Completing the Benefits Summary and Analysis Planning Sheet

January 2016

Summary of Current BenefitsSituation

In the BS&A, address the beneficiary’s Social Security and otherbenefits. Focus on benefits that work and earnings could affect. For each benefit, note in the BS&A any issues you identified during the verification process that you’ll need toaddress.

•List of benefitsverified:

•List of benefits needingverification:

Tips forCWICs:

•In this section, list all publicly funded cash benefits the beneficiary, family members, or both receive; healthcare benefits; and any other federal, state, or localbenefits.

•For benefits you’ve already verified, note any issues thatneed to be resolved. For example, for Title II and SSI benefits, list any information from the BPQY related to employment that appears to be incorrect, such as undeveloped earnings or unidentified work incentive usage. For benefits still needing verification, indicate the source you’ll use toverify.

How Employment May Affect Your Benefits

List of Title II disability work incentives and potential impacts to addressin the BS&A, based on current employment and earnings situation or future employmentplans:

Tips for CWICs: In this section, list the Title II work incentives that apply to the beneficiary, as well as key points to address in theBS&A on how the current earnings or earnings goal impacts the Title II benefit.

List of SSI work incentives and potential impacts to address in the BS&A based on current employment and earnings situation or futureemployment plans:

Tips for CWICs: In this section, list the SSI work incentives that apply to the beneficiary, as well as key points to address in theBS&A on how the current earnings or earnings goal impact the SSIbenefit.

List of health insurance components that current employment andearnings situation or future employment plans mayaffect:

•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, ifapplicable
(e.g., TRICARE, VA, or employerplans)

List of other federal, state, or local benefits (SNAP, HUD, rental subsidies, etc.) and potential impacts and associated work incentives toaddress

for each, based on current employment and earnings situation or future employmentplans:

Tips for CWICs: In this section, for each benefit identified, list all discussion points and work incentives related to the impact of the current earnings or earnings goal. Examples include earned income disregards and time limits related to SNAP, HUD programs, TANF, impact to Worker’s Compensation or Veterans benefits,etc.

Employment Services and Supports

List of employment services the beneficiary is currentlyreceiving:

List of additional employment services, supports, or both that could benefit the beneficiary:

Tips for CWICs: List any appropriate referrals to other agenciessuch as ENs/VR, American Job Center services, transportation providers, assistive technology services, child care providers, and any other service or support provider that may help the beneficiary meet his or her employmentgoal.

Benefits Issues

List any additional benefit issues you’ll need toaddress:

•Issues related to Title II disability benefit (e.g., potential eligibility on another work record,conversion to retirement, overpayment issues,etc.)

•Issues related to SSI benefit (e.g., in-kind support and maintenance, excess resources, deeming, marriage,etc.)

Issues Requiring Immediate Action

List all issues requiring immediate action you’ll need toaddress:

Tips for CWICs: Highlight steps or actions the beneficiary or representative should address immediately or within a short periodof time.

Attachments

List any materials that provide additional information (e.g., SSI calculation sheets, TWP/EPE tracking chart, fact sheets,etc.):

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Additional Guidance on Attachments to Include

•Include companion documents to support your analysis. SSI Calculation Sheets and TWP/EPE Tracking Charts are an essential part of the BS&A. For example, you should create an SSI Calculation Sheet for each possible scenario in a BS&A for an SSI-only or concurrent beneficiary. In addition to the narrative that explains how income is treated in the SSI program, include a separate calculation sheet to illustrate each of thefollowing:

•How unearned income reduces the SSIpayment

•How earned income affects the SSIpayment, including the earned incomeexclusion

•How each additional deduction applies to theSSI formula (SEIE, IRWE, BWE, andPASS

•How in-kind support reduces the SSIpayment

When you develop the BS&A, refer to Module 3 for calculation examples. You can find a blank copy of the SSI Calculation Sheet at the end of Module 3, Unit 6 and on the VCU-NTDC website. The beneficiary may wanttosee a comparison of different wage amounts before deciding on a level of work. Lay out the calculations side by side to provide a visual aide for the beneficiary.

When a Title II beneficiary goes to work, the CWIC will analyze his or her status with regard to the Trial Work Period, the Extended Period of Eligibility, whether Cessation has or will likely occur, Expedited Reinstatement, and continuation of Medicare coverage. The TWP/EPE tracking chart shows progression of these work incentives phases, so the beneficiary will know when to expect changes in his or her benefits.

•If a beneficiary is considering a range of earnings, youmight attach to his or her BS&A a separate document that contains a table with various options outlined. An example isbelow:

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Monthly Earnings / TWP
Impact / EPE
Impact / SGA? / Medicare
$688.00
(20 hours per week at $8.00 perhour) / NoTWP
months
will beused / Won't triggerEPE / Notrelevant / Medicare continues aslongasreceiving
check; EPMC not started until SGA is performed
$1100.80
(32 hours per week at $8.00 perhour) / Willcontinueto use TWP months / EPE will begin after 9 months of work at this level / LikelySGAunless IRWE or subsidy apply, cessation and grace likely to occur, three more monthsof
checks, then payments ceased / Medicare continues for at least 93 months afterTWP
$1376.00
(40 hours per week at $8.00 perhour) / Willcontinueto use TWP months / EPEwillbegin after 9 months
of work at this
level / Likely SGA unless IRWE or subsidy apply, cessation and grace likely to occur, three more months of checks,thenpayments ceased / Medicare continues for at least 93 months afterTWP

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