Summary of Benefits and Coverage

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/ Expiration date: 5/31/2022)(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)
	Welcome to the Coverage Examples Cost Sharing Calculator
	All insurer data entry fields are highlighted in orange.
	The Cost Sharing Calculator operates in two modes.
	Click the button that corresponds to the mode you want to use.
			The user enters data for an individual plan and views the results.
			The user loads data for multiple plans and runs the calculator.
			The user can then browse the results for the individual plans, save
			the results to an external file, or copy and paste the results for
			the individual plans to a separate worksheet.
	PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1146  (Expires 10/31/2022).  The time required to complete this information collection is estimated to average [0.08] hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.