Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 202501-1210-003 · OMB 1210-0147.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0147 can be found here:

2025-04-30 - Extension without change of a currently approved collection

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Summary of Benefits and Coverage

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2715

Information Collection Instruments:

table that charts list of instruments
Document Type	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SBC Template	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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	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 (Completed)	https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/summary-of-benefits	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,007,766

Number of Respondents for Small Entity: 1,746,756

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 58 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	77,096,540	77,096,540
Annual IC Time Burden (Hours)	294,846	294,846
Annual IC Cost Burden (Dollars)	6,672,534	6,672,534

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.

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