Information Collection

SBC disclosure

IC 199007 under ICR 201208-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Maternity Scenario SBC disclosure	Form and Instruction
Form CMS-10407 Blank SBC Template SBC disclosure	Form and Instruction
Form CMS-10407 Diabetes_Narrative SBC disclosure	Form and Instruction
Form CMS-10407 Diabetes_Scenario SBC disclosure	Form and Instruction
Form CMS-10407 Instructions Group SBC disclosure	Form and Instruction
Form CMS-10407 Instructions Individual SBC disclosure	Form and Instruction
Form CMS-10407 Maternity_Narrative SBC disclosure	Form and Instruction
Form CMS-10407 Sample Completed SBC SBC disclosure	Form and Instruction
Form CMS-10407 Uniform Glossary SBC disclosure	Form and Instruction
Form CMS-10407 Appendix A SBC disclosure	Form and Instruction
Why This Matters - No Answers 2-7-12 clean.doc	Instruction
Why This Matters - Yes Answers 2-7-12 clean.doc	Instruction
CMS-10407 Maternity Scenario Maternity Scenario 2-7-12.xlsx	Form and Instruction
CMS-10407 Blank SBC Template Blank SBC Template 2-7-12 clean.doc	Form and Instruction
CMS-10407 Diabetes_Narrative Diabetes_Narrative_2-7-12.doc	Form and Instruction
CMS-10407 Diabetes_Scenario Diabetes_Scenario_2-7-12.xlsx	Form and Instruction
CMS-10407 Instructions Group Instructions Group 2-7-12 clean.docx	Form and Instruction
CMS-10407 Instructions Individual Instructions Individual 2-7-12 clean.docx	Form and Instruction
CMS-10407 Maternity_Narrative Maternity_Narrative_2-7-12.docx	Form and Instruction
CMS-10407 Sample Completed SBC Sample Completed SBC 2-7-12 clean.doc	Form and Instruction
CMS-10407 Uniform Glossary Uniform Glossary 2-7-12 clean.doc	Form and Instruction
CMS-10407 Appendix A Appendix_A_ SBC PlanFinder New Benefit Template.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

SBC disclosure

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.200

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	Maternity Scenario	Maternity Scenario 2-7-12.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Blank SBC Template	Blank SBC Template 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes_Narrative	Diabetes_Narrative_2-7-12.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Diabetes_Scenario	Diabetes_Scenario_2-7-12.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Instructions Group	Instructions Group 2-7-12 clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Instructions Individual	Instructions Individual 2-7-12 clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Maternity_Narrative	Maternity_Narrative_2-7-12.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Sample Completed SBC	Sample Completed SBC 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Uniform Glossary	Uniform Glossary 2-7-12 clean.doc	Yes	Yes	Fillable Fileable
Instruction			Why This Matters - No Answers 2-7-12 clean.doc	Yes	No	Printable Only
Instruction			Why This Matters - Yes Answers 2-7-12 clean.doc	Yes	No	Printable Only
Form and Instruction	CMS-10407	Appendix A	Appendix_A_ SBC PlanFinder New Benefit Template.pdf	Yes	Yes	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: 35

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 54 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	13,000,000	13,000,000
Annual IC Time Burden (Hours)	300,000	300,000
Annual IC Cost Burden (Dollars)	1,300,000	1,300,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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