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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-April 2017
SBC Template April 2017.doc
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Fileable
Instruction
Group Instructions April 2017.docx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-SBC Sample Glossary
UG April 2017.doc
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-SBC Yes Answers -- Why This Matters
Yes Answers April 2017.doc
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-SBC - No Answers - Why This Matters
No Answers April 2017.doc
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Template
Having a baby April 2017.xlsx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Template
Managing Type 2 Diabetes April 2017.xlsx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Template
Simple fracture April 2017.xlsx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Instruction
Coverage_examples_calculator instructions April 2017.docx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Narrative
Coverage-Examples-narrative- maternity April 2017.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Narrative
Coverage-Examples-narrative diabetes April 2017.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Narrative
Coverage-Examples-narrative-foot-fracture April 2017.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-SBC template- 2012
SBC Blank Template - 2012.doc
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Fileable
Instruction
SBCInstructionsGroup - 2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-SBC Yes Answers--Why This Matters
SBCYesAnswers - 2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-No Answers- Why This Matters
SBCNoAnswers - 2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Template
maternity-scenario-2012.xlsx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Printable
Other-Template
diabetes-scenario-2012.xlsx
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Printable
Other-Narrative
maternity-narrative-2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Narrative
diabetes-narrative-2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Instruction
sbc-cover-ex-calc-instructions- 2012.pdf
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Printable Only
Other-Coverage Calculator
sbc-coverage-calculator-2012.xlsm
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Printable
Other-Coverage Calculator
Coverage_examples_calculator April 2017.xlsm
http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html
Yes
No
Fillable Printable
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:
2,299,742
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:
38 %
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
68,686,125
0
0
8,038,784
0
60,647,341
Annual IC Time Burden (Hours)
414,335
0
0
42,471
0
371,864
Annual IC Cost Burden (Dollars)
8,478,862
0
0
991,078
0
7,487,784
Documents for IC
Title
Document
Date Uploaded
Sample Completed SBC
SBC Sample CompletedApril 2017.doc
04/04/2016
Sample Completed SBC
SBC Completed Template - 2012.doc
04/04/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.