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
Other-SBC Template - Carolinian
Other-Uniform Glossary - Carolinian
Other-Why This Matters NO Answers -
Other-Why This Matters - Yes Answers
Other-SBC Template - Chamorro
Other-Uniform glossary - Chamorro
Other-Why This Matters No Answers -
Other-Why This Matters YES Answers -
Other-SBC Template - Chinese
Other-Uniform Glossary - Chinese
Other-Why This Matters NO Answers -
Other-Why This Matters Yes Answers -
Other-SBC Template - Pennsylvania Du
Other-Uniform Glossary - Pennsylvani
Other-Why This Matters No Answers -
Other-Why This Matters YES Answers -
Other-SBC Template - Samoan
Other-Uniform Glossary - Samoan
Other-Why This Matters No Answers -
Other-Why This Matters Yes Answers
Other-SBC Template - Spanish
Other-Uniform Glossary - Spanish
Other-Why This Matters No Answers -
Other-Why This Matters Yes Answers -
Other-Why This Matters Yes Answers -
Other-SBC Template - Tagalog
Other-Uniform Glossary - Tagalog
Other-Why This Matters No Answers -
Other-Why This Matters Yes Answers -
Other-SBC Template Standard Format -
Other-Why This Matters NO Answers -
Other-Why This Matters YES Answers -
Other-Uniform Glossary - Navajo
Form
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-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) English_Why This Matters NO Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters for SBC (Yes Answers) English_Why This Matters YES Answers_Final_11.01.24 (clean).docx 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 English_Sample_Completed_SBC_Final_01.28.25 (clean).docx Yes No Fillable Fileable
Other-SBC Template English_Sample-Completed-SBC-Accessible-Format_Final_11.01.24 (clean).docx 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 English_AIAN-Limited-Cost-Sharing_Final_01.28.25 (clean).docx Yes No Printable Only
Instruction English_AIAN-Zero-Cost-Sharing_Final_01.28.25 (clean).docx Yes No Printable Only
Other-Uniform Glossary English_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Form CMS-10407 SBC Template SBC-Template-Accessible-Format.pdf Yes Yes Fillable Fileable
Other-SBC Template - Carolinian Carolinian_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Carolinian Carolinian_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters NO Answers - Carolinian Carolinian_Why this Matters NO Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters - Yes Answers - Carolinian Carolinian_Why this Matters YES Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Chamorro Chamorro_SBC-Template-Standard-Format_Final_01.28.25 (clean).docx Yes No Printable Only
Other-Uniform glossary - Chamorro Chamorro_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters No Answers - Chamorro Chamorro_Why this Matters NO Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters YES Answers - Chamorro Chamorro_Why this Matters YES Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Chinese Chinese_SBC-Template-Standard-Format_01.28.25 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Chinese Chinese_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters NO Answers - Chinese Chinese_Why This Matters No Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters Yes Answers - Chinese Chinese_Why This Matters Yes Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Pennsylvania Dutch Pennsylvania Dutch_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Pennsylvania Dutch Pennsylvania Dutch_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters No Answers - Pennsylvania Dutch Pennsylvania Dutch_Why this Matters NO Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters YES Answers - Pennsylvania Dutch Pennsylvania Dutch_Why this Matters YES Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Samoan Samoan_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Samoan Samoan_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters No Answers - Samoan Samoan_Why this Matters NO Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters Yes Answers Samoan_Why this Matters YES Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Spanish Spanish_SBC-Template-Standard-Format__Final_11.01.24 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Spanish Spanish_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters No Answers - Spanish Spanish_Why This Matters No Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters Yes Answers - Spanish Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters Yes Answers - Spanish Spanish_Why This Matters Yes Answers__Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template - Tagalog Tagalog_SBC-Template-Standard-Format_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Uniform Glossary - Tagalog Tagalog_Uniform Glossary_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters No Answers - Tagalog Tagalog_Why This Matters No Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-Why This Matters Yes Answers - Tagalog Tagalog_Why This Matters Yes Answers_Final_11.01.24 (clean).docx Yes No Printable Only
Other-SBC Template Standard Format - Navajo Navajo_SBC-Template-Standard-Format_Final_01.07.25 (clean).docx Yes No Printable Only
Other-Why This Matters NO Answers - Navajo Navajo_Why This Matters NO Answers_Final_01.07.25.docx Yes No Printable Only
Other-Why This Matters YES Answers - Navajo Navajo_Why This Matters YES Answers_Final_01.07.25.docx Yes No Fillable Fileable
Other-Uniform Glossary - Navajo Navajo_Uniform Glossary_formatted_Final_01.07.25.docx Yes No Printable Only

Health Health Care Services

 

679 35
   
Private Sector Businesses or other for-profits
 
   70 %

  Requested 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 24,211,211 0 0 0 0 24,211,211
Annual IC Time Burden (Hours) 203,564 0 0 0 0 203,564
Annual IC Cost Burden (Dollars) 10,494,154 0 0 0 0 10,494,154

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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