M21-1, Part V, Subpart iii, Chapter 2, Section B – Aid and Attendance (A&A) Status for Beneficiaries Who Are Patients in a Qualified Nursing Home

In This Section

Introduction

• definition of nursing home for purposes of A&A status
• identification of qualified extended care facilities
• identification of qualified State Veterans home facilities, and Department of Veterans Affairs (VA) nursing home care units, and
• exclusive use of qualified nursing homes.

Change Date

V.iii.2.B.1.a.  Definition of Nursing Home for Purposes of A&A Status

• any extended care facility that is licensed by a State to provide skilled or intermediate-level nursing care
• a nursing home care unit in a State Veterans’ home that is approved for payment, or
• a Department of Veterans Affairs (VA) nursing home care unit.

• who may qualify for A&A status under 38 CFR 3.351, see M21-1, Part V, Subpart iii, 2.A.1.a
• the Medicaid policy for residential care settings in each State, see the U.S. Health and Human Services’ web site, State Residential Care and Assisted Living Policy, and
• medical foster homes, see M21-1, Part III, Subpart v, 6.A.3.

V.iii.2.B.1.b.  Identification of Qualified Extended-Care Facilities

V.iii.2.B.1.c.  Identification of Qualified State Veterans Home Facilities and VA Nursing Home Care Units

• State Veterans home facilities approved for the nursing home care per diem rate, and
• VA nursing home care units.

V.iii.2.B.1.d.  Exclusive Use of Qualified Nursing Homes

Introduction

• authorizing A&A based on qualified nursing home patient status
• A&A status in cases involving protected pension programs
• cases in which a rating is required to award A&A
• actions to take when a claimant is established as a patient in a qualified nursing home, and
• authorizing A&A when a period of hospitalization results in the beneficiary’s discharge to qualified nursing home care.

Change Date

V.iii.2.B.2.a.  Authorizing A&A Based on Qualified Nursing Home Patient Status

• a responsible official of the facility states that the person is a patient in the facility because of a mental or physical disability, and the claimant submitted an appropriate standard form requesting A&A or
• the person is a patient in a VA Nursing Home Care Unit or in a contract nursing home and the claimant submitted an appropriate standard form requesting A&A.

• who may qualify for A&A, see M21-1, Part V, Subpart iii, 2.A.1.a
• what constitutes a standard form, see M21-1, Part III, Subpart ii, 2.B.1.b.

V.iii.2.B.2.b.  A&A Status in Cases Involving Protected Pension Programs

V.iii.2.B.2.c.  Cases in Which a Rating Is Required to Award A&A

• if the Veteran does not meet the requirement of patient status in a qualified nursing home, or
• to authorize A&A from the date of hospital admission when the immediately preceding period of hospitalization exceeded 90 days.

V.iii.2.B.2.d.  Action to Take When a Beneficiary Is Established as a Patient in a Qualified Nursing Home

• enter basic nursing home information in the INSTITUTIONALIZATION screen
• select STATUTORY A&A DECISION in the INSTITUTIONALIZATION ADJUSTMENTS screen, and
• enter Aid and Attendance under 38 CFR 3.351(c)(2) in the OTHER PRINT REMARKS field.

• VETSNET Awards User Guide, and
• VBMS-Awards User Guide.

V.iii.2.B.2.e.  Authorizing A&A When a Period of Hospitalization Results in the Beneficiary’s Discharge to Qualified Nursing Home Care

Introduction

• due process notification requirements
• requirement for a rating decision upon discharge from a qualified nursing home
• action to take after receiving notice of discharge from a qualified nursing home
• action to take if medical evidence is of record to reconsider A&A status
• sending a notice of proposed adverse action to reconsider and/or remove A&A
• content requirements for the notice of proposed adverse action to reconsider and/or remove A&A
• assisting the claimant in obtaining medical evidence to reconsider A&A, and
• establishing controls for the notice of proposed adverse action period.

Change Date

V.iii.2.B.3.a.  Due Process Notification Requirements

• 38 CFR 3.103, and
• M21-1, Part I, 2.

V.iii.2.B.3.b.  Requirement for a Rating Decision Upon Discharge From a Qualified Nursing Home

• no longer has disabilities that meet the required rating criteria, or
• in the case of a Section 306 Pension recipient, is not a patient in a qualified nursing home.

V.iii.2.B.3.c.  Action to Take After Receiving Notice of Discharge From a Qualified Nursing Home

• A&A status has already been established by rating decision, or
• there is medical evidence not previously considered of record that should be submitted to the rating activity.

V.iii.2.B.3.d.  Action to Take if Medical Evidence Is of Record to Reconsider A&A Status

• awards A&A, if the evidence supports an A&A award based on 38 CFR 3.351(c)(1) or establishes a factual need for A&A per 38 CFR 3.351(c)(3), or
• proposes discontinuance of A&A, if the evidence is not sufficient to support the A&A award.

V.iii.2.B.3.e.  Sending a Notice of Proposed Adverse Action to Reconsider and/or Remove A&A

• A&A status must be reconsidered because he/she is no longer a patient in a qualified nursing home,
• he/she has the right to
  • submit evidence
  • request a personal hearing, and
  • have a representative,
• medical evidence must be furnished within 60 days from the date of the letter that
  • establishes a factual need for regular A&A, and
  • provides, if appropriate, a current statement concerning the expected future amount of continuing unreimbursed medical expenses (UMEs) and what the UMEs are for,
• the present payment rate will continue for 60 days to allow time for him/her to exercise his/her rights,
• a hearing request received within 30 days will delay action on the proposal until the hearing is held,
• evidence received within 60 days will delay action on the proposal until the evidence is reviewed, and
• payments will be reduced or discontinued if such evidence is not received.

V.iii.2.B.3.f.  Content Requirements for the Notice of Proposed Adverse Action to Reconsider and/or Remove A&A

• If continuing UMEs are being used to calculate the beneficiary’s award, the beneficiary may have an overpayment if he/she stops paying these expenses or if the expenses are reduced.
• Although a beneficiary will not be overpaid because of removing A&A, the beneficiary may well be overpaid because of this change in income for VA purposes.  The letter must inform the beneficiary of this distinction.

V.iii.2.B.3.g.  Assisting the Claimant in Obtaining Medical Evidence to Reconsider A&A

• try to obtain the necessary medical evidence directly from any sources shown in the claims folder, including requesting a medical report from the beneficiary’s attending physician or former nursing facility, if a release is in the claims folder, and
• use the notice of proposed adverse action to advise the claimant that VA requested evidence on his/her behalf (naming the sources from which requested), but that it is the claimant’s responsibility to see that the evidence is provided.

V.iii.2.B.3.h.  Establishing Controls for the Notice of Proposed Adverse Action Period

Introduction

• award and notification action to take when no medical evidence is submitted for reconsideration of A&A
• determining the effective date to discontinue A&A status under 38 CFR 3.351
• referring cases for reconsideration by the rating activity
• notifying the beneficiary when A&A is established by rating decision
• notifying the beneficiary when A&A is not established, and
• action to take when the award cannot be made in time to comply with the effective date in the rating decision.

Change Date

V.iii.2.B.4.a.  Award and Notification Action to Take When No Evidence Is Submitted for Reconsideration of A&A

• if A&A was established due to nursing home care, reduce or discontinue benefits, as appropriate, without referral to the rating activity; however

• if a decision regarding A&A is made, fully and clearly inform the beneficiary of the decision in a letter that contains
• the elements that appeared in the notice of proposed adverse action, plus
  • the information in M21-1, Part I, 2.D regarding procedural and decision review options
  • determine the effective date of the award action as outlined inM21-1, Part V, Subpart iii, 2.B.4.b, and
• do not create an overpayment in connection with the loss of A&A status.

V.iii.2.B.4.b.  Determining the Effective Date to Discontinue A&A Status Under 38 CFR 3.351

V.iii.2.B.4.c.  Referring Cases for Reconsideration by the Rating Activity

• additional medical evidence is received
• the rating activity had proposed to discontinue A&A status based on the evidence of record, or
• all development associated with a personal hearing is completed (if the beneficiary requests the hearing within 30 days of the notice of proposed adverse action).

• extend the suspense date for the pending end product (EP) 600, and
• continue payments until the rating action is completed.

• If the facts contained in the proposed rating were complete, they need not be repeated in the final formal rating decision, but need only be referenced by citing the proposed decision by date.
• If additional medical evidence has been submitted, it should be specifically disposed of in the final rating.  If the final rating affirms the proposed action, the final rating will show the effective date as the first day of the month following the date of the final rating.  This is the effective date to input into awards systems and is consistent with 38 CFR 3.105(f).  Use the effective date shown on the final rating decision unless that date would create an overpayment.

V.iii.2.B.4.d.  Notifying the Beneficiary When A&A Is Established by Rating Decision

• inform the beneficiary via locally-generated letter that
  • A&A has been established based on medical evidence, and
  • his/her payments will be continued, and
• clear the pending control.

V.iii.2.B.4.e.  Notifying the Beneficiary When A&A Is Not Established

V.iii.2.B.4.f.  Action to Take When the Award Cannot Be Made in Time to Comply With the Effective Date in the Rating Decision

Introduction

• adjusting/discontinuing pension when A&A benefits were erroneously paid based on patient status in a non-qualifying facility
• adjusting for A&A or housebound for a prior period after the patient has been discharged, and
• example:  paying the housebound rate for a prior period of nursing home care after discharge from the facility.

Change Date

V.iii.2.B.5.a.  Adjusting/ Discontinuing Pension When A&A Benefits Were Erroneously Paid Based on Patient Status in a Non-Qualifying Facility

• VA awards Veterans Pension from July 1, 2006.
• Benefits include an administrative award of A&A based on the Veteran’s residence at River Valley Nursing Home.
• The Veteran’s income for VA purposes (IVAP) would exceed the maximum annual pension rate (MAPR) without the allowance for recurring expenses for room and board of $24,000 per year.
• On October 23, 2006, VA discovers that River Valley Nursing Home does not meet the criteria for A&A under 38 CFR 3.1(z).  The facility also does not meet criteria to allow a medical expense deduction.

• Prepare a proposed administrative decision to discontinue benefits as a result of an erroneous award based on administrative error, per 38 CFR 3.500(b)(2).
• Send the Veteran a notice of proposed adverse action regarding discontinuance of pension.
• After expiration of the due process period
  • refer the administrative decision for approval, and
  • discontinue pension effective the date of last payment.

V.iii.2.B.5.b.  Adjusting for A&A or Housebound for a Prior Period After the Patient Has Been Discharged

V.iii.2.B.5.c.  Example:  Paying the Housebound Rate for a Prior Period of Nursing Home Care After Discharge From the Facility

• A Veteran with a spouse receives current-law pension.  The monthly rate does not include A&A or housebound.
• On September 15, 2006, VA receives notice that the Veteran was in a nursing home at VA expense from April 2, 2005, through August 22, 2006.

• Pay the housebound rate from May 1, 2005, through August 31, 2006, only.
• Resume the rate without A&A or housebound as of September 1, 2006, and develop for medical evidence to establish A&A status based on 38 CFR 3.351(c)(1) or 38 CFR 3.351(c)(3).