Information Collection

SBC Disclosure

IC 199007 under ICR 201908-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 SBC Disclosure	Form and Instruction
CMS-10406 - Coverage Examples Calculator.xlsm	Other-Coverage Calculator
CMS-10407 Maternity Scenario CMS-10407 - Maternity-Care-Narrative-.pdf	Form and Instruction
CMS-10407 Diabetes Narrative CMS-10407 - Diabetes Narrative-.pdf	Form and Instruction
CMS-10407 Uniform Glossary CMS-10407 - Uniform Glossary-.pdf	Form
CMS-10407 What the plan covers and What you pay (No Answers) CMS-10407 - Why_this_Matters_for_SBC_No_Answers-.pdf	Form and Instruction
CMS-10407 What the plan covers and what you play (Yes Answes) CMS-10407 - Why_this_Matters_for_SBC_Yes_Answers_English -.pdf	Form and Instruction
CMS-10407 Group Instructions CMS-10407 - Group_Instructions_Updated-.pdf	Form and Instruction
CMS-10407 Instructions - Individual CMS-10407 - Individual_Instructions_Updated-.pdf	Form and Instruction
CMS-10407 Completed SBC Sample CMS-10407 - SBC Completed -.pdf	Form and Instruction
CMS-10407 Blank Template CMS-10407 - SBC_Template-.pdf	Form and Instruction
CMS-10407 Coverage Examples - Narrative Foot Fracture CMS-10407 - Foot-Fracture-Narrative-.pdf	Form
CMS-10407 Coverage Calculator Instructions CMS-10407 - Coverage-Examples-Calculator-Instructions-.pdf	Form and Instruction
CMS-10407 Having a baby CMS-10407 - Having a Baby -.pdf	Form and Instruction
CMS-10407 Managing diabetes CMS-10407 - Managing-Type-2-Diabetes-Guide-.pdf	Form and Instruction
CMS-10407 SBC Glossary Anchor CMS-10407 - List of Anchors -.xlsx	Form
CMS-10407 Simple Fracture Simple-Fracture-Guide_508.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	Diabetes Narrative	CMS-10407 - Diabetes Narrative-.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10407	Maternity Scenario	CMS-10407 - Maternity-Care-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	What the plan covers and What you pay (No Answers)	CMS-10407 - Why_this_Matters_for_SBC_No_Answers-.pdf	Yes	No	Printable Only
Form and Instruction	CMS-10407	What the plan covers and what you play (Yes Answes)	CMS-10407 - Why_this_Matters_for_SBC_Yes_Answers_English -.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Group Instructions	CMS-10407 - Group_Instructions_Updated-.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Instructions - Individual	CMS-10407 - Individual_Instructions_Updated-.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Completed SBC Sample	CMS-10407 - SBC Completed -.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Blank Template	CMS-10407 - SBC_Template-.pdf	Yes	Yes	Printable Only
Form	CMS-10407	Coverage Examples - Narrative Foot Fracture	CMS-10407 - Foot-Fracture-Narrative-.pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10407	Coverage Calculator Instructions	CMS-10407 - Coverage-Examples-Calculator-Instructions-.pdf	Yes	Yes	Printable Only
Other-Coverage Calculator			CMS-10406 - Coverage Examples Calculator.xlsm	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	Having a baby	CMS-10407 - Having a Baby -.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10407	Managing diabetes	CMS-10407 - Managing-Type-2-Diabetes-Guide-.pdf	Yes	No	Paper Only
Form	CMS-10407	SBC Glossary Anchor	CMS-10407 - List of Anchors -.xlsx	Yes	No	Paper Only
Form and Instruction	CMS-10407	Simple Fracture	Simple-Fracture-Guide_508.pdf	Yes	No	Paper Only

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: 128,511

Number of Respondents for Small Entity: 35

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 70 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	24,417,090	-16,747,673	41,164,763
Annual IC Time Burden (Hours)	214,791	-110,062	324,853
Annual IC Cost Burden (Dollars)	4,553,787	437,311	4,116,476

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.