Summary of Benefits and Coverage

Summary of Benefits and Coverage and Uniform Glossary Required Under the Affordable Care Act

OMB: 1210-0147

IC ID: 198888

Documents and Forms
Document Name
Document Type
Other-SBC template-April 2017
Instruction
Other-SBC Sample Glossary
Other-SBC Yes Answers -- Why This Ma
Other-SBC - No Answers - Why This Ma
Other-Template
Other-Template
Other-Template
Instruction
Other-Narrative
Other-Narrative
Other-Narrative
Other-SBC template- 2012
Instruction
Other-SBC Yes Answers--Why This Matt
Other-No Answers- Why This Matters
Other-Template
Other-Template
Other-Narrative
Other-Narrative
Instruction
Other-Coverage Calculator
Other-Coverage Calculator
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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

Document Type Form No. Form Name 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

Health Consumer Health and Safety

 

2,299,742 2,158,601
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   38 %

  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 68,686,125 0 0 8,038,784 0 60,647,341
Annual IC Time Burden (Hours) 414,335 0 0 42,471 0 371,864
Annual IC Cost Burden (Dollars) 8,478,862 0 0 991,078 0 7,487,784

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.
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