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.
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.
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.