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WELCOME. To the Department of Illinois Veterans of Foreign Wars 2010 Service Officer’s Seminar. Service Officer’s Seminar. Agenda Review: Duties & Responsibilities of Post Service Officer Principles of VA Benefits Recent changes in VA forms Recent significant changes in VA regulations

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slide1

WELCOME

To the

Department of Illinois

Veterans of Foreign Wars

2010 Service Officer’s Seminar

service officer s seminar
Service Officer’s Seminar

Agenda

Review:

Duties & Responsibilities of Post Service Officer

Principles of VA Benefits

Recent changes in VA forms

Recent significant changes in VA regulations

Main Agenda Topic:

Principles of Non Service Connected Benefits

slide3

Duties & Responsibilities of Post Service Officer

Confidentiality

Identification of Potential Claims

Assist or Refer claimants to:

Department Service Officer

County Veterans Assistance Commission

Illinois Department of Veterans Affairs

slide4

Veteran Disability Benefits

Service Connected vs Non-Service Connected

All VA Benefits Are Affected

Service Connection = Compensation $

Compare to Workman’s Compensation

Non-Service Connection = Pension $

Compare to Social Security

slide5

Principles of Service Connected Benefits

Methods of Service Connection

Direct

Presumption

Secondary

Aggravation

Pre-existing condition

Non SC condition

Other

Result of VA Treatment

Result of Voc Rehab

slide6

New VA Forms

VA Form 21-526 – Compensation claim

VA Form 21-526b – Reopened Compensation

VA Form 21-526EZ – Fully Developed claim

VA Form 21-527EZ – Pension claim

slide8

PTSD

Regulatory Changes in

Stressor Criteria to establish

service connection for PTSD

effective July 13, 2010

No Changes in Evaluation Criteria

slide10

OLD CRITERIA

Requirements for a Service-Connection Claim for PTSD: 38 CFR 3.304 (f)

a. A current diagnosis of PTSD (which must conform to the diagnostic criteria in DSM-IV);

b. Credible supporting evidence that the claimed in-service stressor actually occurred; and,

c. Medical evidence of a causal nexus between the current symptoms and the claimed in-service stressor.

slide11

OLD CRITERIA

Requirements for a Service-Connection Claim for PTSD: 38 CFR 3.304 (f)

a. A current diagnosis of PTSD (which must conform to the diagnostic criteria in DSM-IV);

b. Credible supporting evidence that the claimed in-service stressor actually occurred; and,

link

c. Medical evidence of a causal nexus between the current symptoms and the claimed in-service stressor.

slide12

(1) If the evidence establishes a diagnosis of posttraumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

slide13

(2) If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

slide14

(3) If the evidence establishes that the veteran was a prisoner-of-war under the provisions of §3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

slide15

(4) If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident.

VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred.

slide16

To prove a service-connection claim for PTSD, the veteran is required to provide “credible supporting evidence that the claimed in-service stressor occurred.”

  • That is, the veteran must show that the stressful event(s) which the he alleges resulted in PTSD actually happened during military service unless proof of combat experience by combat awards are consistent with claim.
  • Veteran’s oral history will not suffice in the absence of combat award.
slide17

PTSD does not need to have its onset during combat.

For example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters would evoke significant distress in most involved persons.

The trauma may be experienced alone (rape or assault) or in the company of groups of people (military combat).

slide18

A stressor may not to be limited to just one single episode. A group of experiences also may affect an individual, leading to a diagnosis of PTSD.

For example, assignment to a grave registration unit, burn care unit, medivac unit (pilot, crew member), combat trauma unit (nurse, doctor) or liberation of internment camps could have a cumulative effect of powerful, distressing experiences essential to a diagnosis of PTSD.

slide19

PTSD as a medical finding can be caused by events which occur before, during or after service.

The relationship between stressors during military service and current symptoms will govern the question of service connection.

Symptoms must have a clear relationship to the military stressor as described in the medical reports.

slide20

PTSD can occur hours, months, or years after a military stressor. Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms.

This association between stressor and symptoms must be specifically addressed in the VA examination report and to a practical extent supported by documentation.

slide21

Every decision involving the issue of service connection for PTSD alleged to have occurred as a result of combat must include a factual determination by VA as to whether or not the veteran was engaged in combat, including the reasons or bases for that finding.

slide22

Any evidence available from the service department indicating that the veteran served in the area in which the stressful event is alleged to have occurred and any evidence supporting the description of the event are to be made part of the record. Corroborating evidence of a stressor is not restricted to service records, but may be obtained from other sources. If the claimed stressor is related to combat, in the absence of information to the contrary, receipt of any of the following individual decorations will be considered evidence of participation in a stressful episode:

slide23

Air Force Cross

Air Medal with "V" Device

Army Commendation Medal with "V" Device

Bronze Star Medal with "V" Device

Combat Action Ribbon

Combat Infantryman Badge

Combat Medical Badge

Distinguished Flying Cross

Distinguished Service Cross

Joint Service Commendation Medal with "V" Device

Medal of Honor

Navy Commendation Medal with "V" Device

Navy Cross

Purple Heart

Silver Star

slide24

A combat veteran's lay testimony alone may establish an in-service stressor for purposes of service connecting PTSD .

However, a noncombat veteran's testimony alone does not qualify as "credible supporting evidence" of the occurrence of an in service stressor as required by 38 CFR 3.304(f).

After-the-fact psychiatric analyses which infer a traumatic event are likewise insufficient in this regard.

slide25

Personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking.

If the military record contains no documentation that a personal assault occurred, alternative evidence might still establish an in-service stressful incident.

Behavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor.

slide26

In personal assault claims, secondary evidence may need interpretation by a clinician, especially if it involves behavior changes. Evidence that documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician.

slide27

NEW PTSD

STRESSOR CRITERIA

All prior criteria remains in place. Nothing has been eliminated from prior regulation.

There has been a new paragraph added to the regulation which addresses those cases that cannot be resolved based on verified combat participation.

slide28

New Paragraph

(3) If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

slide29

For purposes of this paragraph, ‘‘fear of hostile military or terrorist activity’’ means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.

slide30

The new rule will apply to claims:

  • received by VA on or after July 13, 2010;
  • received before July 13, 2010 but not yet decided by a VA regional office;
  • appealed to the Board of Veterans' Appeals on or after July 13, 2010;
  • appealed to the Board before July 13, 2010, but not yet decided by the Board; and
  • pending before VA on or after July 13, 2010, because the Court of Appeals for Veterans Claims vacated a Board decision and remanded for re-adjudication.
slide31

What does this final regulation do?

This final regulation liberalizes the evidentiary standard for Veterans claiming service connection for post traumatic stress disorder (PTSD). Under prior regulations governing PTSD claims, unless the Veteran was a combat Veteran, VA adjudicators were typically required to undertake extensive record development to corroborate whether a Veteran actually experienced the claimed in-service stressor.

slide32

How does this final regulation help Veterans?

The final regulation will simplify and streamline the processing of PTSD claims, which will result in Veterans receiving more timely decisions. A Veteran will be able to establish the occurrence of an in-service stressor through his or her own testimony, provided that:

(1) the Veteran is diagnosed with PTSD;

slide33

(2) a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted confirms that the claimed stressor is adequate to support a PTSD diagnosis;

(3) the Veteran's symptoms are related to the claimed stressor;

and

slide34

(4) the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service and the record provides no clear and convincing evidence to the contrary.

This will eliminate the requirement for VA to search for records, to verify stressor accounts, which is often a very involved and protracted process. As a result, the time required to adjudicate a PTSD compensation claim in accordance with the law will be significantly reduced.

slide35

How does VA plan to monitor the need for examiners in various regions of the country, and how does VA plan to respond if is determined that more examiners are needed in a particular region?

The Veterans Health Administration (VHA) has written into the FY11-13 Operating Plan the need for additional staff to support doing adequate, timely exams.

slide36

VHA proposes: Increase mental health field staff to address the increase in C&P examinations and develop monitoring system to ensure clinical delivery of mental health services does not decrease in VHA. Specifically, VHA has requested 125 clinicians for FY11 with additional 63 staff in FY12 if the need exists. If the Operating Plan and the proposed budget are approved, VA proposes asking the Veterans Integrated Service Networks (VISNs) to develop plans for distributing the funds in order to ensure adequate coverage at sites based on number of claims being processed; the VISNs are well positioned to determine these regional needs.

slide37

What circumstances will still require stressor verification through DoD’s Joint Services Records Research Center (JSRRC) , VBA’s Compensation &Pension Service (C&P Service), or other entity if a Veteran claims that his or her stressor is related to a fear of hostile or terrorist activity?

The regulatory revision will greatly lessen the need for undertaking development to verify Veterans’ accounts of in-service stressors. Now, stressor development may only need to be conducted if a review of the available record, such as the Veteran’s service personnel and/or treatment records, is inadequate to determine that the claimed stressor is “consistent with the places, types and circumstances of the veteran’s service.”

slide38

In such circumstances, the Veterans Service Representative (VSR) will determine on a case-by-case basis what development should be undertaken.

However, it is anticipated that in the overwhelming majority of cases adjudicated under the new version of § 3.304(f), a simple review of the Veteran’s service treatment and/or personnel records will be sufficient to determine if the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service. We also believe that, in some cases, a Veteran’s separation document, DD-Form 214, alone may enable an adjudicator to make such a determination.

slide39

As the regulatory revision seems to require an enhanced role for the examining VA mental health professional, whose role is it to determine whether the claimed stressor is consistent with the Veteran’s service?

VA adjudicators, not the examining psychiatrist or psychologist, will decide whether the claimed stressor is consistent with the Veteran’s service.

slide40

Is a Veteran's testimony about “fear of hostile military or terrorist activity” alone sufficient to establish a stressor?

Yes, if the other requirements of the regulation are satisfied, i.e., a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a PTSD diagnosis and that the Veteran's symptoms are related to the claimed stressor, and the stressor is consistent with the “places, types, and circumstances of the Veteran’s service.”

slide41

Are the stressors accepted as adequate for establishing service connection under new § 3.304(f)(3) limited to those specifically identified in the new regulation?

No. The examples given in the revised regulation do not represent an exclusive list in view of the use of the modifying phrase “such as” that precedes the listed examples. Any event or circumstance that involves actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, would qualify as a stressor under new § 3.304(f)(3).

slide42

How will the Veterans Health Administration (VHA) work with Veterans Benefits Administration (VBA) on the new regulation?

VHA was actively involved in discussion with VBA of the new regulation and fully supports the new regulation.

slide43

The new regulation will provide fair evaluation for Veterans whose military records have been damaged or destroyed, or for whom no definitive reports of combat action appeared in their military records, even though they can report such actions and it is reasonable to believe that these occurred, given the time and place of service.

slide44

This will be especially beneficial to women Veterans, whose records do not specify that they had combat assignments, even though their roles in the military placed them at risk of hostile military or terrorist activity.

slide45

This means that more Veterans will become eligible for VA care and thus be able to receive VA care for mental illness (PTSD) related to their military service, as well as receiving full holistic health care. VHA will work actively with VBA on implementing the regulation.

slide46

VHA staff’s main role is as clinicians conducting C&P interviews to establish diagnoses and obtain other information to be used by VBA raters to determine the outcome of claims.

The new regulation will not change the diagnostic elements of the C&P interview, but may change what additional data are collected for use by VBA raters.

slide48

Service Connection due to Herbicide Exposure

38CFR 3.309 (e)

Requires exposure to herbicides by:

Service in Vietnam

OR other specific locations

List of recognized locations

OR proof of individual exposure

Lets Look at the Current List of Conditions Recognized to be the result of Exposure

slide49

Amyloidosis (AL)

Chloracne or other acneform disease

Type 2 diabetes mellitus

Hodgkin’s disease

Chronic lymphocytic leukemia (CLL)

Multiple myeloma

Non-Hodgkin’s Lymphoma (NHL)

Acute and sub-acute peripheral neuropathy

Porphyriacutaneatarda (PCT - liver disease)

Prostate cancer

Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea)

Soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma)

slide50

Added to list of presumptive conditions:

All chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia CLL)

Parkinson’s disease

Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina)

slide51

Note : For purposes of this section, the term ischemic heart disease does not include:

hypertension

or

peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke,

or

any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease.

how will the va deal with prior claims
How will the VA deal with prior claims?

The Nehmer Court Decision applies!

What is the Nehmer Court Decision?

slide53

38 CFR 3.816

This section states effective-date rules required by orders of a United States district court in the class-action case of Nehmer v. United States Department of Veterans Affairs for disability or death caused by a condition presumptively associated with herbicide exposure.

Nehmer class member means:

(i) A Vietnam veteran who has a covered herbicide disease; or

(ii) A surviving spouse, child, or parent of a deceased Vietnam veteran who died from a covered herbicide disease.

slide54

(1) If VA denied compensation for the same covered herbicide disease in a decision issued between September 25, 1985 and May 3, 1989, the effective date of the award will be the later of the date VA received the claim on which the prior denial was based or the date the disability arose

slide55

(2) If the class member's claim for disability compensation for the covered herbicide disease was either pending before VA on May 3, 1989, or was received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose

slide57

Agent Orange & Blue Water Sailors

Veterans who served on open sea ships off the shore of Vietnam during the Vietnam War are sometimes called “Blue Water Sailors.”

Sample: USS Kitty Hawk, aircraft carrier

In January 2009, the US Supreme Court effectively let stand an earlier court ruling that requires a Veteran to have served on land or on the inland waterways of Vietnam in order to be presumed exposed to Agent Orange.

slide58

38 CFR 3.307: A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service.

General Counsel Opinion: Service on a deep-water naval vessel in waters off the shore of the Republic of Vietnam does not constitute service in the Republic of Vietnam.

slide59

Some ships offshore also conducted operations on the inland waterways of Vietnam. Veterans are presumed exposed to Agent Orange if they served aboard these ships when the ships were on the inland waterways of Vietnam anytime between January 9, 1962 and May 7, 1975.

PRESUMPTION: Sailors that served on ships confirmed to have served on the inland waters or on ships that are confirmed to have docked are presumed to have had feet on the ground. A presumption of feet on the ground results in presumed exposure to herbicides.

slide60

If no presumption can be shown Blue Water Veterans must show on a factual basis that they were exposed to herbicides during military service in order to receive disability compensation for diseases associated with herbicide exposure. 

VA and DOD continue to cooperate to establish the expanding list of naval vessels that served on the inland waterways of Vietnam.

Current list of ships.

slide61

VA has asked the National Academy of Sciences Institute of Medicine (IOM) to review the medical and scientific evidence regarding Blue Water Veterans’ possible exposure to Agent Orange.

IOM is evaluating:

Historical background of the Vietnam War comparing Blue Water Navy, “boots on ground” combat troops, and Brown Water Navy (includes inland waters).

slide62

Exposure levels among Blue Water Navy relative to ground troops in Vietnam or other contemporaneous ground troops deployed elsewhere (“era” Veterans).

  • Comparative exposures for troops on the ground and troops aboard ships in the context of all possible routes of exposure, including herbicide “overspray,” and consumption of contaminated water and food.
slide63

A wide range of potential herbicide and dioxin exposure mechanisms including potential concentrating toxics in drinking water; air exposure possibly from drift from spraying; food; soil; skin, etc.

Comparative risks for long-term health outcomes comparing Vietnam Veteran ground troops, Blue Water Navy Veterans, and other “Era” Veterans serving during the Vietnam War at other locations (assuming relative herbicide and dioxin exposures can be assessed).

slide64

This will be based on previous IOM Veterans and Agent Orange study conclusions on long-term health outcomes from herbicide exposure.

And

Existing studies of Blue Water Navy Veterans for reported health outcomes.

A report should be completed and available by summer 2011.

slide66

Expanded List of Presumptive Conditions for Service Connection due to Service in Iraq and Afghanistan

38 CFR 3.317: For Gulf War Veterans (Desert Shield / Desert Storm), VA has previously recognized certain unexplained clusters of symptoms existing for six months or more as associated with military service in the Gulf.  The illnesses must have appeared during active duty in the Southwest Asia Theater of Operations or by December 31, 2011, and be at least 10 percent disabling. 

slide67

The term Gulf War veteran means a veteran who served on active military, naval, or air service in the Southwest Asia theater ofoperations.

The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations during the Persian Gulf War.

slide68

Illnesses include medically unexplained clusters of symptoms that have existed for six months or more, such as:

Chronic fatigue syndrome

Fibromyalgia

Irritable bowel syndrome

OR

any diagnosed or undiagnosed illness that VA’s Secretary determines should be presumed to be associated with Gulf War service

slide69

Signs or symptoms of an undiagnosed illness may include:

Abnormal weight loss

Cardiovascular signs or symptoms

Fatigue

Gastrointestinal signs or symptoms

Headache

Joint pain

Menstrual disorders

Muscle pain

Neurologic signs or symptoms

Neuropsychological signs or symptoms

Signs or symptoms involving the skin

Signs or symptoms involving respiratory system

Sleep disturbances

slide70

VA has added nine specific infectious diseases as associated with military service in Southwest Asia during the Gulf War from 1990 to the present and in Afghanistan on or after September 19, 2001.

The nine diseases are:

Brucellosis

Campylobacter jejuni

Coxiella burnetii (Q fever)

Malaria

Mycobacterium tuberculosis

Nontyphoid Salmonella

Shigella

Visceral leishmaniasis

West Nile virus

slide71

The final regulation was published in September 2010.

Eligible Veterans may now receive disability compensation for these diseases.

You may apply online now, so VA can begin development of your claim.

slide73

TOPICS

Veteran’s Disability Pension

Death Pension

slide74

Principles of Non-Service Connected Pension

Pension is an income based benefit which guarantees eligible veterans with a minimum level of income.

There three levels of pension benefits:

Basic

Housebound

Aid & Attendance

slide75

Eligibility to Pension Benefits

90 days active duty other than active duty for training, one day of which must have been wartime

WWII 12-7-41 to 12-31-46*

Korea 6-27-50 to 1-31-55

Vietnam 8-5-64 to 5-7-75*

Or

If after 9-7-80, a continuous period of active duty of 24 months or the full period for which called to active duty, after 8-2-90 to some future date

slide76

Eligibility to Pension Benefits

Totally Disabled War Time Veteran

Over Age 65 – total disability presumed

Under 65 - Rated Permanent & Total Disabled

Single 60% disability, or

Combined 70% with major 40% disability

Disabilities determined to be permanent

Found to be totally disabled by another government agency

slide77

Combined Ratings

38CFR 4.25 – whole man concept

Below kneeamputation40%

Depression 30%

Bilateral hearing loss 20%

Arthritis, shoulder 10%

Headaches 10%

Hypertension 10%

Spinal Disc syndrome 10%

Peptic Ulcer 10%

Combined disability 80%

slide78

Whole Man Concept – a man is 100% whole

40% of 100 = 40 100-40= 60

30% of 60 = 18 18+40=58 100-58 = 42

20% of 42 = 8 58+8=66 100-66 = 34

10% of 34 = 3 66+3=69 100-69 = 31

10% of 31 = 3 69+3=72 100-72 = 28

10% of 28 = 3 72+3=75 100-75 = 25

10% of 25 = 3 75+3=78 100-78 = 22

10% of 22 = 2 78+2=80

slide79

Dependants for Pension Purposes

Spouse

Child (minor, disabled, school)

Natural Child

Step Child

Illegitimate Child

Adopted Child

slide80

NSC Basic Pension Rates

Status Annual limit Monthly limit

Veteran $11,830 $ 985

Veteran w/dep $15,493 $1,291

Each Add Dep $2,020 $ 168

slide81

For pension purposes the VA counts HOUSEHOLD income from ALL SOURCES.

Retirement: Social Security & Private pension

Spousal earnings

Investment income

Interest

Rental income

Gambling & Lottery

Garage sales

Babysitting

ALL SOURCES !!

slide82

The VA also considers pension entitlement based on household assets.

The consideration of assets is based on the question: Can the size of the asset provide for the veteran’s needs during his anticipated life expectancy?

In general the asset limit at which the VA will begin evaluating the question is $80,000 excluding the family home in most cases.

Assets include all other real property and convertible financial instruments.

slide83

Pension Calculation

Max benefit – annual income = annual benefit / 12

Veteran Max benefit: $11,830

Social Security $ 6,000

Retirement pension $ 3,600

Other, interest, etc $ 1,200

Total Income $10,800

Annual Benefit $ 1,030

Monthly Benefit $ 85

slide84

In determining final income for VA purposes (IVAP), VA will take into consideration household medical expenses for those persons in the home that the veteran is responsible for.

Allowable medical expenses are the total countable expenses which exceed 5% of the maximum pension benefit based on the number of claimable dependents.

Deductable = 5% of $11,830 = $591

Medical Expense deductible = $591 / $774

slide85

The VA is very liberal in the consideration of countable medical expenses.

The VA will allow:

Doctor visit costs or co-pays

Prescription costs or co-pays

Health insurance premiums

Non prescription medicines and supplies

Milage to doctor visits

In home medical care

Nursing care

slide86

Based on this information or a specific request the VA may consider a portion of the reported annual medical expenses to be recurring for purpose of calculating future pension entitlement.

The formula calculation then becomes:

Reportable medical expenses – deductable = allowable medical expenses.

Reported income – allowable medical expenses = income for VA purposes (IVAP)

Maximum benefit – IVAP = annual payable benefit

Annual payable benefit / 12 = monthly benefit

slide87

Veteran Max benefit: $11,830

Social Security $ 6,000

Retirement pension $ 3,600

Other, interest, etc $ 1,200

Total Income $10,800

Reportable Medical Expenses $ 2,892

Deductible $ 591

Allowed Medical Expenses $ 2,301

Income for VA Purposes $ 8,499

Annual Benefit $ 3,331

Monthly Benefit $ 277

slide88

Special Monthly Pension (SMP) Benefits

The first level of SMP is Housebound (HB)

Housebound benefits are granted when the claimant is determined to be essentially confined to his home except for with the assistance of another person.

Housebound status can only be granted when the qualifying disability is permanent

slide89

Special Monthly Pension (SMP) Benefits

The second level of SMP is

Aid & Attendance (A&A)

A&A benefits are granted when the claimant is determined to be in the need of aid & attendance of another person to protect themselves from the hazards of daily living and keep themselves clean.

A&A benefits may be conceded when the claimant is in the receipt of nursing care in a state licensed nursing care facility.

slide90

NSC Special Monthly Pension Rates

Status Annual limit Maximum Monthly Benefit

Vet Basic $11,830 $ 985

Vet w/ one dep 15,493 1,291

Vet Housebound $14,457 $ 1,204

Vet w/ one dep 18,120 1,510

Vet A&A $19,736 $ 1,644

Vet w/ one dep 23,396 1,949

slide91

Death Pension

Un-remarried spouse of Wartime Veteran

One year marriage requirement*

No age requirement

No disability requirement

Low income benefit

slide92

Death Pension Rates

Status Annual Benefit Monthly Benefit

Spouse $ 7,933 $ 661

W/one dep 10,385 865

Housebound $ 9,696 $ 808

W/one dep 12,144 1,012

A&A $12,681 $ 1,056

W/one dep 15,128 1,260

Medical expense deductible - $397 / $520

slide93

Lets look at a realistic situation:

Veteran is married, 87 years old, has Alzheimer's and suffers from the residuals of stroke. Vet has been prescribed by his doctor to be in the need of home nursing care due to his disabilities. Doctor has completed VA Form 21-2680 which describes his needs, abilities and limitations. Based on the provided evidence the VA has determined in a rating board decision that the vet is in need of the aid & attendance of another person.

What evidence does the VA need to make an award?

slide94

VA must have complete income, net worth and medical expense data.

Income: month annual

Vet Social Security $1,196.40 $14,356.80

Vet retirement 615.00 7,380.00

Spouse Social Security 876.40 10,516.80

Spouse retirement 443.00 5,316.00

Interest on investment 150.00 1,800.00

Total household income $39,369.60

slide95

Problem??

Maximum income limit for veteran in need of A&A with one dependent??

$23,396 annually

Vet’s household income is $39,369.60

Vet is $16,000 over income for pension.

What is the possibility?

slide96

Vet and his wife have medical expenses:

monthly annual

Vet Medicaid premium $ 96.40 $1,156.80

Wife Medicaid premium 96.40 1,156.80

Supplemental insurance policy premium

210.00 2,520.00

Vet prescriptions 310.00 3,720.00

Wife prescriptions 42.50 510.00

MD visit co-pays 50.00 600.00

Vet diapers 144.00 1,728.00

Non prescription needs 32.00 384.00

Nursing Aid (12x6x30) 2,160.00 25,920.00

Total $ 37,695.60

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Remember our formula?

Reportable medical expenses – deductable = allowable medical expenses.

Reported income – allowable medical expenses = income for VA purposes (IVAP)

Maximum benefit – IVAP = annual payable benefit

Annual payable benefit / 12 = monthly benefit

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Reportable medical expenses $37,695

Deductable (vet w/one dep) 774

Allowable medical expenses 36,921

Reported Household Income 39,369

Allowable Medical Expenses 36,921

Income for VA Purposes 2,448

Max VA benefit (vet A&A w/one dep) 23,396

IVAP 2,448

Annual Payable Benefit 20,948

Monthly Benefit $1,745

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Annually, the first of each year, the VA solicits an income and medical expense report from the veteran.

Based on this information the VA will make a retroactive adjustment on past pension entitlement and either pay a retroactive benefit or create an overpayment.

The VA will also make an annual decision of continued pension entitlement based on any changes which may have occurred.

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Claimants requiring nursing care but not in a licensed nursing home must be able to document the services provided and the cost of those services. Nursing (medical) services must be separated from housekeeping services or room & board such as in an Assisted Living or Adult Foster Care facility.

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Certification that a claimant is receiving nursing services as a patient in a licensed nursing home will be accepted as evidence of the need for aid & attendance. The full cost of nursing home care will be accepted as medical expense for pension purposes

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MEDICAID and VA Pension

Maximum benefit payable to either veteran on pension or surviving spouse on death pension in a MEDICAID nursing care bed is $90.00 monthly.