SBC Disclosure

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

OMB: 0938-1146

IC ID: 199007

Documents and Forms
Document Name
Document Type
Other-Maternity Care Narrative
Other-Diabetes 2 Narrative
Other-Uniform Glossary Anchor
Other-What the Plan Covers and What
Other-Why This Matters for SBC (Yes
Instruction
Instruction
Other-Completed SBC Template
Other-SBC Template
Other-Foot Fracture Narrative
Instruction
Other-Coverage Calculator
Other-Template
Other-Diabetes Guide
Other-Glossary Anchor
Other-Template
Instruction
Instruction
Other-Uniform Glossary
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
Other-Coverage Calculator SBC-Coverage-Examples-Calculator-Excel.xlsm Yes No Fillable Printable
Other-Diabetes Guide Managing-Type-2-Diabetes-Guide.pdf Yes No Printable Only
Other-Glossary Anchor List of Anchors_Updated.xlsx Yes No Printable Only
Instruction AIAN Limited Cost Sharing.pdf Yes No Printable Only
Instruction AIAN_Zero_Cost_Sharing.pdf Yes No Printable Only
Other-Diabetes 2 Narrative Diabetes-Narrative.pdf Yes No Printable Only
Other-Template Having-a-Baby-Guide.xlsx Yes No Printable Only
Instruction Individual_Instructions_Updated.pdf Yes No Printable Only
Other-Maternity Care Narrative Maternity-Care-Narrative.pdf Yes No Printable Only
Other-Uniform Glossary Uniform Glossary_Updated.pdf Yes No Printable Only
Other-Uniform Glossary Anchor List of Anchors_Updated.xlsx Yes No Printable Only
Other-What the Plan Covers and What You Pay (No Answers) Why_this_Matters_for_SBC_No_Answers_English.pdf Yes No Printable Only
Other-Why This Matters for SBC (Yes Answers) Why_this_Matters_for_SBC_Yes_Answers_English.pdf Yes No Printable Only
Instruction Group_Instructions_Updated.pdf Yes No Printable Only
Other-Completed SBC Template Sample_Completed_SBC_Standard_Format.docx Yes No Fillable Fileable
Other-SBC Template SBC_Template_Standard_Format_Updated.docx Yes No Fillable Fileable
Other-Foot Fracture Narrative Foot-Fracture-Narrative.pdf Yes No Printable Only
Instruction Coverage-Examples-Calculator-Instructions.pdf Yes No Printable Only
Other-Template Simple-Fracture-Guide_508.pdf Yes No Printable Only

Health Health Care Services

 

128,511 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 41,804,628 0 0 639,865 0 41,164,763
Annual IC Time Burden (Hours) 214,791 0 0 -110,062 0 324,853
Annual IC Cost Burden (Dollars) 4,180,463 0 0 63,987 0 4,116,476

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.
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