by Thomas Day

About Long Term Care
How Many Veterans Need Long Term Care?
About State Veterans Homes
Challenges Facing the Construction of New Veterans Homes
Services Available in State Veterans Homes
Eligibility and Application Requirements for State Veterans Homes
What is Veterans Health Care?
Veterans Health Administration Long Term Care Benefits
Veterans Health Copays
About Compensation, Pension (Aid and Attendance Benefit) and the HISA Grant
Questions about Compensation and Pension (Aid and Attendance Benefit) Claims
Charging a Fee for Filing a Claim

 

About Long Term Care

When a person requires someone else to help him with his physical or emotional needs over an extended period of time, this is long term care. This help may be required for many of the activities or needs that healthy, active people take for granted and may include such things as:

• Walking
• Bathing
• Dressing
• Using the bathroom
• Helping with incontinence
• Managing pain
• Preventing unsafe behavior
• Preventing wandering
• Providing comfort and assurance
• Providing physical or occupational therapy
• Attending to medical needs
• Counseling
• Feeding
• Answering the phone
• Meeting doctors' appointments
• Providing meals
• Maintaining the household
• Shopping and running errands
• Providing transportation
• Administering medications
• Managing money and paying bills
• Doing the laundry
• Attending to personal hygiene
• Helping with personal grooming
• Writing letters or notes
• Making repairs to the home
• Maintaining a yard
• Removing snow

The need for long term care help might be due to a terminal condition, disability, illness, injury or the infirmity of old age. Estimates by experts are that at least 60% of all individuals will need extended help in one or more of the areas above during their lifetime. The need for long term care may only last for a few weeks or months, or it may go on for years. It all depends on the underlying reasons for needing care.

Temporary long term care (need for care for only weeks or months)

• Rehabilitation from a hospital stay
• Recovery from illness
• Recovery from injury
• Recovery from surgery
• Terminal medical condition

Ongoing long term care (need for care for many months or years)

• Chronic medical conditions
• Chronic severe pain
• Permanent disabilities
• Dementia
• Ongoing need for help with activities of daily living
• Need for supervision

Long term care services may be provided in any of the following settings:

• In the home of the recipient
• In the home of a family member or friend of the recipient 
• At an adult day services location
• In an assisted living facility or board-and-care home
• In a hospice facility
• In a nursing home

 

How Many Veterans Need Long Term Care?

VA estimates the number of veterans aged 75 and older has increased from about 2.6 million in 1995 to about 4.9 million in 2005. The older a person the more likely the need for long term care.

According to the Department of veteran affairs, there are currently about 3,500,000 male World War II veterans and about 164,000 female World War II veterans still alive. Since the war ended over 61 years ago, most of these veterans are going to be in their 80s or older. This is the time of life when people are most likely to need long term care. The Alzheimer's Association estimates about half of all 85-year-olds suffer from some form of dementia. Roughly half of all nursing home residents are age 85 and older and other government sources estimate that at least half or more of all people over age 85 need some sort of physical or emotional support from someone else.

Data from VA indicate about 466,000 of these World War II veterans were receiving payments from VA for service-connected disabilities (compensation) and non-service-connected disabilities (pension) in 2005. Based on the incidence of long term care need for this veterans group, those beneficiaries receiving payment probably represent only about 30% of veterans who may be eligible for disability payments from VA but who have never applied or are probably not even aware of what is available. This estimate does not even include Korean Conflict veterans or Vietnam Era veterans who may also be in need of long term care support.

The National Care Planning Council estimates approximately 22% of the U.S. population over age 65 is receiving some sort of long term care help. Applying this estimate to the 9,348,000 veterans over the age of 65 from the chart below, this means that at least 2 million veterans may be receiving long term care help from family members or formal caregivers. A limited number of these veterans may be receiving financial help from Veterans Affairs, but the majority is probably not even aware of VA programs that could help pay the cost of long term care.

About State Veterans Homes

State veterans homes fill an important need for veterans with low income and veterans who desire to spend their last years with "comrades" from former active duty. The predominant service offered is nursing home care. VA nursing homes must be licensed for their particular state and conform with skilled or intermediate nursing services offered in private sector nursing homes in that state. State homes may also offer assisted living or domiciliary care, which is a form of supported independent living.

Every state has at least one veterans home and some states like Oklahoma have six or seven of them. There is great demand for the services of these homes, but lack of federal and state funding has created a backlog of well over 130 homes that are waiting to be built. This problem will be discussed in the section entitled "Challenges Facing the Construction of New Homes".

Unlike private sector nursing homes where the family can walk in the front door and possibly that same day make arrangements for a bed for their loved one, state veterans homes have an application process that could take a number of weeks or months. Many state homes have waiting lists especially for their Alzheimer's long term care units.

No facilities are entirely free to any veteran with an income. The veteran must pay his or her share of the cost. In some states the veterans contribution rates are set, and if there is not enough income the family may have to make up the difference.

 

Challenges Facing the Construction of New Veterans Homes

The State Veterans Home Program is a partnership between the U.S. Department of Veterans Affairs and the States to construct or acquire nursing home, domiciliary, or adult day health care facilities. A state nursing home, domiciliary, or adult day care is owned and operated by the State.

The Veterans Administration may participate in up to 65 percent of the cost of construction or acquisition of state nursing homes or domiciliaries or for renovations to existing state homes.

Over the last five years, VA has awarded over $424 million in grants to the States for construction of or renovations to state veteran’s homes. That is 34 percent of all grants awarded since 1964.

The Veterans Administration Secretary approved the 2005 Priority List on September 23, 2004. The Priority List contained 131 projects from the various States and was valued at over $690 million. There were 81 projects, valued at $435 million, with the required 35% state matching funds -- meaning legislators have set aside the money -- and are eligible for an immediate VA grant awards. These are priority #1 grants and should be built as soon as possible. Unfortunately, there is not enough money to build these priority #1 grant facilities. The States were lucky to complete only 8 or 9 projects in 2005 nationwide instead of the 81 that were eligible.

The VA will commit to as many projects for which funds are available, but funding is woefully inadequate. The State Home Construction Grant Program 2005 budget was approved at $105 million. The President’s 2007 budget request is $85 million in grants for state construction programs. The 2007 budget proposal only represents about 12% of the projects on the priority list. At that amount, needed new facilities on the priority list may not be constructed until 10 or 20 years from now.

 

Services Available in State Veterans Homes

Some state facilities offer assisted living or domiciliary care in addition to nursing care. Some states even build facilities devoted entirely for domiciliary. According to the Veterans Administration the definition of domiciliary care is as follows: "To provide the least intensive level of VA inpatient care for ambulatory veterans disabled by age or illness who are not in need of more acute hospitalization and who do not need the skilled nursing services provided in nursing homes. To rehabilitate the veteran in anticipation of his/her return to the community in a self-sustaining and independent or semi-independent living situation, or to assist the veteran to reach his/her optimal level of functioning in a protective environment."

A domiciliary is a living arrangement similar to assisted living without substantial assistance but is not intended as a permanent residence. Domiciliary rooms in veterans medical centers are designed around this concept and are used for rehabilitation recovery from surgery or accident, alcohol abuse, drug abuse, mental illness, or depression.

The domiciliary concept does not work well in a state veterans home setting and in that context domiciliary is simply another name for assisted living without the assistance. This represents a form of independent retirement living with a little more support where the veteran can stay as long as he or she needs to. As far as state veterans homes go, one should think of domiciliary as a substitute for supported independent retirement living.

Many state veterans facilities have set aside a wing for Alzheimer's patients. In some states this is the most popular service sought by veterans or their families, and waiting lists could require a number of years before a bed opens up. A small number of facilities offer adult day care.

It appears that in most of the states, facilities are run by state employees through their state veterans departments. Some states may contract with third party nursing home administrators to run their programs.

 

Eligibility and Application Requirements for State Veterans Homes

From state to state, facilities vary in their rules for eligible veterans. Even in the same state it is common, where there is more than one state home, for some homes to have very stringent eligibility rules and others to be more lenient. These differing rules are probably based on the demand for care and the available beds in that particular geographic area.

Some homes require the veteran to be totally disabled and unable to earn an income. Some evaluate on the basis of medical need or age. Some evaluate entirely on income -- meaning applicants above a certain level will not be accepted. Some accept only former active duty veterans, while others accept all who were in the military whether active duty or reserve. Still others accept only veterans who served during a period of war. Some homes accept the spouses or surviving spouses of veterans and some will accept the parents of veterans but restrict that to the parents of veterans who died while in service (Goldstar parents).

Federal regulations allow that 25% of the bed occupants at any one time may be veteran related family members, i.e., spouses, surviving spouses, and/or gold star parents who are not entitled to payment of VA aid. When a state home accepts grant assistance for a construction project, 75% of the bed occupants at the facility must be veterans.

Domicile residency requirements vary from state to state. The most stringent seems to be a three-year prior residency in the state; whereas, other homes may only require 90 days of residency.

All states require an application process to get into a home. Typically, a committee or board will approve or disapprove each application. Many states have waiting lists for available beds.

 

What is Veterans Health Care?

• The Veterans Health Administration is the largest single provider of medical care in the United States. Its 22 regions with 154 hospitals and their associated 875 outpatient clinics offer the following services.
• Hospital, outpatient medical, dental, pharmacy and prosthetic services 
• Domiciliary, nursing home, and community-based residential care
• Sexual trauma counseling
• Specialized health care for women veterans
• Health and rehabilitation programs for homeless veterans
• Readjustment counseling
• Alcohol and drug dependency treatment
• Medical evaluation for disorders associated with military service in the Gulf War, or Treatment for exposure to Agent Orange, radiation, and other environmental hazards
• HISA grants
• Other special benefits

An example of one of VA's 22 regions is Region 19--geographically one of the largest in the system. Headquartered in Denver this region covers the states of Montana, Wyoming, Utah, Colorado and part of Nevada. Region 19 includes three health care system hospitals and three satellite hospitals. There are also 33 outpatient clinics in urban centers scattered throughout the five states and 7 Vet Centers in urban areas that provide special services for veterans who served in combat.

The six hospitals in Region 19 offer a wide range of medical specialties and procedures and it is unlikely that any patient would have to be referred to the private care community for any services not offered by these hospitals. But if specialized services are not offered in the region, VA hospitals, region to region, share responsibilities for very specialized treatment and patients needing these specialties not offered in their region are referred to other VA facilities that do offer the care.

Hospitals in the VA system are typically associated with a local medical college where feasible. By acting as teaching hospitals the VA system has access to some of the best doctors and cutting edge medical treatments. In region 19, the Denver Medical Center is affiliated with the medical school, pharmacy, and nursing schools of the University of Colorado Health Sciences Center. The Fort Harrison facility near Helena, Montana is affiliated with nursing schools, pharmacy schools, and physician-assistant schools in over 30 universities in the four adjoining states. The Salt Lake City Regional Medical Center is affiliated with the University of Utah Medical School which is located less than a mile away.

One of the disadvantages in the past of joining the health system was the difficulty of getting to a regional medical center for treatment. With the installation of outpatient clinics within easy driving distance for health care beneficiaries, this challenge has become less of a problem in the past few years. The challenge still remains that major hospitalization, surgery and other specialized treatment must be obtained at a regional hospital. In the case of region 19, this could involve driving distances up to 600 miles one way to obtain the appropriate care.

VA is accommodating to certain low income patients who must drive long distances, and the facilities offer, at no charge or reasonable charge, "hoptel" rooms in the hospital or nearby as an alternative to staying in a motel or hotel. Low income patients are also reimbursed at $.11 per mile for travel to the nearest VA health care facility that can provide their needed care.

Other services are also available to certain qualifying veterans who may receive dental care, vision care, and hearing aids. In addition, Vet Centers provide special counseling for active duty veterans who served in combat zones. VA is also the most experienced health care provider in the country in services for rehabilitating patients with missing limbs, with burn injuries, or with other complications due to combat injuries.

Regional VA hospitals often include associated nursing facilities or domiciliary rooms. They will also contract for home health care and hospice services if needed. For those hospitals that don't have nursing homes or domiciliary, contracts for these services are maintained with facilities in the local community.

Emergency Care in Non-VA facilities is provided as a safety net for veterans under specific conditions. If the non-VA emergency care is for a service-connected condition or if the veteran has been enrolled with health services at least 24 months and has no other health care coverage, then emergency care is covered. Also, it must be determined that VA health care facilities were not feasibly available, that a delay in medical attention would have endangered life or health, and that the veteran remains personally liable for the cost of the services in case of a dispute.

 

Veterans Health Administration Long Term Care Benefits

The following was taken from a Department of Veterans Affairs fact sheet dated January 2005 and distributed by the office of public affairs media relations;

VA Long-Term Care
The Department of Veterans Affairs (VA) offers a spectrum of geriatric and extended care services to veterans enrolled in its health care system. More than 90 percent of VA’s medical centers provide home- and community-based outpatient long-term care programs. This patient-focused approach supports the wishes of most patients to live at home in their own communities for as long as possible. In addition, nearly 65,000 veterans will receive inpatient long-term care this year through programs of VA or state veterans homes.

Non-Institutional Care
Veterans can receive home-based primary care, contract home health care, adult day health care, homemaker and home health aide services, home respite care, home hospice care and community residential care. In fiscal year 2003, 50 percent of VA’s total extended care patient population received care in non-institutional settings, including.

Home-Based Primary Care 
This program (formerly Hospital Based Home Care) began in 1970 and provides long-term primary medical care to chronically ill veterans in their own homes under the coordinated care of an interdisciplinary treatment team. This program has led to guidelines for medical education in home care, use of emerging technology in home care and improved care for veterans with dementia and their families who support them. In 2003, home-based primary care programs were located in 76 VA medical centers.

The Contract Home Health Care
Professional home care services, mostly nursing services, are purchased from private-sector providers at every VA medical center. The program is commonly called "fee basis" home care.

Adult Day Health Care (ADHC)
Adult Day Health Care programs provide health maintenance and rehabilitative services to veterans in a group setting during daytime hours. VA introduced this program in 1985. In 2004, VA operated 21 programs directly and provided contract ADHC services at 112 VA medical centers. Two state homes have received recognition from VA to provide ADHC, which has recently been authorized under the State Home Per Diem Program.

Homemaker and Home Health Aide (H/HHA)
VA began a program in 1993 of health-related services for service-connected veterans needing nursing home care. These services are provided in the community by public and private agencies under a system of case management provided directly by VA staff. VA purchased H/HHA services at 122 medical centers in 2004.

Community Residential Care
The community residential care program provides room, board, limited personal care and supervision to veterans who do not require hospital or nursing home care but are not able to live independently because of medical or psychiatric conditions, and who have no family to provide care. The veteran pays for the cost of this living arrangement. VA's contribution is limited to the cost of administration and clinical services, which include inspection of the home and periodic visits to the veteran by VA health care professionals. Medical care is provided to the veteran primarily on an outpatient basis at VA facilities. Primarily focused on psychiatric patients in the past, this program will be increasingly focused on older veterans with multiple chronic illnesses that can be managed in the home under proper care and supervision.

Respite Care
Respite care temporarily relieves the spouse or other caregiver from the burden of caring for a chronically ill or disabled veteran at home. In the past, respite care admission was limited to an institutional setting, typically a VA nursing home. The Veterans Millennium Health Care and Benefits Act expanded respite care to home and other community settings, and home respite care was provided at 15 VA medical centers in fiscal year 2003. Currently, respite care programs are operating in 136 VA medical centers, with each program typically providing care to approximately five veterans on any given day. Respite care is usually limited to 30 days per year.

Home Hospice Care
Home hospice care provides comfort-oriented and supportive services in the home for persons in the advanced stages of incurable disease. The goal is to achieve the best possible quality of life through relief of suffering, control of symptoms, and restoration or maintenance of functional capacity. Services are provided by an interdisciplinary team of health care providers and volunteers. Bereavement care is available to the family following the death of the patient. Hospice services are available 24 hours a day, seven days a week. VA provided home hospice care at 73 medical centers in fiscal year 2003, the first year the service was offered.

Domiciliary Care
Domiciliary care is a residential rehabilitation program that provides short-term rehabilitation and long-term health maintenance to veterans who require minimal medical care as they recover from medical, psychiatric or psychosocial problems. Most domiciliary patients return to the community after a period of rehabilitation.

Domiciliary care is provided by VA and state homes. VA currently operates 43 facilities. State homes operate 49 domiciliaries in 33 states. VA also provides a number of psychiatric residential rehabilitation programs, including ones for veterans coping with post-traumatic stress disorder and substance abuse, and compensated work therapy or transitional residences for homeless chronically mentally ill veterans and veterans recovering from substance abuse.

Telehealth
For most of VA's non-institutional care, telehealth communication technology can play a major role in coordinating veterans’ total care with the goal of maintaining independence. Telehealth offers the possibility of treating chronic illnesses cost-effectively while contributing to the patient satisfaction generally found with care available at home.

Geriatric Evaluation and Management (GEM)
Older veterans with multiple medical, functional or psychosocial problems and those with particular geriatric problems receive assessment and treatment from an interdisciplinary team of VA health professionals. GEM services can be found on inpatient units, in outpatient clinics and in geriatric primary care clinics. In 2004, there were 57 inpatient GEM programs and more than 195,000 visits to GEM and geriatric primary care clinics.

Geriatric Research, Education and Clinical Centers (GRECC)
These centers increase the basic knowledge of aging for health care providers and improve the quality of care through the development of improved models of clinical services. Each GRECC has an identified focus of research in the basic biomedical, clinical and health services areas, such as the geriatric evaluation and management program. Medical and associated health students and staff in geriatrics and gerontology are trained at these centers. Begun in 1975, there are now 21 GRECCs in all but two of VA’s health care networks.

Nursing Home Care
VA's nursing home programs include VA-operated nursing home care units, contract community nursing homes and state homes. VA contracts with approximately 2,500 community nursing homes. The state home program is growing and currently encompasses 114 nursing homes in 47 states and Puerto Rico. In fiscal year 2003, approximately 70 percent of VA’s institutional nursing home care occurred in contract community and state home nursing homes.

Nursing home care units are located at VA hospitals where they are supported by an array of clinical specialties. The community nursing home program has the advantage of being offered in many local communities where veterans can receive care near their homes and families. VA contracts for the care of veterans in community nursing homes approved by VA. The state home program is based on a joint cost-sharing agreement between VA, the veteran and the state.

According to the VA website the following are eligible for nursing home care;

• Any veteran who has a service-connected disability rating of 70 percent or more
• A veteran who is rated 60 percent service-connected and is unemployable or has an official rating of "permanent and total disabled"
• A veteran with combined disability ratings of 70 percent or more
• A veteran whose service-connected disability is clinically determined to require nursing home care 
• Nonservice-connected veterans and those officially referred to as "zero percent, noncompensable, service-connected" veterans who require nursing home care for any nonservice-connected disability and who meet income and asset criteria or
• If space and resources are available, other veterans on a case-by-case basis with priority given to service-connected veterans and those who need care for post-acute rehabilitation, respite, hospice, geriatric evaluation and management, or spinal cord injury

HISA Grants
A local Regional Medical Center can pay veterans a grant to allow for home improvement and structural authorizations -- HISA grants. These are necessary alterations in order to accommodate disability in the home. As a general rule these grants are typically provided to veterans who are receiving VA health care and who are service-connected disabled. Certain service-connected disabled veterans can receive a lifetime benefit of $4,200 for home improvement projects to aid with disability.

A clause in the eligibility statutes opens the door for veterans who are on Medicaid or receiving pension with aid and attendance or housebound ratings to also receive these grants. Also very low income -- means tested veterans -- may also receive the grant. For this class of veterans the grant is a lifetime payment of $1,200.

Although they are reluctant to provide these grants to veterans who are not in the health-care system, the medical center HISA committee will do so if adequate documentation is provided to justify the grant.

Millennium Act and VA’s Efforts to Increase Long-Term Care Capacity
Public Law 106-117, the Veterans Millennium Health Care and Benefits Act, enacted in November 1999, requires VA to provide extended care services in its facilities, including nursing home care, domiciliary, home-based primary care and adult day health care, with the goal of providing as much care as in 1998.

The budget for VA long-term care grew by more than $850 million between fiscal year 1998 and fiscal year 2003, and the number of full-time employees increased in nursing home care units and outpatient programs.

 

Veterans Health Copays

The most important thing to remember about copays is that a veteran receiving VA pension is classified a priority 5 veteran. Priority 5 veterans receive, for free, inpatient care, outpatient care, and long term care. They have no copayments for medical services. The priority 5 veteran must pay VA prescription drug copays unless that veteran has a household income below the current pension maximum income rate. Those pension incomes for 2007 are found in the second column of the table below. Also note that priority 5 veterans do not have to pay any more than $960 a year for their prescriptions from a VA pharmacy if they do have to pay for drugs.

Veterans Means Test for Copays (Low Income Financial Test ) -- Financial Test Year 2007

Veteran with	Free VA prescriptions and travel benefits (maximum allowable rate)	Free VA Health Care (0% service connected {noncompensable} and nonservice-connected veterans only)	Medical Expenses Deduction (5% of maximum annual pension rate from previous year)
0 dependents	$10,929 or less	$27,790 or less	$529
1 dependent	$14,313 or less	$33,350 or less	$693
2 dependents	$16,179 or less	$35,216 or less	$783
3 dependents	$18,045 or less	$37,082 or less	$873
4 dependents	$19,911 or less	$38,948 or less	$964
For each additional dependent add:	$1,866	$1,866	5% of maximum annual pension rate
Medicare Deductible: $992		Income & Asset net worth: $80,000

The GMT Income Threshold Test (geographic means test) could be higher or lower than VA's means test. To obtain GMT income thresholds per state for purposes of qualifying under an enrollment priority go to https://www.va.gov/healtheligibility/Library/pubs/GMTIncomeThresholds/

 

About Compensation, Pension (Aid and Attendance Benefit) and the HISA Grant

Compensation and pension

There are basically two disability income benefits available to veterans who served on active duty. The first of these is called compensation and is designed to award the veteran a certain amount of monthly income to compensate for potential loss of income in the private sector due to a disability or injury or illness incurred in the service. In order to receive compensation a veteran has to have evidence of a service-connected disability. Most veterans who are receiving this benefit were awarded an amount based on a percentage of disability when they left the service.

However, some veterans may have record of being exposed to extreme cold, having an inservice nondisabling injury, having tropical diseases or tuberculosis or other incidents or exposures that at the time may not have caused any disability but years later have resulted in medical problems. In addition, some veterans may be receiving compensation but their condition has worsened, and they could reapply and get a larger amount based on a higher disability rating. These people should apply to see if they can receive a benefit. There is generally no income or asset test for most forms of compensation, and the benefit is nontaxable.

The second benefit is called pension. It is available to all active-duty veterans who served at least 90 days during a period of war. To be eligible the applicant must be totally disabled or a patient in a nursing home if he or she is younger than 65. Veterans younger than 65 receiving Social Security have a lesser burden of proof. Proof of disability is not required for applicants age 65 or over. Apparently, being old is evidence in itself of disability. The purpose of this benefit is to provide supplemental income to disabled or older veterans who have a low income. If the veteran’s income exceeds the pension amount, then there is no award. However, income can be adjusted for unreimbursed medical expenses, and this allows veterans with household incomes larger than the pension amount to qualify for a monthly benefit.

Compensation and pension claims are submitted on the same form and VA will consider paying either benefit. Generally, for applications associated with the cost of home care, assisted living or nursing home care, the pension benefit is more money.

There are also several death benefit variations of the two incomes for single surviving spouses or dependent minor children or adult dependent children. We will not discuss the death benefits related to service-connected disability but instead will discuss in this chapter only the pension death benefit.

Death pension is a lesser amount based on the same rules for applying for a living pension claimant. In other words, the deceased veteran must have met the rules for pension -- with the exception of being totally disabled or over age 65 -- or have been receiving pension in order for his or her spouse to receive the lesser benefit. In addition, in order to keep receiving the benefit, the surviving spouse must remain single.

Asset tests and income tests also apply to a death pension, and, basically, all the rules are the same for obtaining the benefit as with the living veteran. Benefit levels are lower for a surviving spouse when compared to a single veteran. For example, a single veteran with no dependent children is entitled to an MAPR (maximum annual pension rate) of $10,929 without aid and attendance and $18,234 with aid and attendance. In comparison, a surviving spouse is entitled to an MAPR of $7,329 without aid and attendance and $11,715 with aid and attendance.

HISA Grants

A local Regional Medical Center can pay a veteran a grant to allow for "home improvement and structural alterations" -- HISA grants. These are necessary alterations in order to accommodate disability in the home. As a general rule these grants are typically provided to veterans who are receiving VA health care and who are service-connected disabled. Certain service-connected disabled veterans can receive a lifetime benefit of $4,200 for home improvement projects to aid with disability.

A clause in the eligibility statutes opens the door for veterans who are on Medicaid or receiving pension with aid and attendance or housebound ratings to also receive these grants. Also very low income -- means tested veterans -- may also receive the grant. For this class of veterans the grant is a lifetime payment of $1,200.

Although they are reluctant to provide these grants to veterans who are not in the VA health care system, the medical center HISA Committee will do so if adequate documentation is provided to justify the grant. 

 

Questions about Compensation and Pension (Aid and Attendance Benefit) Claims

Who can submit a claim?
A claim is submitted by the veteran or by the veteran’s single surviving spouse in the case of a death claim. A duly appointed service organization, an employee of the local regional VA office, or a VA approved agent may file a claim on behalf of the veteran or the spouse. A claim cannot be filed with a general or durable power of attorney. The application will be sent back requesting proper documentation for a VA power of attorney. The veteran must sign a document specifically authorizing a power of attorney for someone to submit an initial claim for him. Many chagrined children with a durable power of attorney have submitted claims on behalf of a parent only to have the claim rejected by VA.

What happens if the veteran is incompetent?
If the veteran cannot submit the original application or sign a power of attorney for a surrogate to file an application, then a duly appointed guardian can complete the application. VA also allows the spouse, a parent or next of kin, or a friend to complete and submit an application on behalf of an incompetent veteran if that person submits the proper power of attorney request and indicates the applicant could be considered incompetent for financial affairs. Even though the veteran or surviving spouse may be considered incompetent for financial affairs, he or she should always sign the power of attorney request if he or she is competent to do so. VA may appoint a fiduciary to take over the claim and the affairs for the claimant if VA determines he or she is incompetent.

How does VA handle power of attorney?
Employees of VA and veterans service organizations already have authorization for power of attorney to file an application on behalf of the veteran. They have forms for the veteran to sign to allow this to happen. An attorney representing the veteran in other affairs can also request a power of attorney in the proper format and on his or her letterhead. Any single individual may also submit a letter requesting power of attorney to submit an application if it is signed by the veteran and if the letter provides certain required information. There is also a VA form in the support packet that can be submitted for power of attorney. All attorney requests submitted for power of attorney must state that the veteran is not paying a fee to file the application on his or her behalf.

What is an "aid and attendance" or "housebound" rating?
A "rating" is granted by a veteran service representative where a condition exists that makes the disability more severe. Medical evidence is required unless someone is a patient in a nursing home, and then the requirement is waived. The rating allows VA to pay an additional monthly amount of pension or compensation to a veteran or a surviving spouse for additional costs associated with this disability.

How does one qualify for aid and attendance or housebound rating?
The application form has a block allowing for a request for either rating. Submitting medical evidence in advance instead of waiting for a request from VA can help expedite the process of getting this rating. We have provided in the support packet, a sample form that might be used for this purpose.

Can the non-veteran spouse receive a rating for aid and attendance or housebound?
If the veteran is a receiving compensation and is at least 30% or more service connected disabled there is a small allowance available if the spouse needs aid and attendance. According to VA a rating is not available to the non-veteran spouse of a living veteran for pension. A rating is available to the single surviving spouse for death pension.

What documentation is required?
The veteran must provide an original copy of discharge from service, typically a DD 214 or a WD. A photocopy is allowed if it is certified by a government agency recognized to do this. This could be the local courthouse. For a death benefit, a death certificate must be furnished as well. VA may request copies of other documents, but, generally, providing sufficient information on the claim form will satisfy the need for other documentation. If an applicant for pension is younger than 65, medical evidence of total disability must also be submitted. Total disability or 65 and older is not a requirement for death pension.

What is the effective date?
The effective date is generally the day VA receives an original application. If it takes three months for the process of approval or six months, it doesn't matter. The effective date still reverts to receipt of the original application.

When does payment begin?
Generally, payments start on the first day of the month following the month of the effective date. This means that if it took six months to get approval, at least five months of benefit will be paid retroactively. VA requires automatic deposit of awards in a checking or savings account.

What happens if the veteran dies during the period of application?
If the veteran dies during the period of application and the application was not approved prior to the death, there may be accrued benefits. If the regional office had all of the information in its possession that would have led to an approval, then there is an accrued benefit payable. Otherwise there is none. The full benefit is available for the month of death of the veteran and to a surviving spouse through an application on Form 21-534. This is the same form a surviving spouse uses for a death benefit claim for himself or herself. VA will award either an accrued benefit or death benefit to the surviving spouse whichever is larger. If there is no surviving spouse or dependent child, VA will pay the unreimbursed costs of last illness and burial to the person who paid those costs. A special claim must be submitted for these costs, not Form 21-534.

What is a veteran’s federal fiduciary, and does that affect the application?
For a veteran who is considered incompetent to handle his own financial affairs, VA will appoint a fiduciary to receive the money and pay the bills. A federal fiduciary is an individual appointed for this purpose, usually a spouse or a family member. In most cases -- except for the spouse living with the veteran -- there is an interview required and mounds of paperwork. This process can take a long time, and it is to the advantage of the person filing an original claim to request the appointment of himself or herself as a fiduciary or for some other appropriate person or organization to help expedite the process. VA always makes the final decision on whom it appoints as a fiduciary. In fact, the agency might well ignore court appointed fiduciaries. In general, the decision favors declaring the veteran competent and avoiding a fiduciary where at all possible.

What is the difference between compensation and pension?
Compensation is paid for service-connected disabilities; whereas, pension is paid to veterans who are disabled because of nonservice-connected causes. Compensation is meant to compensate a veteran for loss of income due to the disability. pension is meant to provide more income to low income, disabled, active duty veterans who served during a period of war.

Which benefit is better?
The veteran can choose the larger of either benefit but cannot have both. If the veteran is receiving military retirement or has received other reimbursement related to military service, those monies will be reduced by the amount of compensation. pension does not reduce military retirement. For veteran families with expensive home care services, assisted living, or nursing home costs, pension is typically the larger benefit.

Can a veteran apply for compensation years after leaving the military?
A recent survey by VA found that a large percentage of older veterans had never applied for compensation but could be eligible based on injuries or illnesses incurred while they were in the service. A veteran can apply for these benefits at any time.

Can a veteran receiving compensation reapply for additional income?
Many veterans are receiving compensation, but their disability related to service may have become worse. They can apply for a higher disability rating and thus more money at any time. There are also additional benefits for veterans who may have lost limbs, eyesight, hearing, or the use of other parts of their body.

Can a veteran receiving military retirement pay also receive compensation?
A veteran cannot receive compensation and military retirement at the same time. Generally, the veteran will waive a portion of military retirement that equals compensation because retirement is taxable and compensation is not. Since 2004 military retirees with a VA rated disability of 50% or more are no longer being required to waive military retirement pay to receive VA disability compensation. This new law is being phased in over a 9-year period. However military retirees with a VA rated disability of 40% or less are still required to waive a portion of their military retirement pay to receive compensation.

What is the income test for pension?
If the household income adjusted for medical expenses is greater than the Maximum Annual Pension Rate -- MAPR -- there is no benefit. In 2007, the maximum allowable rate for a couple with aid and attendance allowance is $21,615 a year. For a single it is $18,234 a year. Without aid and attendance or housebound allowance the maximum couple's rate is $14,313 a year and for a single it is $10,929 a year. Death pension rights are lower. People seeking a benefit with adjusted incomes greater than these levels will be denied.

Can a household with income above the maximum limit qualify for pension?
A quirk in the way benefits are calculated can allow individuals and couples earning between $24,000 to $60,000 a year to still qualify for a benefit. It has to do with the treatment by VA of the very large recurring medical costs associated with home care, assisted living, or nursing home care.

What is the pension household asset test, and what can be done if the asset test is not met?
As a general rule assets cannot exceed $80,000. But there is no specific test in the regulations. Veterans service representatives are required to file paperwork justifying their decision if they allow assets greater than $80,000. Thus this amount has become a traditional ceiling. The service representative is encouraged to analyze the veteran's household needs for maintenance and weigh those needs against assets that can be readily converted to cash. In the end, the decision as to allowable assets is a subjective decision made by a service representative. In certain cases a benefit award could be denied unless assets are below $20,000 or $10,000 or even zero dollars. There are ways to get around the asset test if assets are too high.

What proofs and documents are required with the pension claim?
We have already discussed the requirements for power of attorney and fiduciary if they apply. In addition, an original copy of the discharge from service -- typically DD 214 or form WD -- is required and the discharge must have been honorable. If there is a question about the marriage relationship, a marriage certificate or other proof may be necessary. Birth certificates of dependent children are usually not required but may be necessary under certain conditions. A dependent child is a minor, a dependent student under age 23, or a totally dependent adult child. There are certain documents that need to be submitted to prove future recurring medical expenses and to prove need for aid and attendance or housebound allowances. VA does not furnish these documents nor provide any information that they are required. The types of documents that could be used for these purposes will be discussed in the sections below.

Can someone charge to help fill out the form?
Federal code and VA regulations prohibit an agent or attorney from helping with the claims process prior to award or denial of a claim. VA regulations further define this prohibition to mean that no one can charge a veteran a fee in conjunction with the application process. Most practitioners or providers help their clients for free, sometimes in the context of solving other retirement issues or providing long term care services. Some practitioners offer advice for a fee but will send their clients to a veterans' service organization to complete the application. Some assisted living facilities or home care providers also offer free advice or help and this seems to be an acceptable practice. An agent or attorney can also be paid by a disinterested third party under certain conditions to complete an application. A recent letter from VA General Counsel condones charging a fee for advice but considers charging a fee to complete the application as a violation of the statute.

How are assets, income and unreimbursed medical expenses determined?
The applicant must submit details on the application of all income and all assets including retirement savings accounts such as IRAs. Almost any type of money received or anything received that can be converted into money is income. The only exclusions for assets are a personal residence and a reasonable amount of land it sits on as well as vehicles and other personal possessions. Personal possessions used as an investment such as a coin collection are counted as assets. Unreimbursed medical expenses can be almost any expense related to medical needs.

Are there any other reporting requirements?
VA requires that any change in income or assets be reported immediately. The award is calculated for 12 months in advance, but at the beginning of each calendar year, a formal report called an EVR (eligibility verification report) must be filed detailing all income, assets and unreimbursed medical expenses for the coming calendar year. For example if the award is granted in April for 12 months in advance, an EVR must be submitted in January of the next year that could affect the award amount for the remaining four months. The EVR will be used for determining benefits for the calendar year on which it is based.

What is a veteran’s federal fiduciary, and does that affect the application?
VA can appoint a number of different types of fiduciaries to manage the funds on behalf of an incompetent veteran. A federal fiduciary is typically an individual such as the spouse or a child whom the VA is most likely to appoint. If VA is not notified with the application that the veteran may be incompetent and that a fiduciary appointment is requested, this could slow down the application and approval process.

Will the pension benefit pay a nonlicensed homecare provider?
VA does not pay providers directly but provides extra income to make up for the cost of medical care providers. Medical conditions or injuries or diseases that require a need for ongoing homecare will allow the applicant to reduce household income by the cost of homecare making it possible to receive the additional income from a pension award. If the beneficiary has an aid and attendance or housebound allowance, VA will pay nonlicensed providers.

Will the pension benefit pay a member of the family to provide care at home?
As explained above, VA will not pay providers directly but only indirectly through extra income. If the beneficiary receiving care in the home has received a rating for aid and attendance or housebound, VA will allow expenses paid to a family member for care to be counted as unreimbursed medical expenses to qualify for the benefit.

Does the pension benefit pay the costs of a nursing home?
The application form has provision for indicating residency in a nursing home and whether or not the applicant is eligible for Medicaid. VA will automatically apply the monthly cost of the nursing home in determining the pension benefit. If the applicant is single with no dependent children at home and is eligible for Medicaid, VA is required to stop any payment of benefits and only provide the veteran with $93 a month.

Does the pension benefit pay the costs of assisted living?
As explained above, VA will not pay providers directly but only indirectly through extra income. If the beneficiary receiving care in assisted living has received a rating for aid and attendance or housebound, VA will allow expenses paid to assisted living for aid and attendance or housebound including room and board to be counted as unreimbursed medical expenses. The cost of assisted living being used as a retirement residence is not considered a medical expense.

What are the requirements to receive a death pension benefit?
The applicant must be a surviving spouse or a dependent child of an eligible veteran. VA form 21-534 is used to apply for death pension, death compensation, accrued benefits, or dependency and indemnity compensation (DIC). The surviving spouse must be single. A surviving spouse of any age is eligible as long as the deceased veteran served at least 90 days during a period of war. They had to be married at least a year prior to death or have a child as a result of the marriage. There is no requirement for total disability for the surviving spouse nor for the deceased veteran to have been totally disabled or older than age 65.

How does one prove that unreimbursed medical expenses will recur every month?
VA has specific rules for proving future recurring medical expenses. Information below will outline the type of paperwork that must be submitted for each type of long term care service. Neither the claims form nor information from the regional office provides any guidance on the rules for proving future recurring medical expenses for home care or assisted living. One simply has to know how to do it.

What if the veteran or spouse is currently receiving Medicaid?
Our interpretation of the rules leads us to believe that VA will not consider Medicaid payments as income. However, Medicaid will consider the nonallowance portion of the pension to be income. This could affect Medicaid eligibility in income test states. There is evidence that some income test states count the entire pension benefit including the allowance as income. According to federal Medicaid rules this should not happen.

What happens when the veteran or spouse wants to receive pension & Medicaid together?
Federal law requires that a single veteran receiving Medicaid with no spouse or dependent children can receive no more than $93 a month from VA. Veterans in state veterans homes are exempt from this requirement. The veteran with a spouse can receive the benefit to help defray the costs of a nursing home. As a general rule, the pension benefit would probably not work if Medicaid were paying the bill. But the benefit does work well for non-Medicaid nursing home beds and while the recipient is going through the Medicaid spend down.

Is a veteran entitled to compensation and pension at the same time?
The veteran cannot receive both benefits at the same time but must choose which one to receive. It does not have to be the larger income.

What happens if the veteran dies during the pension claims process?
If the veteran dies during the claims process, there may be an accrued benefit payable to the surviving spouse or dependent child. If there are no surviving spouse or dependent children, there may be an accrued benefit to pay the unreimbursed costs of final medical expenses and funeral and burial.

 

Charging a Fee for Filing a Claim

38 USC sections 5901, 5902, 5903, 5904 and 5905 cover prohibitions for representatives, allowable practices for representatives and who can be a representative for a veteran in the filing of a claim.

For further details we include an addendum with all of 38 USC Chapter 59 with amendments. We also include a Federal appeals court decision concerning the challenge of payment to a third-party for filing a claim. Finally we include a letter from Tim McClain, VA General Counsel, to the Hon. Lane Evans, ranking Democratic member of the House Committee on Veterans Affairs, dated May 24, 2004. The letter addresses, directly, charging a fee for advice relating to a claim. The source of this document is: 
http://veterans.house.gov/democratic/officialcorr/pdf/5-24-04attorneys.pdf

Our purpose here is not to offer legal interpretation. You must make up your own mind what is acceptable based on current rules and regulations. Our addendum material is not all-inclusive but can give you great insight into the attitude of the Department of Veterans Affairs. Here is how the National Care Planning Council would handle a typical case regarding charging fees:

1.  From the letter from VA General Counsel, it appears to be acceptable to VA that we can charge for advice relating to the filing of a claim but not charge for filling out and filing a claim.

2.  It is our opinion that home care agencies, nursing homes and assisted living facilities that pay a specialist to file a claim on behalf of one of their residents or clients are in violation of the third-party fee provisions allowed by VA. We believe it is an obvious intent to circumvent the statute.

VA does allow disinterested third party organizations to pay someone to file an application on behalf of the veteran--based on 38 C.F.R. § 20.609(d) (1992). This regulation, addressing disinterested third-party fee payers, provides that “[a]n attorney-at-law or agent may receive a fee or salary from an organization, governmental entity, or other disinterested third party for representation of a claimant or appellant even though the conditions set forth in paragraph (c) (38 USC section 5904) [regarding fees for services after a final decision by the DVA] have not been met.”

VA amended its rules pertaining to this regulation on May 23, 2002. The following rules now apply:

• First, it prohibits an attorney or agent from charging a fee contingent, in whole or in part, upon whether the matter is resolved favorably to the claimant or appellant.
• Second, it establishes a rebuttable presumption that the spouse, child, or parent of the claimant, or a person residing with the claimant, is not a disinterested third party.
• Third, it requires that all agreements for payment by a third party be in writing, be filed with the Board, and include a certification by the attorney or agent that “no agreement, oral or otherwise, exists under which the claimant or appellant will provide anything of value to the third-party payer . . . in return for payment of [the attorney’s] fee or salary, including, but not limited to, reimbursement of any fees paid.” 38 C.F.R. § 20.609(d)(2); 67 Fed. Reg. at 36,104. (See enclosed addendum court decision for more detail.)

3.  We would refer the actual filing of claims on behalf of a veteran to a veterans service organization or to a duly VA appointed representative. We have included a list of these entities in Appendix 1 in our book.

We do believe, however, that all kinds of advice and constructive help (not directly involved in the claims process) should be given prior to the filing of an application or even during the claims process in order to help increase the chance of a successful award. We feel this might include educating clients on what information is required, recommending supportive forms or documents that might be effective in the claims process, providing guidance on VA's asset test, making sure the evidence for recurring medical costs and for a rating is presented in the most favorable manner and providing advice on the steps necessary to complete the application.

In our opinion, the actual process of obtaining documents and filling out forms should be done, free of charge, by the client, family members, a duly appointed power of attorney or a veterans service organization such as a state department of veteran affairs or local VFW.

The accompanying addendum letter from VA General Counsel gives an example in the third to last sentence where an attorney (VA considers any representative for the claimant an attorney) could charge for a prefiling consultation and complete the application for the veteran pro bono. For various reasons, including the fact that a veterans service organization has a better understanding of all available benefits, we recommend using a veterans service organization for the filing of claims.