Author: benefitbrokers

Using Aid and Attendance to Pay for Assisted Living

Using Aid and Attendance to Pay for Assisted Living

Filing a claim can be time-consuming and complicated. It’s important to get help.
Applications for Pension that involve a rating, evidence of prospective, recurring medical expenses, appointments for VA powers of attorney and fiduciaries, and an understanding of the actual application process should not be attempted without prior knowledge. We recommend you purchase our book to avoid lengthy delays in a decision or possible denials of the claim. Not only does the book help you understand how to shorten the decision process from VA and ensure a successful claim but the support forms we provide also help you present medical evidence and costs in a format familiar to VA service representatives. Applications that also involve reallocation of assets in order to qualify should not be attempted without the help of a qualified veterans aid and attendance benefit consultant.  

Annualizing Costs of Assisted living, Residential Care, Adult Day Care or Other Similar Arrangements
These facilities are not categorized by VA as nursing homes. As such, annualization of costs and a rating are not automatic. If the beneficiary is not rated, the service representative will only allow recurring unreimbursed medical expenses for specific medical care provided by licensed health professionals. Costs for room and board or custodial care cannot be applied.

For information on ratings please go to the article entitled “Who is eligible for the aid and attendance Pension benefit?”

On the other hand, if a beneficiary residing in one of these living arrangements has been rated a need for “aid and attendance” or “housebound”, VA will allow all reasonable costs to be counted as prospective, annualized medical expenses as long as some of those costs are paid for medical care. The providers do not have to be licensed. In the case of Alzheimer’s, the physician’s statement used for rating must indicate the person needing care must be in a protective environment; otherwise, only medical costs are covered. Applying for a rating is discussed in a previous section above. All reasonable costs would include room and board as well as other unreimbursed billable services.

For an explanation of the special annualized treatment of unreimbursed long term care costs and insurance premiums please go to the article entitled “Understanding the special case of long term care medical costs.”

The director of the facility must sign a statement verifying the type of care being given and the fact that the person receiving the care is expected to remain a resident in the facility. We have included in our book, a copy of a form entitled “Form 2 — Care Provider Report (used to provide evidence of recurring medical expenses)” We highly recommend this form or a similar form be submitted with the application. A copy of the contract for services as well as invoices and statements from the facility should also be included with Form 2.

There may be a possibility of a non-veteran spouse of a living veteran receiving annualized credit for recurring costs of non-nursing home facility care. Requesting annualization for the spouse may be a problem because the amount of allowable costs without a rating for “aid and attendance” or “housebound” could be much smaller or disallowed. We recommend checking the box on the application for a rating. This will probably confuse the service representative but may alert that person to the request of the spouse’s expenses. We also recommend submitting a letter with the application requesting recurring, annualized treatment of the cost of the care facility and assuring VA the spouse does deserve a rating. Otherwise, the spouse’s cost of assisted living may not be allowed as a deduction.

VA will not allow a Pension rating for a non-veteran spouse of a living veteran, but the point is to try and convince the service representative that the total cost of room and board should be annualized as if there were a rating. All of the corroborating evidence such as medical reports, statements, verification reports by directors of the facilities, and contracts should be submitted in the same manner as if applying for these benefits for the veteran. We cannot assure any applicant that this request will be granted, but it is worth a try. We recommend you contact a qualified aid and attendance benefit consultant to help you with this special case scenario of a non-veteran spouse.

Of course, a death claim is different because the surviving spouse can receive a rating in that case. If VA allows annualization of facility costs for a spouse of a living veteran, there will be no Pension allowance for aid and attendance or housebound, and the Pension award will be much smaller.

Article courtesy of Tom Day

When the Family Should Use an Aid and Attendance Benefit Consultant

Paying a Fee for Help with Filing a Claim
Federal code and VA regulations prohibit an anyone from charging a fee to fill out an application prior to filing a notice of disagreement. Some 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 may offer information for a fee but will send their clients to a veterans’ service organization to complete the application. Charging a fee for information is an acceptable practice allowed by VA. Charging a fee to prepare, present, and prosecute a claim is a punishable offense.

We believe it is critical for the advisor or the consultant to offer advice and constructive help 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 client understands that evidence for recurring medical costs and for a rating is presented in the most favorable manner,
  • providing advice on dovetailing VA benefits with Medicaid, and
  • providing advice on the steps necessary to complete the application without giving specific instruction on what goes in each block or helping in any way with gathering information for the claims process.

Knowing how to submit a successful claim is 95% of the battle and filling out the form is a formality.

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. We have not had favorable reports from people who use a VA regional office for help with filing a claim.

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. This is an obvious intent to circumvent the regulation.

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.)

Situations Where a Consultant Should Be Used for Advice in Filing a Claim

Below are six situations where using a consultant, who understands the claims process for Pension, can be of great help or in some situations a necessity. There are undoubtedly more situations that may exist and as reports come in from consultants, we will add them to this list. We have described, with each situation below, the reason for needing a consultant as opposed to using our book or trying to do it on your own.

Using a Consultant Where Complexity or Time Constraints Justify Paying Someone for Advice
Attempting to gather up the necessary forms and researching what information is necessary for a successful claim can be a daunting task. This is especially true for busy family members who are employed full time and are trying to help a loved one obtain a VA benefit.

Busy care providers might find it easier to pay for information for filling out and presenting a claim. Many advisers will refer their clients to a capable veterans service organization that will file the claim for free.

Using a Consultant When Submitting Claims Applications for Nursing Homes
We discussed in a previous section that a Pension claim for a potential beneficiary in a nursing home is a straightforward task that by itself, would not require the help of a consultant. Unfortunately, the pension benefit is usually not sufficient to cover the difference between the beneficiary’s income and the cost of the nursing home. In many cases, the veteran or the surviving spouse in the nursing home is forced to apply for Medicaid.

Dovetailing Medicaid income with the Pension benefit could work in some cases but in other cases Medicaid and Pension don’t mix. In those cases where it fits, Pension can be a valuable additional resource for a nursing home patient. When trying to make Medicaid and Pension work together, a potential claimant should always seek out the advice of a knowledgeable consultant. Certain legal strategies relating to Medicaid eligibility could be applied in these special cases. Advisers, who understand Medicaid rules and VA eligibility, might be able to apply some of these strategies to produce more household income.

Using a Consultant with Applications Where a Single Claimant Will Be Abandoning the Principal Residence
When a single veteran or a single surviving spouse of a veteran leaves his or her principal residence to live in assisted living or in a nursing home, there could be a potential conflict with a Pension benefit award. VA will not count the principal residence against eligibility for Pension income even if it is not being occupied by the veteran or spouse.

On the other hand, the family or the beneficiary may wish to rent out the house or sell it. These activities must be reported to VA and could affect the amount of the Pension income or even disqualify the Pension income.

In these situations it is better to get the ownership of the home out of the name of the single veteran or spouse. There is no penalty from VA to do this but gifting the property will create a five-year look back penalty for Medicaid. If the VA recipient needs to apply for Medicaid within five years of making the gift, Medicaid will refuse to pay for long term care for a certain period of time based on the value of the gift.

A consultant should always be sought out in these cases as there are strategies that can be used to avoid the Medicaid penalty or make it less severe.

Using a Consultant with Applications Where Assets Are Gifted or Converted to Income to Qualify for Pension
VA does allow potential applicants to give away assets or convert those assets to income to remove the asset test that would block a Pension award. There are strategies that can be used to retain income from gifted assets and still have those assets out of the name of the veteran household.

There are also income strategies that must be utilized in case the Pension beneficiary will apply for Medicaid. Finally, all pension applicants must be certain that asset transfers that occur within the five-year look back period for Medicaid, don’t disqualify the Pension beneficiary for Medicaid benefits. When assets are to be gifted or converted to income, a knowledgeable consultant should always be used. Failure to do so could result in dire consequences.

Using a Consultant with Applications That Require Estate and Tax Planning
Gifting of assets many cause tax problems for unwary benefactors. This might include loss of the step-up in value for real estate or conversion of capital gains to ordinary income. Also, outright transfers to members of the family may not be a good idea in certain situations. Charitable gifting should also be considered as a way to create income tax credits and reduce costly capital gains taxes on appreciated real estate.

Tax planning and orderly distribution of assets should be part of the gifting process. This usually requires specific legal documents in order to achieve the desired outcomes. For those contemplating gifting to qualify for pension, a qualified consultant should always be retained.

Using a Consultant with Applications That Involve Business Ownership, Farms, Business and Investment Property and Assets That Are Difficult to Turn into Cash
Disposition of these types of assets is always more difficult than transferring a more liquid estate. It is an absolute necessity for business owners, farmers and those with substantial real estate holdings to consult with someone who can provide reliable advice on transferring these assets to family members, partners or other interested parties. In some cases, non-liquid assets can be retained and still not disqualify for a Pension income. Tax considerations are always paramount with gifting these types of properties.

Courtesy of: Tom Day

Using Aid and Attendance for Professional Home Care Services

About Us- Money

Let us help you get your Pension benefit at NO COST TO YOU OR YOUR FAMILY!

Filing a claim can be time-consuming and complicated. It’s important to get help. 

Applications for Pension that involve a rating, evidence of prospective, recurring medical expenses, appointments for VA powers of attorney and fiduciaries, and an understanding of the actual application process should not be attempted without prior knowledge. We recommend you purchase our book to avoid lengthy delays in a decision or possible denials of the claim. Not only does the book help you understand how to shorten the decision process from VA and ensure a successful claim but the support forms we provide also help you present medical evidence and costs in a format familiar to VA service representatives. Applications that also involve reallocation of assets in order to qualify should not be attempted without the help of a qualified veterans aid and attendance benefit consultant.  

Annualization of Home Care Costs
Medical expenses for home care aides are allowed prospectively for annualization if those expenses are reasonably predictable. The evidence would also have to show that the need for care is ongoing and regular. Expenses may be allowed whether the care recipient has a rating for aid and attendance or housebound or is not rated. However, deductible payments to a non-rated beneficiary are more restrictive.

Evidence must be submitted indicating an ongoing need for the care and the level of care in order for the Veterans Service Representative to consider the medical expense as recurring and eligible to be annualized. A form such as the one we provide in our block entitled “Form 2 — Care Provider Report (used to provide evidence of recurring medical expenses)” should be used for this purpose. Also a copy of a contract between the provider and the recipient, covering at least a year, and outlining the provisions and the cost should be submitted to prove the intent of the care recipient and the provider.

For an explanation of the special annualized treatment of unreimbursed long term care costs and insurance premiums please go to the article entitled “Understanding the special case of long term care medical costs.”

The non-veteran spouse of a living veteran may also be eligible for annualization of home health aide costs. If the home care is being furnished by a licensed health professional, then not much further proof is necessary other than the documentation proving the care is being provided. If the provider is not licensed, we are not sure much could be done to allow deduction for anything other than direct medical services. As outlined below, payments to nonlicensed providers are only allowed if the care recipient has a rating for “aid and attendance” or “housebound.” Unfortunately, a non-veteran spouse of a living veteran cannot receive a rating and therefore would not be eligible for annualization of costs.

Our readers could try the suggested approach outlined for assisted living and other similar facilities in order to request annualization and deduction for non-rated beneficiaries, but there is no assurance VA would allow the deductions. The idea is to try to convince the service representative the spouse should have a rating even though officially none is allowed.

VA will not rate a non-veteran spouse of a living veteran for “aid and attendance” or “housebound” and even though the spouse’s home care medical expenses may be annualized to produce a benefit, the Pension award will be much smaller without the allowance for a rating. Of course, a death claim is different because the surviving spouse can receive a rating in that case.

For information on ratings please go to the article entitled “Who is eligible for the aid and attendance Pension benefit?”

Home Care Recipient Is Not Rated
Payments for care at home for a recipient who is not rated for housebound, or aid and attendance are only allowed for annualization if made to a licensed health professional. The term “licensed health professional” refers to an individual licensed to furnish health services by the state in which the services are provided. The term includes registered nurses, licensed vocational nurses and licensed practical nurses. Some states also license non-medical home care providers to provide services as well. Since this is a fairly new practice, we don’t know if these people would qualify under the definition above but we suspect they will.

All reasonable fees paid to the licensed health professional for personal care of the disabled person and maintenance of the disabled person’s immediate environment may be allowed. This includes such services as cooking for the disabled person and housecleaning for the disabled person. It is not necessary to distinguish between “medical” and “nonmedical” services. However, services which are beyond the scope of personal care of the disabled person and maintenance of the disabled person’s immediate environment may not be allowed.

Services beyond the scope might be services such as driving the veteran’s spouse to appointments, paying bills, answering the phone, providing shopping errands for the household, and so on. If an hourly rate is being paid to the home care provider, a portion of this rate may be disallowed for services beyond the scope of personal care.

Care Recipient Is Rated for “Aid and Attendance” or “Housebound”
If the disabled care recipient has been rated “housebound” or in need of “aid and attendance” by VA, all fees paid to an in-home attendant will be allowed as long as the attendant provides some medical or nursing services for the disabled person. The attendant does not have to be a licensed health professional.

All reasonable fees paid to the individual for personal care of the disabled person and maintenance of the disabled person’s immediate environment may be allowed. This includes such services as cooking for the disabled person and housecleaning for the disabled person. It is not necessary to distinguish between “medical” and “nonmedical” services. However, as with an unrated beneficiary, services which are beyond the scope of personal care of the disabled person and maintenance of the disabled person’s immediate environment may not be allowed.

For a disabled person who has been rated, a family member may be considered an in-home attendant, but that family member has to be paid for services duly rendered. There is potential for fraud here where a family member may move into the home and ostensibly receive payment as a caregiver but not actually provide the level of care paid for. Documentation for this care must be provided to VA, and it is reasonable for VA to question whether the services being purchased from someone living in the household are legitimate.

Whether this type of care is eligible for annualization is also questionable. The family member who is living in the home can certainly request consideration of this care as a recurring monthly cost, but our guess is, if VA allows it, the relationship will be scrutinized very carefully month-to-month.

We suspect the service representative is more likely to grant a request for annualization for a family member who is not living in the home. In either case, evidence must be submitted that this care will be required month-to-month and that the cost and the amount of care will remain fairly constant. Otherwise prospective annualization of the expenses is unlikely. We also suggest drawing up a contract between the family member and the person receiving the care and a copy of this furnished to VAalong with actual evidence of payment.

Documentation of Home Care Expenses
If the fees for an in-home attendant are an allowable expense, receipts or other documentation of this expense are required. Documentation includes any of the following:

1. a receipt bill
2. statement on the provider’s letterhead
3. computer summary
4. ledger, or
5. bank statement.

The evidence submitted must include:

1. the amount paid
2. the date payment was made
3. the purpose of the payment (the nature of the product or service provided)
4. the name of the person to or for whom the product or service was provided
5. identification of the provider to whom payment was made.

Courtesy of Tom Day- NCPC

Staying Connected

Ironically, one of the biggest challenges of the age we live in is staying connected to everyone. At a time when we have so many communication tools and social media sites of every sort, one of the greatest ironies of life is that it is still difficult to keep up with everyone we know. Between work, family, getting to the grocery store, making sure the car gets to the shop, making all the kid’s sports events, and maybe an occasional outing with friends, it often seems we’re lucky to even get to our social media accounts!

Working with Veterans on a regular basis, we see how easily they become disconnected from those outside the military and vice versa. It’s as if there’s an invisible dividing line and many civilians don’t often see or appreciate much of what their military friends and acquaintances do every day to serve the rest of us.

Now, however, The National Veterans Art Museum has a way to help us all stay connected to Veterans and their stories. On one of those days when we actually can get away, or even if we just plan a get away to the Windy City, we all have an opportunity to share in the lives of soldiers and Veterans.

The museum offers a variety of experiences as it is part gallery and part hands-on classroom, providing a creative outlet for veteran artists and educating the public.

The museum’s gallery coordinator, Destinee Oitzinger, said. “A lot of the art tries to explain things civilians don’t understand.”

The museum began as an art exhibition by Vietnam War veterans who opened the museum in 1996. With the wars in Iraq and Afghanistan creating a new generation of combat veterans, the museum expanded to include art from and about veterans of all U.S. conflicts. The art varies greatly, but every piece is by or about veterans.

In a small upstairs gallery in the artsy Portage Park neighborhood, the museum features a temporary exhibition — currently it’s a nine-year portrait project called “100 Faces of War Experience”, a permanent installation on the Vietnam War based on the book “The Things They Carried.” The Vietnam exhibit offers a literal and figurative illustration of the book’s title, with an extensive collection of everyday items that American troops carried in the jungles of Vietnam, from grenades to canteens, that visitors can pick up and examine. Also included are photos, letters and art showing the war experience through their lens.

The museum also rotates exhibitions from its 2,500-piece collection. One of several on display now is Maurice Costello’s “Autobiography,” in which the phases of the artist’s life, motorcycle-riding young man; soldier in combat; drug-addled veteran and family man, are laid out chronologically. His experiences are reflected in sunglasses drawn on brightly colored, enlarged cutouts of his head.

The nonprofit museum, which is supported though grants and donations, emphasizes education and consistently brings in groups of high school and college students. It also draws a mixed group, including those with no military connection, many veterans and even more loved ones of veterans who often yearn to learn about the experiences of those who don’t share them, Oitzinger says.

“It’s a way to get the story out,” said Jim Moore, a Vietnam vet, filmmaker and longtime museum board member. “It’s cathartic to a lot of the artists…they get to express some thoughts and ideas and feelings they don’t normally get to express in their day-to-day life.”

Healing and understanding are themes that come up repeatedly in conversations with those connected to the exhibits, and it sponsors art therapy classes by licensed clinicians. Executive director Brendan Foster said that outside of that environment, the museum, and it’s art,  the outlet it provides can help veteran artists who often deal with multiple stigmas — the perception that they are damaged, a persistent negative image associated with seeking help for the effects of trauma, and the very fact of working as an artist.

“We think there is inherent in the creative process a therapeutic element,” Foster said. “Bringing this all together can help alleviate some of those stigmas.”

Much of the museum’s collection deals with Vietnam, but with hundreds of thousands of veterans having served in Iraq and Afghanistan, new generations of artists are bringing their own style to the exhibits. Oitzinger said the GI Bill is now allowing more Iraq and Afghanistan veterans to get formalized art education.

Their art is “more conceptual,” she said, “whereas Vietnam veterans tend to be more, ‘This is how it was, this is what I saw.’ ”

For Giuseppe Pellicano, an Oregon artist and Army veteran who served in Kosovo, the museum is the hub of the veteran artist community. Pellicano, whose work has been displayed there, said veterans showing their experiences through art can bring them closer to other Americans, who often misunderstand them.

Exhibits are chosen by the board, and Oitzinger and Foster say they keep politics out of the equation. That is not to say the art is always apolitical — it ranges from anti-war to supportive of U.S. wars — but the museum strives to be open to all ideas and mediums.

“We’re here to support that open conversation,” Oitzinger said.

Encompassing that range is Matt Mitchell’s “100 Faces of War Experience.” Mitchell, who is not a veteran, spent nine years seeking to paint a cross-section of those who went to war in Iraq and Afghanistan to better understand their experiences. Starting in 2005, he traveled the country to paint 100 portraits and gave his subjects a chance to provide up to 250 words to go unedited with their portraits.

Some wrote about their struggles, some wrote about their pride in service, some wrote poetry, a few wrote nothing; a collage of experiences veterans have, rather than the simplified version often portrayed in popular culture. For Mitchell, the National Veterans Art Museum was one place he could trust to portray those mixed messages, from subversive to flag-waving.

“Here is a group who is not going to try to gloss over or simplify the message,” he said. “They’re not afraid of a complex nature to veterans’ experiences.”

-Partial content courtesy of Heath DruzinStars and Stripes

About Long Term Care

What Is 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
  • 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:

Custodial Care versus Skilled Care

Custodial care and skilled care are terms used by the medical community and health care plans such as health insurance plans, Medicare, Medicaid and the Veterans Administration. They are used primarily to differentiate care provided by medical specialists as opposed to care provided by aides, volunteers, family or friends. The use of these terms and their application is important in determining whether a health care plan will pay for services or not. Generally, skilled services are paid for by a health care plan and custodial services, not in conjunction with skilled care, are not covered. However, custodial services are almost always a part of a skilled service plan of care and by being included, custodial services are paid by the health care plan as well. Many people have the misconception that only skilled services are covered. This is simply not true.

According to the American College of Medical Quality:

” Skilled care is the provision of services and supplies that can be given only by or under the supervision of skilled or licensed medical personnel. Skilled care is medically necessary when provided to improve the quality of health care of patients or to maintain or slow the decompensation of a patient’s condition, including palliative treatment. Skilled care is prescribed for settings that have the capability to deliver such services safely and effectively.

Custodial care is the provision of services and supplies that can be given safely and reasonably by individuals who are neither skilled nor licensed medical personnel. The medical necessity and desired results of skilled care must be clearly documented by a written treatment plan approved by a physician. A patient may have skilled and custodial needs at the same time. In these circumstances, only those services and supplies provided in connection with the skilled care are to be considered as such. The treatment plan must include:

•  The applied therapies;
•  The frequency of the treatment which is consistent with the therapeutic goals;
•  The potential for a patient’s restoration within a predictable period of time, if applicable;
•  The time frame in which the prescribing physician will review the case for the purpose of evaluating a patient’s status and before reassessing the medical necessity of ongoing treatment; or
•  The maintenance, palliative relief, or the slowing of decompensation in a patient’s status, if applicable.

Determinations of the medical necessity of skilled care must be based on the applicable standard of care.”

Writers and advisers who are not part of the medical community often confuse custodial care and skilled care with specific care activities. For example help with the activities of daily living and many of the items on the list in the previous section are care activities thought to be by definition custodial care. Whereas the monitoring of vital signs, ordering medical tests, diagnosing medical problems, administering of intravenous injections, prescribing and dispensing medicine, drawing blood, giving shots, dressing wounds, providing therapy and counseling are all activities normally associated with skilled care. But many non-medical advisers and writers don’t know that skilled and custodial refer to the people who deliver the care not the actual care given.

A skilled care provider can also provide services normally thought to be provided by custodial caregivers. Such things as help with activities of daily living and so-called instrumental activities of daily living are often furnished by skilled providers in the course of their treatment. Or a skilled care plan may call for services that can be delivered by a custodial caregiver but it would still be under the skilled plan of care for that individual. On the other hand people who deliver custodial services may from time to time perform those activities supposedly reserved for skilled providers. Such things as taking blood pressure, administering medicines, giving shots or changing wounds might be provided under certain circumstances by a custodial provider.

Please remember that the terms skilled and custodial do not refer to specific types of long-term care services but rather who delivers those services. Also the delivery of skilled services must be done under a written plan of care which often includes custodial care services.

Does Medicare Cover Custodial Care?
Of course it does. Medicare routinely pays for custodial care in every skilled care setting for which it provides payment. Medicare will not pay for custodial care in the absence of a skilled care plan.

Medicare covered nursing home stay
A patient receiving skilled care in a nursing home from Medicare not only receives care from skilled providers such as nurses, therapists or doctors but also receives care from custodial providers such as aides or CNA’s. This care usually consists of help with bathing, dressing, ambulating , toileting, incontinence, feeding and medicating. Medicare does not exclude the custodial services but pays the entire bill because custodial care is a necessary part of the skilled care plan in a nursing home.

Medicare covered home care
Custodial care is always a part of a skilled care plan for home care. The patient receives skilled care from a nurse or therapist and custodial care from an aide for help with bathing, dressing, ambulating , toileting, incontinence, medicating and possibly feeding. Medicare pays for both types of services.

Medicare hospice care
The hospice team consists of a doctor, a nurse, a social worker, a therapist when needed, a counselor and an aide to provide custodial care. Help with activities of daily living is provided at home or in a Medicare approved hospice facility. Custodial care is always a part of a hospice plan of care and Medicare routinely pays for these services.

Please note that there is no such thing as a custodial nursing home.  All nursing homes are by definition skilled care facilities because they have nurses who are skilled care providers.  Also be aware that not all states license intermediate care facilities which might provide less than 24 hour registered nursing care. “Skilled care patients” in nursing homes are referred to as such because they are receiving payment from Medicare or sometimes payment from private health insurance plans.  Practically all nursing home residents have medical needs but Medicare and other insurance plans will only pay for patients that have certain acute medical needs where recovery is anticipated.  Patients with chronic medical problems are typically not covered by Medicare but would be covered by Medicaid.

The confusion with understanding the term “skilled nursing care” probably comes from Medicare itself. To be a certified Medicare nursing home and receive payments from Medicare a nursing home must meet the Medicare definition of a “skilled nursing facility”. This means there must be registered nurses on duty 24 hours a day, there must be a doctor on call at all times and there must be ambulance service to a local hospital. Medicare may also require additional staffing and facility arrangements to receive certification. It is unfortunate that the word “skilled” is used in this definition. All nursing homes whether they meet the definition of a “skilled nursing facility” or not provide services from a nurse, doctor or therapist and this meets the medical definition of skilled care. Many states have adopted the same federal criteria for licensing their nursing homes. In some states the “skilled” definition is the only option for a nursing home. But in some states facilities with lesser services can receive different licensing classes. These might be called intermediate care facilities or “small nursing homes”.

by Thomas Day; courtesy of NCPC

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 than in the past few years. The challenge still remains that major hospitilization, 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 healthcare provider in the country in services for rehabilitating patients with missing limbs, 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.

Outpatient Pharmacy Services

VA provides free outpatient pharmacy services to:

1. Veterans with a service-connected disability of 50% more.

2. Veterans receiving medication for service-connected conditions.

3. Veterans whose annual income does not exceed the maximum annual rate of the VA Pension.

4. Veterans enrolled in priority group 6 who received medication for service-connected conditions.

5. Veterans receiving medications for conditions related to sexual trauma while serving on active duty.

6. Certain veterans receiving medication for treatment of cancer of the head or neck.

7. Veterans receiving medication for a VA-approved research project.

8. Former prisoners of war.

Other veterans will be charged a co-pay of $8 for each 30-day or less supply of medication. For veterans enrolled in Priority Groups 2 through 6, the maximum co-pay amount for calendar year 2008 is $960.

Co-pays apply to prescription and over-the-counter medications, such as aspirin, cough syrup or vitamins, dispensed by a VA pharmacy. However, veterans may prefer to purchase over-the-counter drugs, such as aspirin or vitamins, at a local pharmacy rather than making the co-pay. Co-pays are not charges for medications injected during the course of treatment or for medical supplies, such as syringes or alcohol wipes.

Veterans receiving pension can also have their prescriptions from doctors in the private sector provided by a VA pharmacy for free or with co-pay depending on their income.

A face-to-face interview with a pharmacy specialist must be conducted with any new prescription. This is part of the process that helps VA control unnecessary drug reactions or interactions with other drugs. Subsequent refills can be ordered on the phone and will be sent through the mail or picked up in person.

Long Term Care Benefits

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


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% 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.


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% of VA’s total extended care patient population received care in non-institutional settings, including:


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.


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 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.


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.


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 bases 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 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 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 is a residential rehabilitation program that provides short-term 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 transitional residences for homeless chronically mentally ill veterans and veterans recovering from substance abuse.


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.


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.


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 networks.


VA’s nursing home programs include VA-operated nursing home care units, contract community nursing homes and state homes. VA contracts with approximately 2500 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 begin 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 the VA, the veteran and the state.


– 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 combines 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-acutre rehabilitation, respite, hospice, geriatric evaluation and management, or spinal cord injury.


A local Regional Medical Center can pay veterans a grant to allow for home improvement and structural alteration — 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 $4200 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 $1200.

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 the 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, with the goal of providing as much care as in 1998.

The budget for Va long-term care grew by more then $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.

Who Is Eligible for the Aid and Attendance Pension Benefit?

Filing a claim can be time-consuming and complicated. It’s important to get help.
Applications for Pension that involve a rating, evidence of prospective, recurring medical expenses, appointments for VA powers of attorney and fiduciaries, and an understanding of the actual application process should not be attempted without prior knowledge. We recommend you purchase our book to avoid lengthy delays in a decision or possible denials of the claim. Not only does the book help you understand how to shorten the decision process from VA and ensure a successful claim but the support forms we provide also help you present medical evidence and costs in a format familiar to VA service representatives. Applications that also involve reallocation of assets in order to qualify should not be attempted without the help of a qualified veterans aid and attendance benefit consultant.

Eligibility Rules for Pension
To receive Pension, a veteran must have served on active duty, at least 90 days, during a period of war. There must be an honorable discharge. Single surviving spouses of such veterans are also eligible. If younger than 65, the veteran must be totally disabled. If age 65 and older, there is no requirement for disability. There is no disability requirement for a single surviving spouse.

The veteran household cannot have income — adjusted for unreimbursed medical expenses — exceeding the Maximum Allowable Pension Rate– MAPR — for that veteran’s Pension income category. If the adjusted income exceeds MAPR, there is no benefit. If adjusted income is less than the MAPR, the veteran receives a Pension income that is equal to the difference between MAPR and the household income adjusted for unreimbursed medical expenses. The Pension income is calculated, based on 12 months of future household income, but paid monthly.

The Special Case for Long Term Care Costs
A special provision for calculating Pension income, allows household income to be reduced by 12 months worth of future, recurring medical expenses. Normally, income is only reduced by medical expenses incurred in the month of application. These allowable, annualized medical expenses are such things as insurance premiums, the cost of home care, the cost of paying any person to provide care, the cost of adult day care, the cost of assisted living and the cost of a nursing home facility. In most cases, these expenses are only deductible if there is a rating.

This special provision can allow veteran households earning more than the annual MAPR to qualify for Pension. As an example, a veteran household earning $6,000 a month could still qualify for Pension if the veteran is paying $4,500 to $6,000 a month for nursing home costs. The applicant must submit appropriate evidence for a rating and for recurring costs in order to qualify for this special provision. VA normally does not tell applicants about this special treatment of medical expenses or how to qualify for it. Our book provides ample information on this special treatment and provides appropriate forms to present medical and cost evidence in the most favorable manner.

For an explanation of the special annualized treatment of unreimbursed long term care costs and insurance premiums please go to the article entitled “Understanding the special case of long term care medical costs.”

Dealing with Assets That May Disqualify the Applicant
There is also an asset test to qualify for Pension. Any asset or investment that could be easily converted into income might disqualify the claimant. An asset ceiling of $80,000 is often cited in the media as being the test. The $80,000 has to do with VA internal filing requirements and is not an actual test. In reality, there is no dollar amount for the test and any level of assets could block the award. The asset test ultimately becomes a subjective decision made by the veterans service representative, processing the application.

A home, used as a residence, vehicles and difficult-to-sell property are generally excluded from the asset test. VA will allow assets to be transferred or converted to income in order to meet the asset test. There is no look back penalty for transferring assets as there is with Medicaid. There are specific rules governing transfers of assets and what constitutes income from assets and it must be done correctly.

We recommend using a qualified aid and attendance benefit consultant when dealing with assets that may disqualify. It is extremely important that assets that might be gifted or converted to income also meet Medicaid gifting rules in case the veteran or the surviving spouse may have to apply for Medicaid. The consultant can help avoid Medicaid penalties associated with reallocating assets.

The Rating
A rating for “aid and attendance” or “housebound” allows VA to pay additional benefits beyond the regular Pension benefit ceiling in order to help cover the additional costs associated with added disabilities. A rating for these allowances is determined by a veteran service representative who has been trained to recognize from medical reports and interviews whether the veteran or his surviving spouse needs the additional care.

Determinations of a need for aid and attendance or housebound benefits may be based on medical reports and findings by private physicians or from hospital facilities. Authorization of aid and attendance benefits without a rating decision is automatic if evidence establishes the claimant is a patient in a nursing home. Aid and attendance is also automatic if the claimant is blind or nearly blind or having severe visual problems.

According to 38 CFR Part Three, the following criteria are used to determine the need for aid and attendance:

•  inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable;

•  frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.);

•  inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness;

•  inability to attend to the wants of nature;

•  or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment.

Not all of the disabling conditions in the list above are required to exist before a favorable rating may be made. The personal functions which the veteran is unable to perform are considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need “regular” (scheduled and ongoing) aid and attendance from someone else, not that there be a 24-hour need.

“Bedridden” is a definition that allows a rating for aid and attendance by itself. “Bedridden” is a condition which requires that the claimant remain in bed. A person who has voluntarily taken to bed or who has been told by the doctor to remain in bed will not necessarily receive the favorable rating for aid and attendance. There must be an actual need for personal assistance from others.

Housebound means “permanently housebound by reason of disability or disabilities.” This requirement is met when the veteran or his or her widow is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime.

A person who cannot leave his immediate premises unless under the supervision of another person is considered housebound. This might include the inability to drive because of the disability.

A housebound rating does not mean a person needs to be confined to a personal residence. It can apply to any place where the person is living whether in a facility or in the home of someone else.

In order to receive one of these ratings the claimant must check the “Yes” box on VA Form 21-526 (claim for a living veteran) or VA Form 21-534 (claim for death Pension from a surviving spouse) that states: “Are you claiming a special monthly Pension because you need the regular assistance of another person, are blind, nearly blind, or having severe visual problems, or are housebound?” Failure to check this box may result in no rating and in some cases a denial of the claim as well as a loss of the rating allowance.

Medical evidence for a rating for “aid and attendance” or “housebound” for living arrangements other than a nursing home should be submitted with the application to avoid a delay in the approval process. Waiting for the regional office to order medical records is a time-consuming process, mainly because doctors offices don’t respond quickly to these kinds of requests.

We recommend a report completed by the physician, and obtained by the family prior to submission of the claim. This report is then included with the initial application. We provide in our book a form entitled “Form 1 — Statement of Attending Physician (used to determine rating for A&A or HB).” This document is similar to a form used internally by VA to obtain information from veterans medical facilities for determining a rating. It is in a format that a veterans service representative would recognize.

Ratings are requested by checking the appropriate box for aid and attendance or housebound on VA Form 21-526 or VA Form 21-534.

How Pension Is Calculated
The monthly award is based on VA totaling 12 months of estimated future income and subtracting from that 12 months of estimated future, recurring and predictable medical expenses. Allowable medical expenses are reduced by a deductible to produce an adjusted medical expense which in turn is subtracted from the estimated 12 months of future income.

The new income derived from subtracting adjusted medical expenses from income is called “countable” income or IVAP (Income for Veterans Affairs Purposes). This countable income is then subtracted from the Maximum Allowable Pension Rate — MAPR — and that result is divided by 12 to determine the monthly income Pension award. This award is paid in addition to the family income that already exists. See examples below.

Example #1 — Veteran is in assisted living with aid and attendance allowance. Monthly family income is $4,000 a month. Spouse is living at home. Unreimbursed medical expenses include prescription drugs, Medicare premiums, Medicare supplement premiums, and 12 months of prospective assisted living monthly costs. Family meets the asset test.

Example #2 — Veteran receiving paid home care with aid and attendance allowance. Monthly family income is $1,900 a month. Unreimbursed medical expenses include prescription drugs, Medicare premiums, Medicare supplement premiums, and 12 months of prospective home health aide monthly costs. Family meets the asset test.

Example #3 — Surviving spouse receiving paid home care with aid and attendance allowance. Monthly income is $850 a month. Unreimbursed medical expenses include prescription drugs, Medicare premiums, Medicare supplement premiums, and 12 months of prospective home health aide monthly costs. Surviving spouse meets the asset test.


This article is courtesy of

Did you know?

Great story about another great hero!

Just Cruisin 2

Remember Van Thurman Barfoot? Need a hint? He was
the guy who fought with his homeowners’ association
over putting a flagpole in his front yard in 2009.
He didn’t back down and got his flagpole. Even at
age 90 he would hoist the flag in the morning and
lower and fold it at dusk every day.

Barfoot died in 2012 when he was 92 of
complications from a fall. But we don’t remember
hearing his story before, until a friend passed
along some interesting information. So please read
on and learn a little about the man.


He was born on June 5, 1919 in Edinburg,
Mississippi. He joined the Army in 1940 and spent
the following 34 years in uniform and retired with
the rank of Colonel. He fought in World War II, the
Korean War, and the Vietnam War and was awarded a
Medal of Honor, the Silver Star…

View original post 116 more words

What is the Aid and Attendance Pension Benefit?

Filing a claim can be time-consuming and complicated. It’s important to get help.
Applications for Pension that involve a rating, evidence of prospective, recurring medical expenses, appointments for VA powers of attorney and fiduciaries, and an understanding of the actual application process should not be attempted without prior knowledge. We recommend you purchase our book to avoid lengthy delays in a decision or possible denials of the claim. Not only does the book help you understand how to shorten the decision process from VA and ensure a successful claim but the support forms we provide also help you present medical evidence and costs in a format familiar to VA service representatives. Applications that also involve reallocation of assets in order to qualify should not be attempted without the help of a qualified veterans aid and attendance benefit consultant.  

Understanding VA Pension and VA Pension with Aid and Attendance
“Aid and attendance” is a commonly used term for a little-known veterans’ disability income. The official title of this benefit is “Pension.” The reason for using “aid and attendance” to refer to Pension is that many veterans or their single surviving spouses can become eligible if they have a regular need for the aid and attendance of a caregiver or if they are housebound. Evidence of this need for care must be certified by VA as a “rating.” With a rating, certain veterans or their surviving spouses can now qualify for Pension. Pension is also available to low income veteran households without a rating, but it is a lesser dollar amount.

For information on ratings please go to the article entitled “Who is eligible for the aid and attendance Pension benefit?”

Pension Is One of Two Disability Income Benefits from VA
The Department of Veterans Affairs offers two disability income benefits for veterans who served on active duty.

The first of these benefits — Pension — is the subject of this website and is discussed briefly in a section above. The purpose of this benefit is to provide supplemental income to disabled or older veterans who have a low income. Pension is for war veterans who have disabilities that are not connected to their active-duty service. 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. There is also an asset test to qualify for Pension.

The second disability income benefit is called “Compensation” and it 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 shortly after they left the service. There is generally no income or asset test for most forms of Compensation, and the benefit is nontaxable.

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. Most elderly veterans who never applied for compensation, may not realize they can apply many years after leaving the service. In fact, VA recognizes this issue and in 2006 conducted an outreach program to these veterans in five selected states with low elderly Compensation enrollment and ended up adding an additional 8,000 beneficiaries to the roles.

Some veterans may be receiving Compensation but their condition has worsened. They can reapply and get a larger amount based on a higher disability rating. In fact, in 2007, VA expects twice as many cases of existing compensation to be reopened for new consideration as new first-time claims. In 2007, VA anticipates 216,000 new claims for Compensation but will receive 448,000 claims for reconsideration of existing Compensation benefits.

Compensation and Pension claims are submitted on the same form and VA will consider paying either benefit. If a claimant is awarded both benefits, the claimant can only receive one of them. Generally, for applications associated with the cost of home care, assisted living or nursing home care, the Pension benefit results in more income.

Of the two benefits, Compensation provides 10 times more total income and covers 6 times more beneficiaries than Pension. In 2007, Compensation will pay 3,116,728 beneficiaries a total of $34,750,690,000 and Pension will pay 523,824 beneficiaries a total of $3,671,997,000.

Compensation is a rapidly growing program and VA estimates that approximately 35% of all veterans leaving the service will eventually submit a claim for Compensation benefits. Compensation is already a major government entitlement program and currently chews up 45% of the entire VA budget. In years to come, it will continue to become a larger proportion of the Veterans Affairs and federal budget.

We will devote little mention of Compensation benefits on this site. The application process is fairly clear and requires no additional knowledge to submit a claim. The balance of this site will be devoted almost exclusively to Pension since Pension fits very nicely with long term care costs.

There are also several death benefit variations of the two disability 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 on this site only the Death Pension benefit.

Pension for Veterans with Low Income, Little Savings and Few Investments
Although the Veterans Administration does not differentiate between various Pension applicants, there are, in practice, two kinds of Pension applications. The first type of application or claim, as it’s called by VA, deals with veteran households that do not generally require the rating mentioned above in order to receive a benefit or as VA calls it, an award. These applicants will have household income less than the monthly allowable Pension rate. In addition, they will have very little in savings or investments. And, with no ratings, the size of their Pension awards will be much smaller.

It is our opinion that most veterans or their surviving spouses, receiving Pension, are in this category. We believe this is true for several reasons. One reason is that Veterans Service Representatives in the local regional office, who deal with the public, will tell callers that Pension is only available to veteran households with low income. VSR’s turn away a lot of potential applicants. This is probably because these employees are not trained sufficiently to understand the special case of veterans with higher income and high long term care costs. A second reason is that callers will be told — if they have significant savings or investments — they will not qualify as well. It is possible to give away assets in order to qualify for Pension. Naturally, Veterans Service Representatives will not mention this as an option. A third reason is that veterans with higher income and significant assets generally don’t know they can qualify for Pension under certain conditions. No one has ever told them. As a result, they never apply. A compelling fourth reason is that most people don’t know the aid and attendance Pension benefit (includes A&A allowance) can help cover home care costs paid to any person or professional providers. Most people don’t attempt to apply until they have become single and enter a nursing home where VA refuses to pay the benefit if the single claimant is eligible for Medicaid.

The table below, labeled “Exhibit 3.3,” is from a study conducted for VA to determine how many veterans might apply for Pension in coming years. The subjects of this report are most likely veterans with low household income and few assets. This group would be included because it is easy to research their demographics in government statistical reports. Those veteran households with higher income and high long term care costs would not show up in this report because it is difficult to predict how many veteran households will actually need long term care and what those costs might be.

It is apparent from the report that only about 28% of the eligible veteran households will actually apply for and receive Pension over the next seven years. It also appears from the study, that even for those households where Pension naturally fits, VA is not doing a good job of educating potential beneficiaries about this benefit or more would be applying.

In fact, the 2008 federal operating budget projected by Veterans Affairs shows a decline in the number of people applying for Pension; whereas, based on the table below, the program should be serving more than 3 1/2 times as many people as it does now.

VA wants to get the word out and in January of 2007, VA Secretary Jim Nicholson issued a news release that was carried by many major papers about this benefit. State Veterans Affairs departments also want the public to know about Pension, but lacking advertising budgets, they are not very effective at letting people know.

The table below does not reflect the number of surviving spouses of eligible veterans or their dependent children who are also eligible for a lesser Pension benefit called “Death Pension.” In 2005, approximately 207,000 of these eligible beneficiaries were also receiving Death Pension payments from VA, in addition to the 331,000 estimated living veteran beneficiaries. Since the 2005 numbers are now available, the actual number of living veteran beneficiaries in 2005, receiving Pension, was 336,000.

The following was taken from a survey by ORC Macro Economic Systems Inc., Hay Group, December 22, 2004 called “VA Pension Program Final Report”

Pension for Veterans Who Require a Rating for “Aid And Attendance” or “Housebound” in Order to Receive an Award
This is the second type of VA application generally submitted for a claim. Claimants in this category often have income above the maximum Pension rate and they may also have significant savings or investments. Typically, this category of application requires a potential beneficiary to be paying for ongoing and expensive long term care or other medical costs.

For veteran households receiving expensive long term care services and whose incomes exceed maximum Pension rates, a rating is almost always necessary in order to receive a benefit. In most cases, without a rating, there is no benefit.

Because we believe the study above does not include an estimate for individuals requiring future VA disability ratings, we offer evidence that there is a significantly larger category of potential Pension beneficiaries. This group of eligible veterans or their survivors is about 10 times larger than the one million or so anticipated eligible beneficiaries covered by the study and expected to be awarded over the next seven years. On the other hand, this larger group of roughly 10 million Pension beneficiaries can only receive an award under certain special conditions and typically only if they receive a rating.

Receipt of a Pension benefit for this larger group is generally dependent upon whether these people have a need for long term care services. But, based on the incidence of long term care in an older population, at least 60% to 80% of this larger group might have a good chance of qualifying for Pension sometime during their remaining years.

For an explanation of the special annualized treatment of unreimbursed long term care costs and insurance premiums please go to the article entitled “Understanding the special case of long term care medical costs.”

The table below examines this sizable group of potential beneficiaries and also compares them to the smaller group in “Exhibit 3.3” above. Estimates of the number of survivor beneficiaries in the table below were based on the percentage of that group actually receiving benefits over the number of living veterans actually receiving the benefit. Data for this table were taken from the 2007 Statistical Abstract of the United States for the most recent years of 2005.

What is surprising about these numbers is that a third of all people — 33% — in this country, over the age of 65, have a potential for receiving a Pension benefit.That’s how many war veterans or their survivors there are in the US.

The potential for receiving a benefit is huge. But, in actuality, only 4.7% of this large population of potential beneficiaries is actually receiving a benefit. This is truly astounding and appalling! We are working to educate both veterans AND their families so many more will begin to receive this hard earned benefit!

The Appeal of Living in a State Veterans Home

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 to 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 a 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.

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 state the veterans contribution rates are set and if there’s not enough income the family may have to make up the difference. Federal legislation, effective 2007, also allows the federal government to substantially subsidize the cost of veterans with service-connected disabilities in state veterans homes.


We believe most veterans or their families seek out residency in a state veterans nursing home because they believe this service is one more VA entitlement that should be available to them. But there is also a similar entitlement available to anyone in most private sector nursing homes–facilities that may be geographically closer to the family than the nearest veterans home. This is Medicaid. Veterans seeking long term care from VA programs generally don’t have the funds for private pay in a people in a private sector Medicaid certified facility. Most families who are seeking help for their loved ones, who are veterans, generally look to VA first before considering Medicaid. Or they are simply not aware of Medicaid. In many cases, Medicaid may be the better choice.

Aside from seeking long term care because of an expectation of entitlement are there any other reasons that veterans would prefer a state home? We ask this question of ourselves because we have noticed that in some states veterans homes are in distant rural areas. The fact that some of these homes are hundreds of miles from urban areas where the majority of veterans would tend to live, made us wonder why some veterans would move long distances to reside in these facilities.

To answer this question we contacted a number of rural state veterans homes on the phone and asked them why a veteran or his or her family would seek out their services as opposed to seeking services in a closer non-veterans facility under Medicaid. Almost unanimously the answer we got was that some veterans like the idea of sharing their living arrangement with other veterans. The facilities almost always referred to this as “camaraderie”– a band of brothers.

Statistically, private sector nursing homes are mostly populated by older women who are generally in poor health. Some men may not feel comfortable in an environment where the activities and the social atmosphere are centered on women. In contrast, veterans homes are almost exclusively populated by men. In addition, based on our observation, we suspect the population of state homes is younger and healthier than that of private sector facilities.

These demographics would suggest that activities and social atmosphere revolve around the needs of men not women. A younger, healthier population would also suggest veterans homes would offer more opportunity in the form of transportation or scheduled outings for the residents to be out in the community. One veterans home reported to us that they regularly scheduled fishing trips and outings to sporting events for their residents. These would be unheard of activities for the typical private nursing home.

The second most common reason reported to us why veterans seek out state homes is for financial reasons. In many states the cost of the home is subsidized for veterans who meet an income test. The vet’s income is considered sufficient to cover the cost. These veterans may own a home or other assets that they wish to protect from Medicaid and leave tot their family. The state veterans home will allow them to give these assets to the family without penalty. Medicaid would require a spend down of those assets or impose a penalty for gifting.

Another reason related to finances may be there are no available Medicaid beds in the veteran’s area. The veteran may be paying out of pocket ofr a nursing facility but have his name on a waiting list for a State Home where the out-of-pocket cost would be much less. When his name comes up he will move to the State home.

A financial incentive for the veteran is that all state veterans homes will apply for the pension benefit for those residents who are eligible. Federal law prohibits VA from paying any more than $90 a month to single veterans who are eligible for Medicaid in a non-veteran nursing home. State veterans homes are exempt from this rule and the single veteran can keep the entire pension amount although most of it will have to apply to the cost of care. For those state veterans homes that also accept Medicaid, pension represents additional disposable income.

Medicaid is not allowed to apply the aid and attendance allowance from pension towards the cost of care but must let the veteran retain that money. The fortunate veteran who has this additional #300-$500 a month can use this money for additional personal needs. One veterans home that has this dual arrangement with Medicaid and Va pension reports that the veterans receiving this benefit, pool the money with other veterans in the facility and it helps pay for dinner tickets, theatre tickets, expensive outings and other amenities that would not normally be available to private sector nursing home residents.


The Veterans Administration pays the state veterans homes an annually adjusted rate per day for each veteran in the home. This is called the per diem. In most states the per diem falls we short of this goal.

The per diem program and construction subsidies mean that State veterans homes can charge less money for their services than private facilities. Some states have a set rate, as an example, $1400/mo, and they may be relying on the pension benefit with aid and attendance plus the per diem to cover their actual costs. Other states may charge a percentage of the veterans income but be relying on other subsidies to cover the rest of the cost.

Most of the states with income-determined rates are selective about the veterans they accept. These states may rely on a variety of private and public sources to help fund the cost of care.

States without set rate subsidies may charge 50% to 70% of the rate of private facilities based on private or semi private room occupancy and if the veteran does not have enough income, these homes accept Medicaid or Medicare to make up the difference. In these state the veterans homes are Medicaid and possibly Medicare certified.


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 the 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. A far as state veterans homes go you should think of domiciliary as a substitute for supported independent living retirement.

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.