SBC Disclosure

Summary of Benefits and Coverage and Uniform Glossary

OMB: 0938-1146

IC ID: 199007

Information Collection (IC) Details

View Information Collection (IC)

SBC Disclosure
 
No Modified
 
Mandatory
 
45 CFR 147.200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10407 Maternity Scenario CMS-10407 - maternity_scenario.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10407 Diabetes Scenario CMS-10407 - diabetes_scenario.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10407 Diabetes Scenario Narrative CMS-10407 - diabetes_scenario_narrative.pdf Yes Yes Fillable Fileable
Form CMS-10407 Uniform Glossary CMS-10407 - uniform_glossary.pdf Yes No Printable Only
Form and Instruction CMS-10407 Why This Matters (No Answers) CMS-10407 -instructions_why_this_matters_no_answers.pdf Yes No Printable Only
Form and Instruction CMS-10407 Why This Matters (Yes Answes) CMS-10407 -instructions_why_this_matters_yes_answers.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Group Instructions CMS-10407 - sbc_instructions_group.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Instructions - Individual CMS-10407 - sbc_instructions_individual.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Completed SBC First Year CMS-10407 - sample_completed_sbc_first_year.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Completed SBC Second Year CMS-10407 - sample_completed_sbc_second_year.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Blank SBC template second year CMS-10407 - sbc_blank_template_second_year.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10407 Blank SBC Template First Year CMS-10407 - sbc_template_first_year.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

408 35
   
Private Sector Businesses or other for-profits
 
   54 %

  Approved 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 15,927,928 0 0 0 0 15,927,928
Annual IC Time Burden (Hours) 322,411 0 0 0 0 322,411
Annual IC Cost Burden (Dollars) 1,592,793 0 0 0 0 1,592,793

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

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