SBC Disclosure

Summary of Benefits and Coverage and Uniform Glossary (CMS-10407)

OMB: 0938-1146

IC ID: 199007

Documents and Forms
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Document Type
Form and Instruction
Form and Instruction
Form and Instruction
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Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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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 Narrative.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10407 Diabetes Narrative CMS-10407 - Diabetes-Narrative.pdf Yes Yes Fillable Fileable
Form CMS-10407 Coverage Examples - Narrative Foot Fracture CMS-10407 - Coverage-Examples-Narrative-Foot-Fracture.pdf Yes Yes Printable Only
Form and Instruction CMS-10407 Simple Fracture Simple fracture.xlsx Yes No Paper Only
Form and Instruction CMS-10407 Coverage Examples Calculator coverage_examples_calculator 02 07 02 FINAL.pdf Yes Yes Printable Only
Form CMS-10407 Coverage Examples Calculator Copy of Copy of coverage_examples_calculator 02 07.xlsm Yes No Fillable Fileable
Form and Instruction CMS-10407 Group Instructions Group Instructions 4 4 clean.docx Yes Yes Printable Only
Form and Instruction CMS-10407 Having a baby Having a baby.xlsx Yes No Fillable Fileable
Form and Instruction CMS-10407 Instructions - Individual Individual Instructions 4 4 clean.docx Yes Yes Printable Only
Form and Instruction CMS-10407 Managing diabetes Managing Type 2 Diabetes.xlsx Yes No Paper Only
Form CMS-10407 SBC Glossary Anchor sbc-glossary-anchors.xlsx Yes No Paper Only
Form CMS-10407 Uniform Glossary UG 4-1-16 -12 pm clean.doc Yes No Printable Only
Form and Instruction CMS-10407 What the plan covers and What you pay (No Answers) No Answers 4 1 12 pm clean.doc Yes No Printable Only
Form and Instruction CMS-10407 Completed SBC Sample SBC Sample Completed 4 4 clean.doc Yes Yes Printable Only
Form and Instruction CMS-10407 Blank Template SBC Template 4 4 clean.doc Yes Yes Printable Only
Form and Instruction CMS-10407 What the plan covers and what you play (Yes Answes) Yes Answers 4 1 12 pm clean.doc Yes Yes Printable Only

Health Health Care Services

 

126,544 35
   
Private Sector Businesses or other for-profits
 
   70 %

  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 41,164,763 0 0 25,236,835 0 15,927,928
Annual IC Time Burden (Hours) 324,853 0 0 2,442 0 322,411
Annual IC Cost Burden (Dollars) 4,116,476 0 0 2,523,683 0 1,592,793

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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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