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-Nov 2019
Other-SBC template-Nov 2019
Instruction
Instruction
Other-SBC Sample Glossary
Other-SBC Sample Glossary
Other-SBC Yes Answers -- Why This Ma
Other-SBC Yes Answers -- Why This Ma
Other-SBC - No Answers - Why This Ma
Other-SBC - No Answers - Why This Ma
Other-Template
Other-Template
Other-Template
Other-Template
Other-Template
Other-Template
Instruction
Instruction
Other-Narrative
Other-Narrative
Other-Narrative
Other-Narrative
Other-Narrative
Other-Narrative
Other-Coverage Calculator
Other-Coverage Calculator
Other-AIAN Limited Cost Sharing
Other-AIAN Limited Cost Sharing
Other-AIAN Zero Cost Sharing
Other-AIAN Zero Cost Sharing
Other-Crosswalk of Changes
Other-Crosswalk of Changes
Instruction
Instruction
Other-List of Anchors
Other-List of Anchors
Other-Sample Completed- SBC Accessib
Other-Sample Completed- SBC Accessib
Other-Sample Completed- SBC Standard
Other-Sample Completed- SBC Standard
Other-SBC Template Accessible Format
Other-SBC Template Accessible Format
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
Other-SBC template-Nov 2019 sbc-template-new.docx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Fillable Fileable
Instruction sbc-instructions-for-completing-the-group-health-plan-coverage-new.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-SBC Sample Glossary sbc-uniform-glossary-of-coverage-and-medical-terms-new.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-SBC Yes Answers -- Why This Matters sbc-why-this-matters-language-for-yes-answers-new.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-SBC - No Answers - Why This Matters sbc-why-this-matters-language-for-no-answers-new.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Template Having-a-Baby-Guide-11-2019.xlsx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Template Managing-Type-2-Diabetes-Guide-11-2019.xlsx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Template Simple-Fracture-Guide-11-2019.xlsx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Instruction Coverage-Examples-Calculator-Instructions-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Narrative Maternity-Care-Narrative-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Narrative Diabetes-Narrative-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Narrative Foot-Fracture-Narrative-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Coverage Calculator SBC-Coverage-Examples-Calculator-Excel-11-2019.xlsm https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Fillable Printable
Other-AIAN Limited Cost Sharing AIAN Limited Cost Sharing-11-2019-v2.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-AIAN Zero Cost Sharing AIAN-Zero-Cost-Sharing-11-2019-v2.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Crosswalk of Changes Crosswalk-of-changes-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Instruction Individual-Instructions-11-2019.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-List of Anchors List-of-Anchors-Updated-11-2019.xlsx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Sample Completed- SBC Accessible Format Sample-Completed-SBC-Accessible-Format-11-2019-v2.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-Sample Completed- SBC Standard Format Sample-Completed-SBC-Standard-Format-11-2019-v2.docx https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only
Other-SBC Template Accessible Format SBC-Template-Accessible-Format-11-2019-v2.pdf https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits Yes No Printable Only

Health Consumer Health and Safety

 

2,007,766 1,746,756
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   58 %

  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 77,096,540 0 0 7,131,896 0 69,964,644
Annual IC Time Burden (Hours) 294,846 0 0 -15,845 0 310,691
Annual IC Cost Burden (Dollars) 6,672,534 0 0 481,235 0 6,191,299

Title Document Date Uploaded
Sample Completed SBC Sample-Completed-SBC-Standard-Format-11-2019-v2.docx 12/10/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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