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M21-1, Part III, Subpart v, Chapter 6, Section C – Adjusting Awards Involving an Aid and Attendance (A&A) Allowance

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4
5

1.  General Information on the Reduction of A&A Upon Hospitalization


Introduction

This topic contains general information on the reduction of A&A when a Veteran is hospitalized, including

Change Date

March 27, 2018

III.v.6.C.1.a.  Regulatory Requirements of 38 CFR 3.552

The provisions of 38 CFR 3.552(b)(1) require the discontinuance of additional compensation or increased disability pension for aid and attendance (A&A) effective the first day of the second calendar month following the month of admission to a Department of Veterans Affairs (VA) medical center (VAMC), unless the disability is
  • paraplegia involving paralysis of both lower extremities together with the loss of anal and bladder control
  • Hansen’s disease, or
  • in pension cases only, blindness (visual acuity 5/200 or less) or concentric contraction of visual field to 5 degrees or less.
Exception:  When a Veteran entitled under 38 U.S.C. 1114(r) is hospitalized at U.S. Government expense, discontinuance of A&A is required under 38 CFR 3.552(b)(2).
References:  For more information about

III.v.6.C.1.b.  Effect of the Recovery of Cost of Care

Under 38 U.S.C. 1729, the United States has the right to recover or collect the cost of medical care VA furnishes to a Veteran for treatment of a non-service connected disability.  Costs recoverable from insurance companies or other third parties liable under a healthcare contract are the amounts the Veteran or the service provider would be able to receive if the care had not been provided by the United States.  However, recovery of such costs does not limit the applicability of 38 CFR 3.552(b)(1).

III.v.6.C.1.c.  Screening CAPRI Reports

Use the Special Report for A&A/Pension option available in the Compensation and Pension Record Interchange (CAPRI) Reports menu in CAPRI to generate reports for Veterans who are
  • in receipt of A&A and still active patients, or
  • discharged at government expense.
Example:
Image of the CAPRI Reports Menu screen
Screen each report against information in the corporate record and, if necessary, review the claims folder to determine if an adjustment under 38 CFR 3.552 is required.
Reference:  For more information on generated reports, see the CAPRI User Guide.

III.v.6.C.1.d.  Due Process and Control Procedures for Hospitalization

Notice of proposed adverse action is required before reducing or adjusting an award.  Provide proper notification by
  • preparing two notices of proposed adverse action, sending
    • one notice to the Veteran’s address of record, and
    • one notice to the Veteran at the medical facility
  • incorporating into the notice of proposed adverse action any potential action to be taken if the Veteran is subject to further reduction under 38 CFR 3.551
  • establishing an end product (EP) 600 control to mature 65 days from the date that the notice of proposed adverse action is sent, and
  • clearing EP 135.
Reference:  For information on notice of proposed adverse action requirements, see M21-1, Part I, 2.B.1.

III.v.6.C.1.e.  Procedures for Reducing Awards for Hospitalization

After the control period expires (or sooner, if the Veteran asks VA to take action to reduce the amount of potential overpayment),
  • discontinue payment of the A&A allowance effective the first day of the second calendar month following the month of admission
  • request a notice of discharge to determine if the Veteran remains hospitalized
  • send the Veteran final notification of the reduction, and
  • determine the rate payable, as outlined in M21-1, Part III, Subpart v, 6.C.1.g.

III.v.6.C.1.f.  VETSNET Adjustment of A&A Due to Hospitalization

When completing A&A or hospitalization adjustments, utilize the following screens in the claims-processing system:
  • Use the INSTITUTIONALIZATION screen to record basic information, such as the
    • facility where hospitalized, and
    • inclusive dates of hospitalization.
  • The INSTITUTIONALIZATION ADJUSTMENTS screen can identify the type of benefit or type of adjustment involved, such as adjustment of SMC.
Reference:  For more detailed information on adjusting awards using

III.v.6.C.1.g.  Determining Hospitalization Rate Payable

Use the table below to determine the award rate payable when discontinuing the A&A allowance during hospitalization of the Veteran.
If the benefit is …
Then …
pension
award the housebound rate effective the date of reduction per 38 CFR 3.552(e), subject to further reduction under one of the following, as appropriate:
Notes:
  • If the Veteran is also eligible for service-connected  compensation, and the reduction of pension results in compensation being the greater benefit,
    • ask the Veteran whether he/she wishes to elect compensation, and
    • do not pay the greater benefit unless the election is received.
  • An election is not a claim.  Rather, it represents a beneficiary’s confirmation of his/her choice to receive one type of benefit over another.
    • VA does not require beneficiaries to use a prescribed form to make an election.  Under 38 CFR 3.701(b), VA may accept as an election a statement from a beneficiary.
    • An election does not need to meet the requirements of a complete claim, as defined in 38 CFR 3.160(a).
  • If the income for VA purposes (IVAP) exceeds the housebound rate, prepare an award with a withholding of the rate payable based on the A&A entitlement.
compensation
determine entitlement to the housebound or other appropriate hospitalized rate, as shown in the Disability Compensation – Basic Rates table, under one of the following provisions:

2.  Determining the Need for a Hospital Summary


Introduction

This topic contains information on determining the need for a hospital summary, including when a hospital summary

Change Date

March 27, 2018

III.v.6.C.2.a.  When a Hospital Summary Is Required

A hospital summary is required in cases that involve conditions that are subject to improvement.
Follow the steps in the table below to request the appropriate reports in these cases.
Step
Action
1
In cases involving conditions subject to improvement, and in cases in which authorization has granted A&A on the basis of nursing home patient status, request a
  • discharge report, and
  • hospital summary.
Note:  A condition subject to improvement may be identified by a scheduled review examination shown on the latest rating decision or in the master record.
Reference:  For more information about review examinations, see
2
After receiving a notice of discharge showing release from hospital care or other termination of VA care, restore the allowance for A&A effective the date of release from hospitalization.
3
Control the case for receipt of the final summary by establishing a local diary.
4
After receiving the hospital summary, refer the case to the rating activity for consideration of continued entitlement.
5
If the final summary shows that the Veteran
  • returned to a nursing home, file the summary in the claims folder, or
  • did not return to a nursing home, determine continued entitlement to the A&A allowance on a factual basis.
Notes:
  • If a claimant is admitted to a nursing home with costs covered by Medicaid, see special instructions in M21-1, Part V, Subpart iii, 3.1.
  • If a Veteran was entitled to special monthly pension (SMP) for A&A and the pension is discontinued due to excess income, the Veteran may still be entitled to drugs and medicines from VA.
References:  For more information on the

III.v.6.C.2.b.  When a Hospital Summary Is Not Required

A hospital summary is not required when
  • a rating decision has properly granted A&A, and
  • the condition on which A&A is based is
    • not subject to improvement (no future examination), or
    • terminal.
In these cases, request only a discharge report.  Reinstate the benefit following release from VA care.

3.  Granting or Discontinuing an A&A Award During Hospitalization


Introduction

This topic contains information on granting or discontinuing an A&A award during hospitalization, including

Change Date

April 21, 2015

III.v.6.C.3.a.  Granting an A&A Award

Use the table below to determine the appropriate actions to take when granting an A&A award during hospitalization of a Veteran.
If the grant …
Then …
is from an effective date prior to the first day of hospitalization
  • award the full benefit from the first day of the month following the effective date of entitlement
  • reduce the benefit effective the first day of the second calendar month following admission, in accordance with 38 CFR 3.552(a)(1), and
  • award the
    • housebound rate in pension cases, and
    • applicable hospitalized rate in compensation cases.
involves an effective date of initial entitlement that is on or after the date of hospitalization
  • do not pay the A&A allowance until the date of discharge or release from the hospital, and
  • pay the Veteran the housebound rate from the first day of the month following the date of the grant until the date of discharge, per 38 CFR 3.552(k).
Note:  Payment of the housebound rate is subject to the 38 CFR 3.551 reduction requirement in pension cases

III.v.6.C.3.b.  Discontinuing an A&A Award

If entitlement to A&A or the housebound rate while hospitalized is discontinued by rating while the Veteran is hospitalized
  • continue the hospital rate
  • send notice of proposed adverse action to the Veteran
  • set a control for 65 days from the date the notice of proposed adverse action is sent, and
  • reduce the award and send final notification to the Veteran after the control period ends.
Note:  If the IVAP exceeds the housebound rate, see M21-1, Part III, Subpart v, 6.C.1.g.

4.  Adjusting an A&A Award When a Veteran Leaves or Returns to a Hospital


Introduction

This topic contains information on adjusting an award when a Veteran is discharged from, granted an authorized absence from, or returns after an absence from a hospital, including

Change Date

March 27, 2018

III.v.6.C.4.a.  Resuming the Payment of Benefits at the A&A Rate Upon Discharge From a Hospital

After receiving a notice of discharge from the hospital, resume the payment of benefits at the A&A rate, effective the date of discharge, without waiting for receipt of a hospital report.

III.v.6.C.4.b.  Adjusting for Hospital Absences of 30 Days or More

Adjust benefit payments for authorized absences from the hospital of 30 days or more as follows:
  • After receiving a report showing an authorized absence of 30 days or more, amend compensation or pension to restore payment at the full A&A rate effective the date the Veteran left the hospital, under 38 CFR 3.401(a)(2).
  • After receiving a report showing hospitalization resumed, discontinue the additional allowance for A&A effective the date of readmission to a VA hospital or the resumption of hospitalization at VA expense, under 38 CFR 3.556(a)(2), for Section 306 or Old-Law Pension.  Reduce
    • Old-Law Pension to $30, or
    • Section 306 Pension to $50.

III.v.6.C.4.c.  When an Authorized Absence of 30 Days or More Occurs During an Initial Period of Hospitalization

Under 38 CFR 3.556(a)(1), do not continue a reduced payment for Old-Law or Section 306 Pension when a report showing non-bed care status or authorized absence of 30 days or more is received during an initial period of hospitalization.  When notice of non-bed care status or authorized absence of 30 days or more is received, restore the regular pension rate for
  • Old-Law Pension effective from the date of reduction, or
  • Section 306 Pension effective from the date of departure from the hospital.
For either Old-Law or Section 306 Pension, if entitlement to the A&A allowance had been established, resume payment for SMP effective the date of departure from the hospital.

III.v.6.C.4.d.  When a Veteran Returns From an Authorized Absence of 30 Days or More

Take the following actions under 38 CFR 3.556(a)(2) when a Veteran resumes his/her hospitalization after an authorized absence of 30 days or more.
  • Discontinue any allowance for A&A from the date of readmission.
  • Reduce Old-Law Pension to $30 effective the date of readmission, under38 CFR 3.551(b).
  • Reduce Section 306 Pension to $50 effective the date of readmission, under 38 CFR 3.551(c).

III.v.6.C.4.e.  Example:  Report of a 30-Day Authorized Absence Received During an Initial Period of Hospitalization

Situation:  A Veteran receiving Section 306 Pension with SMP for A&A is
  • admitted for VA hospitalization on August 10
  • granted a 30-day absence on November 15, and
  • readmitted for VA hospitalization on January 5 of the following year.
Result:
  • The award is reduced to
    • the housebound rate, effective October 1, under 38 CFR 3.552(b)(1), and
    • $50, effective November 1.
  • SMP at the A&A rate is resumed effective November 15, the date of the authorized absence of 30 days or more.
  • SMP at the A&A rate is discontinued and pension is reduced to $50 effective January 5, the date of readmission to the hospital.

III.v.6.C.4.f.  Retroactive Adjustments for Hospital Absences of Less than 30 Days

Make no adjustment for additional pension or increased compensation for regular A&A for periods of authorized absence of less than 30 days until after discharge from hospitalization.
When a retroactive award is prepared to resume the full A&A rate, from a date earlier than the date of discharge in order to cover several short periods of authorized absence from hospitalization, annotate the award to show the total number of days of absence.
Situation:
  • A Veteran entitled to SMP at the A&A rate
    • was admitted to a VAMC for hospitalization on September 15, and
    • received a regular discharge on December 12.
  • While hospitalized, the Veteran had an authorized absence from
    • November 8 through November 11, and
    • November 21 through November 24.
Result:
  • The Veteran’s award is reduced to the hospitalized rate effective November 1, under 38 CFR 3.552(b)(1).
  • Following the regular discharge, SMP at the A&A rate is restored effective December 4.  This adjusted date allows for the eight days of authorized absence.

III.v.6.C.4.g.  Readmission for Hospitalization Following an Irregular Discharge

If notice is received of a Veteran’s readmission for hospitalization
  • within six months of the date of an irregular discharge, discontinue the allowance for A&A effective the date of readmission, per 38 CFR 3.552(b)(3), or
  • six months or more after the date of an irregular discharge, discontinue the allowance for A&A effective the first day of the second calendar month following the month of readmission.
Note:  Follow the due process procedures described in M21-1, Part III, Subpart v, 6.C.1.d.
Reference:  For a definition of “irregular discharge,” see M21-1, Part III, Subpart v, 6.D.3.f.

5.  Expedited SMP Entitlement Determinations for Chronic Invalids Hospitalized at VA Expense


Introduction

This topic contains information on expedited SMP entitlement determinations for Veterans who are chronic invalids, including

Change Date

March 27, 2018

III.v.6.C.5.a.  Rationale for Expediting an SMP Entitlement Determination

In some instances, an expedited determination of entitlement to SMP may be warranted.  There are Veterans who are patients in VAMCs or maintained by VA in other hospitals who are permanently and totally disabled and may be entitled to SMP by rating decision because they require A&A or are housebound due to chronic invalidism or incapacity for self-care.
These individuals do not require hospital treatment and might leave the VAMCs and return to their homes or enter private nursing homes if they were assured prior to leaving that they would receive the increased pension because VA recognizes they require A&A or are housebound.
In addition, if rated as being in need of regular A&A, such individuals may also be entitled to housebound benefits while still hospitalized.

III.v.6.C.5.b.  Actions Taken by the Medical Facility

After identifying the type of case described in M21-1, Part III, Subpart v, 6.C.5.a, the VAMC or the Chief, Medical Administrative Specialist (MAS), determines whether
  • it is medically feasible to authorize the Veteran’s discharge from the hospital
  • the Veteran is willing to accept discharge, and
  • arrangements can be made to ensure adequate care of the Veteran at his/her home or at some other suitable place.
If the conditions described in the preceding bullets are met, the Chief, MAS, or other authorized medical center official

III.v.6.C.5.c.  Actions Taken by the SOO

The table below describes how the SOO processes the VA Form 21-2680referenced in M21-1, Part III, Subpart v, 6.C.5.b.
Stage
Description
1
The SOO’s rating activity determines whether the Veteran requires A&A or is housebound.
Notes:
  • If the rating activity decides the Veteran requires A&A, it will also indicate on the rating decision whether the Veteran remains entitled to benefits at the A&A rate while hospitalized.
  • For pension, a rating decision only determines eligibility for consideration of the increased maximum annual pension rate (MAPR).  A Veteran is not entitled to payment of the increased pension if his or her income exceeds the A&A MAPR.
2
After the rating activity makes a decision, authorization activity takes action to
  • award the A&A rate, or
  • award the hospitalized rate if the rating activity decided the Veteran is not entitled to benefits at the A&A rate while hospitalized.
3
After receiving a discharge report, the authorization activity adjusts the award to pay benefits at the A&A rate effective the date of discharge.
Notes:
  • The date of claim may be the date of a VA examination or the date of admission for hospitalization.
  • If evidence of eligibility for SMP is received within one year of the notification of basic pension eligibility, A&A may be paid from the effective date of the basic pension.
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