Information Collection

SBC Disclosure

IC 199007 under ICR 202210-0938-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Maternity-Care-Narrative-05-05-22.pdf	Other-Maternity Care Narrative
Maternity-Care-Narrative-05-05-22.pdf	Other-Maternity Care Narrative
SBC_Diabetes-Narrative-051222 508.pdf	Other-Diabetes 2 Narrative
SBC_Diabetes-Narrative-051222 508.pdf	Other-Diabetes 2 Narrative
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary Anchor
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary Anchor
Why This Matters language for SBC_No-Answers-English-051222 508.pdf	Other-What the Plan Covers and What
Why This Matters language for SBC_No-Answers-English-051222 508.pdf	Other-What the Plan Covers and What
Why This Matters language for SBC_Yes-Answers-English-051222 508.pdf	Other-Why This Matters for SBC (Yes
Why This Matters language for SBC_Yes-Answers-English-051222 508.pdf	Other-Why This Matters for SBC (Yes
Group-Instructions-051222 508.pdf	Instruction
Group-Instructions-051222 508.pdf	Instruction
Individual-Instructions-051222 508.pdf	Instruction
Individual-Instructions-051222 508.pdf	Instruction
Sample-Completed-SBC-Accessible-Format 051222.pdf	Other-Completed SBC Template
Sample-Completed-SBC-Accessible-Format 051222.pdf	Other-Completed SBC Template
Sample-Completed-SBC-Accessible-Format 051222.pdf	Other-SBC Template
Sample-Completed-SBC-Accessible-Format 051222.pdf	Other-SBC Template
Foot-Fracture-Narrative-051222 508.pdf	Other-Foot Fracture Narrative
Foot-Fracture-Narrative-051222 508.pdf	Other-Foot Fracture Narrative
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Instruction
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Instruction
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Other-Coverage Calculator
Coverage-Examples-Calculator-Instructions-051222 508.pdf	Other-Coverage Calculator
Having-a-Baby-Guide-051222 508.pdf	Other-Template
Having-a-Baby-Guide-051222 508.pdf	Other-Template
Managing-Type-2-Diabetes-Guide-051222 508.pdf	Other-Diabetes Guide
Managing-Type-2-Diabetes-Guide-051222 508.pdf	Other-Diabetes Guide
Uniform-Glossary-051222 508.pdf	Other-Glossary Anchor
Uniform-Glossary-051222 508.pdf	Other-Glossary Anchor
Simple-Fracture-Guide-051222 508.pdf	Other-Template
Simple-Fracture-Guide-051222 508.pdf	Other-Template
AIAN Limited Cost Sharing.pdf	Instruction
AIAN Limited Cost Sharing.pdf	Instruction
AIAN_Zero_Cost_Sharing.pdf	Instruction
AIAN_Zero_Cost_Sharing.pdf	Instruction
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary
Uniform-Glossary-051222 508.pdf	Other-Uniform Glossary
CMS-10407 SBC Template SBC-Template-Accessible-Format.pdf	Form

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
Other-Maternity Care Narrative			Maternity-Care-Narrative-05-05-22.pdf	Yes	No	Printable Only
Other-Diabetes 2 Narrative			SBC_Diabetes-Narrative-051222 508.pdf	Yes	No	Printable Only
Other-Uniform Glossary Anchor			Uniform-Glossary-051222 508.pdf	Yes	No	Printable Only
Other-What the Plan Covers and What You Pay (No Answers)			Why This Matters language for SBC_No-Answers-English-051222 508.pdf	Yes	No	Printable Only
Other-Why This Matters for SBC (Yes Answers)			Why This Matters language for SBC_Yes-Answers-English-051222 508.pdf	Yes	No	Printable Only
Instruction			Group-Instructions-051222 508.pdf	Yes	No	Printable Only
Instruction			Individual-Instructions-051222 508.pdf	Yes	No	Printable Only
Other-Completed SBC Template			Sample-Completed-SBC-Accessible-Format 051222.pdf	Yes	No	Fillable Fileable
Other-SBC Template			Sample-Completed-SBC-Accessible-Format 051222.pdf	Yes	No	Fillable Fileable
Other-Foot Fracture Narrative			Foot-Fracture-Narrative-051222 508.pdf	Yes	No	Printable Only
Instruction			Coverage-Examples-Calculator-Instructions-051222 508.pdf	Yes	No	Printable Only
Other-Coverage Calculator			Coverage-Examples-Calculator-Instructions-051222 508.pdf	Yes	No	Fillable Printable
Other-Template			Having-a-Baby-Guide-051222 508.pdf	Yes	No	Printable Only
Other-Diabetes Guide			Managing-Type-2-Diabetes-Guide-051222 508.pdf	Yes	No	Printable Only
Other-Glossary Anchor			Uniform-Glossary-051222 508.pdf	Yes	No	Printable Only
Other-Template			Simple-Fracture-Guide-051222 508.pdf	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-Uniform Glossary			Uniform-Glossary-051222 508.pdf	Yes	No	Printable Only
Form	CMS-10407	SBC Template	SBC-Template-Accessible-Format.pdf	Yes	Yes	Fillable Fileable

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: 679

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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24,211,211	-17,593,417	41,804,628
Annual IC Time Burden (Hours)	203,564	-11,227	214,791
Annual IC Cost Burden (Dollars)	10,494,154	6,313,691	4,180,463

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.