Information Collection

Summary of Benefits and Coverage

IC 198888 under ICR 202503-1210-005 · OMB 1210-0147.

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: 2,506,660

Number of Respondents for Small Entity: 2,199,660

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	74,798,145	-2,298,395	77,096,540
Annual IC Time Burden (Hours)	285,938	-8,908	294,846
Annual IC Cost Burden (Dollars)	6,467,977	-204,557	6,672,534

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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