Benefits Summary & Analysis Planning Sheet
Beneficiary Name:
Date:
Summary of Current Benefits Situation
List of Social Security and other benefits received that need to beaddressed in the BS&A. (Focus on benefits that could be affected by work and earnings. For each benefit, note any issues identified during the verification process that need to be addressed in theBS&A.)
•List of benefitsverified:
•List of benefits needingverification:
Summary of CurrentEmployment/ Future EmploymentPlans
Current employment situation:
•JobTitle:
•#hours/week:
•Startdate:
•Rate ofpay:
•Any future employment plans and earnings goalsidentified:
Analysis of How Employment May Affect YourBenefits
List of Title II disability work incentives and potential impacts toaddress in BS&A based on current employment and earnings situation or future employmentplans:
List of SSI work incentives and potential impacts to address in BS&A based on current employment and earnings situation or future employmentplans:
List of health insurance components that may be affected bycurrent employment and earnings situation or future employmentplans:
•Medicaid (include all categories of coverage suchas Medically Needy, HCBS Waiver, or MedicaidBuy-in)
•Medicare (include Medicare Savings Programand Part D low-income subsidy ifapplicable)
•Other health insurance options, if applicable, such as TRICARE, VA, or employerplans
List of other federal, state or local benefits (SNAP, HUD, rental subsidies, etc…) and potential impacts / associated work incentives to address for each based on current employment and earnings situation or future employment plans.
Updated January 2017
Employment Services andSupports
List of employment services currentreceiving:
List of employment services and/or supports the beneficiary couldbenefit from:
BenefitsIssues
List any additional benefit issues that need to beaddressed.
•Issues related to Title II disability benefit (i.e., potential eligibility on another work record,conversion to retirement, overpayment issues,etc.)
•Issues related to SSI benefit (i.e., in-kind support and maintenance, excess resources, deeming, marriage,etc.)
Issues Requiring ImmediateAction
List all issues requiring immediate action to address inBS&A.
List any materials to include that would provide additional information (i.e., SSI calculation sheets, TWP/EPE tracking chart, fact sheets,etc.)
Updated January 2017