Information Collection

Summary of Benefits and Coverage and Uniform Glossary

IC 199007 under ICR 201108-0938-003 · OMB 0938-1146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1146 can be found here:

2025-04-10 - No material or nonsubstantive change to a currently approved collection
2024-12-20 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10407 Summary of Benefits and Coverage and Uniform Glossary	Form and Instruction
CMS-10407 Blank CMS-10407_Blank.xlsx	Form and Instruction
CMS-10407 CMS-10407_Appendices_Part_7_(D-1)-F CMS-10407_Appendices_Part_7_(D-1)-F.pdf	Form
CMS-10407 CMS-10407_Coverage_Example_Narratives CMS-10407_Coverage_Example_Narratives.pdf	Form and Instruction
CMS-10407 CMS-10407_Blank_Template_of_Coverage-Example_Condition-F CMS-10407_Blank_Template_of_Coverage-Example_Condition-F.pdf	Form and Instruction
CMS-10407 CMS-10407_Brst_Cncer CMS-10407_Brst_Cncer.xlsx	Form and Instruction
CMS-10407 CMS-10407_Diabetes CMS-10407_Diabetes.xlsx	Form and Instruction
CMS-10407 CMS-10407_Maternity CMS-10407_Maternity.xlsx	Form and Instruction
CMS-10407 CMS-10407_PPACA_Glossary CMS-10407_PPACA_Glossary-F.pdf	Form and Instruction
CMS-10407 CMS-10407_PPACA_No_Answers CMS-10407_PPACA_No_Answers.pdf	Form and Instruction
CMS-10407 CMS-10407_PPACA_Yes_Answers CMS-10407_PPACA_Yes_Answers.pdf	Form and Instruction
CMS-10407 CMS-10407_Summary_of_Coverage_(Blank)-F CMS-10407_Summary_of_Coverage_(Blank)-F.pdf	Form and Instruction
CMS-10407 CMS-10407_Summary_of_Coverage_(Populated)-F CMS-10407_Summary_of_Coverage_(Populated)-F.pdf	Form and Instruction
CMS-10407 CMS-10407_Summary_of_Coverage_(Populated)-F CMS-10407_Summary_of_Coverage_(Populated)-F.pdf	Form and Instruction
CMS-10407_Draft_Instruction_Guide_for_Group_Policies.pdf CMS-10407_Draft_Instruction_Guide_for_Group_Policies	IC Document
CMS-10407_Draft_Instruction_Guide_for_Individually_Purchased_or_Non-Group_Policies.pdf CMS-10407_Draft_Instruction_Guide_for_Individually_Purchased_or_Non-Group_Policies	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Summary of Benefits and Coverage and Uniform Glossary

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10407	Blank	CMS-10407_Blank.xlsx	Yes	No	Fillable Fileable
Form	CMS-10407	CMS-10407_Appendices_Part_7_(D-1)-F	CMS-10407_Appendices_Part_7_(D-1)-F.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Coverage_Example_Narratives	CMS-10407_Coverage_Example_Narratives.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Blank_Template_of_Coverage-Example_Condition-F	CMS-10407_Blank_Template_of_Coverage-Example_Condition-F.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Brst_Cncer	CMS-10407_Brst_Cncer.xlsx	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Diabetes	CMS-10407_Diabetes.xlsx	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Maternity	CMS-10407_Maternity.xlsx	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_PPACA_Glossary	CMS-10407_PPACA_Glossary-F.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_PPACA_No_Answers	CMS-10407_PPACA_No_Answers.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_PPACA_Yes_Answers	CMS-10407_PPACA_Yes_Answers.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Summary_of_Coverage_(Blank)-F	CMS-10407_Summary_of_Coverage_(Blank)-F.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Summary_of_Coverage_(Populated)-F	CMS-10407_Summary_of_Coverage_(Populated)-F.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	CMS-10407_Summary_of_Coverage_(Populated)-F	CMS-10407_Summary_of_Coverage_(Populated)-F.pdf	Yes	No	Fillable Fileable

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: 333

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	13,000,000	13,000,000
Annual IC Time Burden (Hours)	310,000	310,000
Annual IC Cost Burden (Dollars)	1,600,000	1,600,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10407_Draft_Instruction_Guide_for_Group_Policies	CMS-10407_Draft_Instruction_Guide_for_Group_Policies.pdf	08/25/2011
CMS-10407_Draft_Instruction_Guide_for_Individually_Purchased_or_Non-Group_Policies	CMS-10407_Draft_Instruction_Guide_for_Individually_Purchased_or_Non-Group_Policies.pdf	08/25/2011

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