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Agenda
Reg Review
ICR
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-SBC template-Nov 2019
SBC-Template-Standard-Format-11-2019.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
Group-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-SBC Sample Glossary
Uniform-Glossary-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-SBC Yes Answers -- Why This Matters
Why-this-Matters-for-SBC-Yes-Answers-English-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-SBC - No Answers - Why This Matters
Why-this-Matters-for-SBC-No-Answers-English-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-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.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.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.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.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.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
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:
2,327,850
Number of Respondents for Small Entity:
2,158,601
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
56 %
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
69,964,644
0
0
0
0
69,964,644
Annual IC Time Burden (Hours)
310,691
0
0
0
0
310,691
Annual IC Cost Burden (Dollars)
6,191,299
0
0
0
0
6,191,299
Documents for IC
Title
Document
Date Uploaded
Sample Completed SBC
Sample-Completed-SBC-Standard-Format-11-2019.docx
11/08/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.