Summary of Benefits and Coverage

Affordable Care Act Section 2715 Summary Disclosures

OMB: 1210-0147

IC ID: 198888

Information Collection (IC) Details

View Information Collection (IC)

Summary of Benefits and Coverage
 
No New
 
Mandatory
 
29 CFR 2590.715-2715

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form NEW Summary of Benefits and Coverage (SBC) Template SBCtemplate.pdf http://www.dol.gov/ebsa/pdf/SBCtemplate.pdf Yes Yes Fillable Printable
Instruction SBCInstructionsGroup.pdf http://www.dol.gov/ebsa/pdf/SBCInstructionsGroup.pdf Yes Yes Paper Only
Instruction SBCInstructionsIndividual.pdf http://www.dol.gov/ebsa/pdf/SBCInstructionsIndividual.pdf Yes Yes Paper Only
Other-Model SBCYesAnswers.pdf http://www.dol.gov/ebsa/pdf/SBCYesAnswers.pdf Yes Yes Paper Only
Other-Model SBCNoAnswers.pdf http://www.dol.gov/ebsa/pdf/SBCNoAnswers.pdf Yes Yes Paper Only

Health Consumer Health and Safety

 

858 274
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   38 %

  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 77,000,000 77,000,000 0 0 0 0
Annual IC Time Burden (Hours) 630,000 630,000 0 0 0 0
Annual IC Cost Burden (Dollars) 4,350,007 4,350,007 0 0 0 0

Title Document Date Uploaded
Sample Completed SBC - Individual Health Insurance Coverage SBCSampleCompleted.pdf 08/19/2011
Guide for Coverage Examples Calculations SBCCoverageGuide.xls 08/19/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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