Benefits Checklist
 

 

You can use this checklist to create an overall picture of your network of benefits. When you review them, you may identify additional services that you need. At the end of this section is a list of resources that can help you in obtaining those services.

Download the Benefits Checklist (2 pages).

 
 


Benefits Checklist
Medical Care and Services
I receive medical care from: ____________________________________________
My primary care physician is: __________________________________________
I get my laboratory test and blood work done at: ____________________________
Other medical services that I need include: _________________________________
___________________________________________________________________
___________________________________________________________________
Medical Insurance Coverage

What medical insurance coverage do you have?

Medicare

 _____

Private

 _____

Medicaid

 _____

Other

 _____

Do you have additional coverage for medical expenses not covered by your primary policy?


How much do you pay for:

Monthly premiums
Annual deductible
Co-payment

 $__________
$__________
$__________
List the services that are covered:
List the services that are not covered:

Page 1 of 2

 
Do you receive assistance to pay for deductibles, co-pays, and monthly insurance premiums?

_____

 Yes

_____

 No

If yes, what are the income eligibility requirements of that assistance?
HIV/AIDS Medications

Where do you get your medications?


How are they paid for?


Do you have limited or no drug benefit under your insurance policy(ies)?

_____

 Yes

_____

 No

If yes, are you enrolled in an AIDS Drug Assistance Program?

_____

 Yes

_____

 No

What is the income eligibility requirement of that program?
Housing Assistance

Are you currently receiving housing or rental assistance?

_____

 Yes

_____

 No

If yes, how much assistance do you receive each month?





What is the income eligibility requirement of that program?





Are you receiving any other supportive services? If yes, describe:

Page 2 of 2

Return to Top

  

























 
 


Benefits Analysis Worksheet
 

 

This worksheet is designed to help you analyze the impact of work on your benefits. Download the Benefits Analysis Worksheet.
  First
Record your current income and expected future income level.
  Second
In the first column list the assistance programs for which you are eligible at your current income level, e.g., AIDS Drug Assistance program, housing assistance, childcare, food bank, and others.
  Third
In the second column list all of the programs for which you would qualify at your expected future income level.
  Fourth
Review the two columns and examine the differences.

Questions to ask yourself:

What changes and what stays the same?
What impact might those changes have on your life?
What concerns or fears come up?
What possibilities and options do you see?
Do you need more information before deciding whether or not to increase your income?

 
             
 
Income Level

  


Current

  


Future

  
 
 
 
 
 
 
 
  Program:
Description of Benefit:
Assistance Received:
Eligibility Requirement:

  

 $
  

 $
  
     
 
 
  Program:
Description of Benefit:
Assistance Received:
Eligibility Requirement:

  

 $
  

 $
  
     
 
 
  Program:
Description of Benefit:
Assistance Received:
Eligibility Requirement:

  

 $
  

 $
  
     
 
 
  Program:
Description of Benefit:
Assistance Received:
Eligibility Requirement:

  

 $
  

 $
  
     
 
 
  Program:
Description of Benefit:
Assistance Received:
Eligibility Requirement:

  

 $
  

 $
  
             

Return to Top