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View Information Collection (IC)

Summary of Benefits and Coverage
 
No Modified
 
Mandatory
 
29 CFR 2590.715-2715

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-SBC Template English_SBC-Template-Accessible-Format CLEAN.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 sbc-instructions-for-completing-the-group-health-plan-coverage-new.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 sbc-uniform-glossary-of-coverage-and-medical-terms-new.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 sbc-why-this-matters-language-for-yes-answers-new.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 sbc-why-this-matters-language-for-no-answers-new.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-v2.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-v2.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-SBC Template (Completed) English_Sample-Completed-SBC-Accessible-Format CLEAN.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

Health Consumer Health and Safety

 

2,506,660 2,199,660
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   58 %

  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 74,798,145 0 0 -2,298,395 0 77,096,540
Annual IC Time Burden (Hours) 285,938 0 0 -8,908 0 294,846
Annual IC Cost Burden (Dollars) 6,467,977 0 0 -204,557 0 6,672,534

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.