Overview
In This Section |
This section contains the following topics:
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1. Identifying Qualified Nursing Homes
Introduction |
This topic contains information on identifying qualified nursing homes, including
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Change Date |
June 15, 2015
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V.iii.2.B.1.a. Definition of Nursing Home for Purposes of A&A Status |
38 CFR 3.351(c)(2) provides that an individual meets the aid and attendance (A&A) criteria without a rating decision if he or she is a patient in a facility that meets the 38 CFR 3.1(z) definition of a nursing home.
For purposes of meeting the A&A criteria, 38 CFR 3.1(z) defines a nursing homeas
Note: For pension purposes, a medical foster home that VA has recognized and approved under 38 CFR 17.73 is equivalent to a nursing home.
References: For more information on
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V.iii.2.B.1.b. Identification of Qualified Extended-Care Facilities |
Use the Medicare.gov’s Nursing Home Compare website to determine whether or not an extended-care facility is licensed by a State to provide skilled or intermediate-level nursing care.
Note: If verification of a facility’s status is needed, send the facility VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance, for certification.
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V.iii.2.B.1.d. Exclusive Use of Qualified Nursing Homes |
Use the facilities identified by the State licensing or certification authority, or by the VA medical administration activity, as the exclusive basis for consideration as a nursing home for the purposes of an administrative award of A&A under 38 CFR 3.351(c)(2).
Note: An administrative award of A&A requires no rating activity determination.
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2. Awarding A&A Based on a Beneficiary’s Status as a Patient in a Qualified Nursing Home
Introduction |
This topic contains information on awarding A&A to a beneficiary based on his or her status as a patient in a qualified nursing home, including
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Change Date |
May 10, 2016
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V.iii.2.B.2.a. Authorizing A&A Based on Qualified Nursing Home Patient Status |
Award A&A based on patient status in a qualified nursing home if
Note: The term contract nursing home refers to a non-VA nursing home under contract with VA to provide nursing home care at VA expense for a specified period of time.
Important: Reports of hospitalization received without a standard form will be treated as a request for application.
Reference: For information on
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V.iii.2.B.2.b. A&A Status in Cases Involving Protected Pension Programs |
In Section 306 Pension and Old-Law Pension cases, unless a beneficiary’s A&A status arose on or before December 31, 1978, a Veteran or surviving spouse must elect current-law pension to receive A&A.
Reference: For information on the procedures to follow when a Section 306 Pension or Old-Law Pension beneficiary claims A&A, see M21-1, Part V, Subpart iii, 5.6.
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V.iii.2.B.2.c. Cases in Which a Rating Is Required to Award A&A |
A&A for a Veteran’s disability compensation always requires a rating decision.
A rating decision is also required in a Veterans Pension case
Reference: For more information on authorizing A&A following hospitalization, seeM21-1, Part V, Subpart iii, 2.B.2.e.
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V.iii.2.B.2.d. Action to Take When a Beneficiary Is Established as a Patient in a Qualified Nursing Home |
If evidence establishes that a beneficiary is a patient in a qualified nursing home, and there are no concurrent issues requiring a rating decision, then
Reference: For more information on using systems to award A&A without a rating decision, see the
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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 |
If a period of VA or non-VA hospitalization results in a discharge of the beneficiary, within 90 days, as a patient to a qualified nursing home, authorize A&A without a rating decision from the first day of the month following such hospital admission.
Note: VA cannot pay an increase because of A&A to a beneficiary who is currently receiving Section 306 Pension or Old Law Pension. These beneficiaries must elect current-law pension in order for their A&A status to affect their benefit.
Reference: For information on conditional elections, see M21-1, Part III, Subpart v, 4.A.1.c.
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3. Reviewing A&A Status Following Discharge From a Qualified Nursing Home
Introduction |
This topic contains information on reviewing A&A status following a beneficiary’s discharge from a qualified nursing home, including
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Change Date |
February 19, 2019
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V.iii.2.B.3.a. Due Process Notification Requirements |
Due process requires that a notice of proposed adverse action be sent before reducing or discontinuing a benefit.
Reference: For more information on due process, see
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V.iii.2.B.3.d. Action to Take if Medical Evidence Is of Record to Reconsider A&A Status |
If medical evidence is of record, submit the case to the rating activity to prepare a rating decision that either
Note: If there are any favorable findings from the original decision that relate to the beneficiary’s medical necessity for aid and attendance, those favorable findings arenot binding on running awards.
References: For more information on the
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V.iii.2.B.3.g. Assisting the Claimant in Obtaining Medical Evidence to Reconsider A&A |
To assist the beneficiary
Note: The rating activity requests a VA examination if medical evidence received establishes a reasonable probability of eligibility, but is not adequate for a decision
Reference: For more information on medical evidence of probable eligibility, seeM21-1, Part V, Subpart i, 2.2.
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V.iii.2.B.3.h. Establishing Controls for the Notice of Proposed Adverse Action Period |
Establish a 65-day control for the notice of proposed adverse period in accordance with M21-1, Part I, 2.B.4.
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4. Taking Award Action on A&A Status Following Discharge From a Qualified Nursing Home
Introduction |
This topic contains information on taking action on A&A status following the discharge of a claimant from a qualified nursing home, including
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Change Date |
February 19, 2019
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V.iii.2.B.4.a. Award and Notification Action to Take When No Evidence Is Submitted for Reconsideration of A&A |
If, after requested by a notice of proposed adverse action, no medical evidence is submitted by a claimant within the 65 day notice of proposed adverse action period, then
if the claims folder contains a rating decision proposing to discontinue A&A, refer the case to the rating activity
Reference: For information on referring cases to the rating activity, see M21-1, Part V, Subpart iii, 2.B.4.c.
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V.iii.2.B.4.b. Determining the Effective Date to Discontinue A&A Status Under 38 CFR 3.351 |
Use the table below to determine the effective date to discontinue an A&A award under 38 CFR 3.351.
Note: Award housebound status for a Veteran or surviving spouse, if entitlement exists, effective the date following the date that A&A status was discontinued.
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V.iii.2.B.4.c. Referring Cases for Reconsideration by the Rating Activity |
Refer the case to the rating activity for reconsideration if
If medical evidence was submitted and forwarded for a rating decision, and the rating activity action on the A&A issue is still pending when the predetermination period elapses
Notes:
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V.iii.2.B.4.d. Notifying the Beneficiary When A&A Is Established by Rating Decision |
When A&A is established by rating decision for a beneficiary who has left a nursing home
Note: If the amount payable was based on deductible nursing home expenses allowed prospectively, develop for current medical expenses when the beneficiary is no longer in the nursing home, and adjust accordingly.
Reference: For more information on prospective medical expenses, see M21-1, Part V, Subpart iii, 1.G.4.
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V.iii.2.B.4.e. Notifying the Beneficiary When A&A Is Not Established |
Use the table below to determine what notification action to take when the rating activity determines that the evidence does not support an award of A&A status.
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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 |
If an award cannot be completed in time to implement the effective date shown on the rating decision without creating an overpayment, return the case to the rating activity to prepare a new decision with a later effective date.
Rationale: The provisions of 38 CFR 3.105(f) prohibit reduction or discontinuance of a pension award, due to a reduction in disability or employability, retroactively, unless the reduction is based on an erroneous award that is based on an act of commission or omission by a payee or with the payee’s knowledge, per 38 CFR 3.500(b).
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5. Reducing or Discontinuing an Award Because of a Change in A&A Status
Introduction |
This topic contains information on reducing or discontinuing an award because of a change in A&A status, including
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Change Date |
May 10, 2016
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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 |
If A&A was erroneously awarded based on patient status in a facility that does not meet the criteria under 38 CFR 3.1(z), a reduction or discontinuance of pension may result.
After the due process period in such a case expires, reduce or discontinue pension as of the date of last payment under the administrative error regulation, 38 CFR 3.500(b)(2), unless administrative error clearly does not apply.
Situation:
Result:
Reference: For more information on administrative error procedures, see M21-1, Part III, Subpart v, 1.I.2.
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V.iii.2.B.5.b. Adjusting for A&A or Housebound for a Prior Period After the Patient Has Been Discharged |
Use the table below to determine whether to increase benefits because of A&A or housebound status for a previous period of nursing home care when notification is received after the patient is discharged from the facility.
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V.iii.2.B.5.c. Example: Paying the Housebound Rate for a Prior Period of Nursing Home Care After Discharge From the Facility |
Situation:
Result:
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Historical_M21-1V_iii_2_SecB_5-10-16.doc | May 20, 2019 | 142 KB |
Historical_M21-1V_iii_2_SecB_06-15-15.doc | May 20, 2019 | 144 KB |
05-10-16_Key-Changes_M21-1V_iii_2_SecB.docx | May 20, 2019 | 63 KB |
2-19-19_Key-Changes_M21-1V_iii_2_SecB.docx | May 20, 2019 | 54 KB |
Change-June-15-2015-Transmittal-Sheet-M21-1MRV_iii_2_SecB_TS.docx | May 20, 2019 | 41 KB |
Change-June-15-2015-Transmittal-Sheet-M21-1MRV_iii_1_SecB_TS.docx | May 20, 2019 | 40 KB |
Change-June-15-2015-Transmittal-Sheet-M21-1MRIII_iv_4_G_TS.docx | May 15, 2019 | 47 KB |
Change-June-15-2015-Transmittal-Sheet-M21-1III_iii_2_SecH_TS.docx | May 12, 2019 | 41 KB |
Change-June-15-2015-Transmittal-Sheet-M21-1III_ii_5_SecB_TS.docx | May 11, 2019 | 40 KB |
in Chapter 2 Aid and Attendance and Housebound Status Under 38 CFR 3.351, Part V Pension and Parents Dependency and Indemnity Compensation (DIC), Subpart iii Authorization issues
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