Summary of Benefits and Coverage and Uniform Glossary

OMB: 0938-1146

IC ID: 199007

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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:

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 %

	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

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.