Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 201602-1210-002 · OMB 1210-0147.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0147 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SBC Template April 2017.doc www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC template-April 2017
Group Instructions April 2017.docx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
UG April 2017.doc www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC Sample Glossary
Yes Answers April 2017.doc www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC Yes Answers -- Why This Ma
No Answers April 2017.doc www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC - No Answers - Why This Ma
Having a baby April 2017.xlsx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Template
Managing Type 2 Diabetes April 2017.xlsx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Template
Simple fracture April 2017.xlsx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Template
Coverage_examples_calculator instructions April 2017.docx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
Coverage-Examples-narrative- maternity April 2017.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Narrative
Coverage-Examples-narrative diabetes April 2017.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Narrative
Coverage-Examples-narrative-foot-fracture April 2017.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Narrative
SBC Blank Template - 2012.doc www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC template- 2012
SBCInstructionsGroup - 2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
SBCYesAnswers - 2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-SBC Yes Answers--Why This Matt
SBCNoAnswers - 2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-No Answers- Why This Matters
maternity-scenario-2012.xlsx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Template
diabetes-scenario-2012.xlsx www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Template
maternity-narrative-2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Narrative
diabetes-narrative-2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Narrative
sbc-cover-ex-calc-instructions- 2012.pdf www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Instruction
sbc-coverage-calculator-2012.xlsm www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Coverage Calculator
Coverage_examples_calculator April 2017.xlsm www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Other-Coverage Calculator
SBC Sample CompletedApril 2017.doc Sample Completed SBC	IC Document
SBC Completed Template - 2012.doc Sample Completed SBC	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Summary of Benefits and Coverage

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2715

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Group Instructions April 2017.docx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-SBC template- 2012	SBC Blank Template - 2012.doc	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Fileable
Other-SBC Yes Answers--Why This Matters	SBCYesAnswers - 2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-No Answers- Why This Matters	SBCNoAnswers - 2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Template	maternity-scenario-2012.xlsx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Printable
Other-Template	diabetes-scenario-2012.xlsx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Printable
Other-Narrative	maternity-narrative-2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Narrative	diabetes-narrative-2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Instruction	sbc-cover-ex-calc-instructions- 2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Narrative	Coverage-Examples-narrative diabetes April 2017.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Narrative	Coverage-Examples-narrative-foot-fracture April 2017.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Instruction	SBCInstructionsGroup - 2012.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-SBC Sample Glossary	UG April 2017.doc	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-SBC Yes Answers -- Why This Matters	Yes Answers April 2017.doc	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-SBC - No Answers - Why This Matters	No Answers April 2017.doc	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Instruction	Coverage_examples_calculator instructions April 2017.docx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-SBC template-April 2017	SBC Template April 2017.doc	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Fileable
Other-Template	Having a baby April 2017.xlsx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Template	Managing Type 2 Diabetes April 2017.xlsx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Template	Simple fracture April 2017.xlsx	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Narrative	Coverage-Examples-narrative- maternity April 2017.pdf	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Printable Only
Other-Coverage Calculator	sbc-coverage-calculator-2012.xlsm	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Printable
Other-Coverage Calculator	Coverage_examples_calculator April 2017.xlsm	http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,299,742

Number of Respondents for Small Entity: 2,158,601

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	68,686,125	8,038,784	60,647,341
Annual IC Time Burden (Hours)	414,335	42,471	371,864
Annual IC Cost Burden (Dollars)	8,478,862	991,078	7,487,784

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Completed SBC	SBC Sample CompletedApril 2017.doc	04/04/2016
Sample Completed SBC	SBC Completed Template - 2012.doc	04/04/2016

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