Material, is a Centers for Medicare & Medicaid Services form addressed to the Center Director, Center for Medicaid & CHIP Services. Its instructions say to use it to transmit State plan material to the Center for Medicaid & CHIP Services for approval, with a separate typed transmittal form for each plan or amendment.
The state fills in blocks 1 to 15: the transmittal number, state, program (Title XIX Medicaid or Title XXI CHIP), proposed effective date, citation, federal budget impact, page numbers, subject, the Governor's review and the State official's signature. Blocks 16 to 22 are for CMS use only and record when the plan material was received and approved.
The instructions are printed on the back of the form, and it estimates an average of 1 hour per response. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-179
Blocks 5 and 6: citation and budget impact
The federal statute or regulation citation, and the estimated federal share of the cost for the first and second federal fiscal years, in whole dollars.
Blocks 7 to 9: pages and subject
Page numbers of the new plan section or attachment, page numbers of the superseded section if applicable, and a brief subject of the amendment.
Block 10: Governor's review
One box for the Governor's review. The instructions point to SMM section 13026 A.
Blocks 11 to 15: State official
Signature of the State agency official, typed name, title, date submitted, and the name and address of the State official the form is returned to.
Blocks 16 to 22: for CMS use only
Date received, date approved, effective date of approved material, approving official's signature, typed name and title, and remarks.
The back of the form explains each block.
How to fill out Form CMS-179
- 1
Number the transmittal
The instructions say to assign consecutive numbers on a calendar year basis, starting with the two-digit year, because states have different state fiscal years.
- 2
Identify the state, program and date
Enter the two-letter code, Title XIX or Title XXI, and the proposed effective date. The instructions say a new plan's effective date may not be earlier than the first day of the calendar quarter in which an approvable plan is submitted.
- 3
Enter citation and budget impact
Add the citation, then the first and second federal fiscal years and the estimated federal share for each, in whole dollars, not thousands, as the instructions say.
- 4
List the pages and subject
New pages go in block 7 and superseded or deleted pages in block 8, not both. The instructions say to use bond paper if more space is needed.
- 5
Record the Governor's review
Check the box in block 10 that matches the Governor's office response.
- 6
Sign and date
An authorized State official signs block 11 and adds name, title, date submitted and a return address. The instructions say the date submitted is not revised unless the state officially withdraws and resubmits the amendment.
Why fill Form CMS-179 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Sending it and what the form says
Who it goes to
The form is addressed to the Center Director, Center for Medicaid & CHIP Services, Department of Health and Human Services. The instructions describe the date received as the date the submission reaches CMCS via the subscribed submission process. No mailing address is printed.
One form per amendment
The instructions say to submit a separate typed transmittal form with each plan or amendment.
Approval
CMS completes blocks 16 to 22. If the approved material has more than one effective date, the instructions say to list each provision and its effective date in block 22 or attach a sheet.
Time to complete
The form estimates an average of 1 hour per response. Its OMB number is 0938-0193.
Related forms
CMS-R-0235M
Medicaid Agency Data Use Agreement
45 fields, 6 pages
CMS-R-0235MA
Addendum to the Medicaid State Agency Data Use Agreement
26 fields, 1 page
CMS-R-0235MC
Compliance Plan for Accounting for Disclosures of Privacy Protected Data Released From a System of Records (SOR) Housed in a State-Located Server
10 fields, 1 page
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
CMS-632FOI
FREEDOM OF INFORMATION ACT REQUEST
73 fields, 2 pages
Who uses Form CMS-179?
The form goes from a state to the Center for Medicaid & CHIP Services, and CMS completes the bottom part.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form CMS-179
What is Form CMS-179 used for?
The instructions say to use Form CMS-179 to transmit State plan material to the Center for Medicaid & CHIP Services for approval, with a separate typed form for each plan or amendment.
How is the transmittal number written?
The instructions say to assign consecutive numbers on a calendar year basis, with the two-digit year first, for example 21-0001 and 21-0002.
Which programs does the form cover?
Block 3 lists Title XIX of the Social Security Act (Medicaid) and Title XXI (CHIP).
Are the budget amounts in thousands?
No. The instructions for block 6 say whole dollars, not thousands, for the estimated federal share in each of the first two federal fiscal years.
Can the date submitted be changed later?
The instructions say the date in block 14 should not be revised unless the state officially withdraws the amendment and then resubmits it.
Who fills out blocks 16 to 22?
They are marked For CMS Use Only. CMS records the dates received and approved, the effective date, the approving official and any remarks.
What if there is not enough room?
For blocks 7, 8 and 22, the instructions say to use bond paper if more space is needed.