Nursing Home/Assisted Living Facility/Residential Living Facility

Nursing Home/Assisted Living Facility/Residential Living Facility Many of the facilities our claimants reside in have multiple divisions and care levels. One facility may be a qualified nursing home for VA purposes, but it may have an assisted and/or independent living side as well. To qualify for the reduction to $90.00 per month, the beneficiary must be a patient in a nursing home because of mental or physical disability. The nursing facility must be licensed by the state to provide skilled or intermediate level nursing care. They can have no dependents, and their nursing care covered by a Medicaid plan (Title XIX) for services provided by the facility. Aid and Attendance can be administratively granted to a person receiving skilled or intermediate nursing care in an approved facility. Beneficiaries that receive nursing care in State Veteran s Homes will not be reduced to the $90.00 rate. Often times, in some of the states that we serve, a beneficiary may reside in an assisted living facility, and is receiving the support of a state s Medicaid diversion program or other similar plan. These beneficiaries would not be subject to the $90.00 Medicaid nursing home reduction. Those individuals that live in Assisted Living facilities are there primarily for the health care services that are provided. In order to have Assisted Living Facility fees considered, in total, the beneficiary must have a rating for Aid and Attendance or Housebound. The fees must be reported on a 21-8416 and should be accompanied by a document form the ALF saying when the beneficiary entered, the monthly fees and what level of care is provided. To consider the fees paid to an ALF by the spouse of a living veteran in receipt of pension, a statement from a physician stating that the spouse must live in a protected environment and a diagnosis of the disabilities that require such care must be of record. Residential or Independent Living Facilities generally provide less care than an Assisted Living Facility and often do not provide medical or nursing home type care. (See the attached to check when Room and Board in a Residential Living Facility may be considered). Facility care statements or the 21-0779 with details of the level of care, when the beneficiary entered the facility and the monthly costs should be provided with claims to consider the full amount of the fees as medical expenses. If it is for a Medicaid Patient subject to the $90.00 reduction, the date the Medicaid plan began should also be included. Claiming Assisted Living Facility or Nursing Home Fees Be specific as to dates paid for irregular amounts AND indicate regular recurring monthly or daily amounts. Provide full contact details for a person at the facility we can call to verify information. Tell them we may be calling! For nursing home, if Medicaid is assisting, include VAF 21-0779 and be specific as to patient paid amount. Accepting RLF Fees

Room and Board expenses from an RLF are acceptable if: The individual s physician states in writing that the claimant must reside in that facility and separately contract for custodial care with a third-party provider. Or The facility provides the individual with custodial care in the form of assistance with two or more activities of daily living. What are Custodial Care and Activities of Daily living? Custodial Care: assisting a person with activities of daily living Activities of Daily living: items of basic self-care which include; Bathing or showering, Dressing, Eating, Getting in or out of bed or a chair, Toileting To accept the room and board fees as medical expenses the facility must provide at least 2 of the above services Non- Medical Related services Medication management Meal preparation, Shopping or traveling with the individual Providing security monitoring Housework, other chores, etc. Are NOT considered basic self-care activities of daily living Services such as these would not make the facility fees deductible. IN-HOME CAREGIVERS The fees paid to in-home caregivers may be considered medical expenses if the beneficiary is rated A&A or Housebound and they have a statement from the caregiver(s) detailing the services provided the amount they receive for their services, the dates of payment, the person being cared for and contact information. (See Attached) If the caregiver is a family member, proof that the beneficiary is actually paying for the services is also required. If the caregiver is the spouse, the expenses will not be considered, as this will also represent income received by the spouse.

Please Have Your Caregiver Provide the Following Information 1. My Name is: (Please print Caregiver s name.) Address: Phone: 2. (X) I am a licensed: caregiver or healthcare professional. (Circle and identify licensing.) Licensed by: 3. (X) I am not a licensed caregiver or healthcare professional. 4. I became 's caregiver on. (X) I stopped providing services on. (X) I continue to provide these services. 5. I work hours per: day / week / month. (Please circle answers.) 6. I am paid $ per: hour / day / week / month for my services. 7. I provide assistance with the following Activities of Daily Living: (Please circle all that apply.) Bathing Dressing Toileting Assistance getting in and/or out of a chair or bed Eating I provide the following medical services:. Please identify any additional services you provide: 8. Comments or explanations: Signature of Caregiver: Date:

OMB Control No. 2900-0161 Respondent Burden: 30 minutes FOR VA USE ONLY MEDICAL EXPENSE REPORT 1. FIRST NAME OF VETERAN 2. MIDDLE NAME OF VETERAN 3. LAST NAME OF VETERAN 4. SUFFIX NAME OF VETERAN 5. VETERAN'S SOCIAL SECURITY NO. 6. VA FILE NUMBER 7. FIRST NAME OF CLAIMANT 8. MIDDLE NAME OF CLAIMANT 9. LAST NAME OF CLAIMANT 10. SUFFIX NAME OF CLAIMANT 11. STREET ADDRESS OF CLAIMANT 12. APT. NO. 13. CITY 14. STATE 15. ZIP CODE 16. DAYTIME TELEPHONE NO. OF CLAIMANT (Include Area Code) 17. EVENING TELEPHONE NO. OF CLAIMANT (Include Area Code) 18. CHANGE OF ADDRESS (Check box if address in Items 11-15 is different from last address furnished to VA) 19. E-MAIL ADDRESS OF CLAIMANT (If applicable) 20. ITEMIZATION OF EXPENSES RELATED TO TRANSPORTATION FOR MEDICAL PURPOSES Report expenses related to transportation to a hospital, doctor, or other medical facility that you paid between the dates medical expenses.. If no dates appear on this line, refer to the accompanying letter or Eligibility Verification Report for the dates you should report NOTE: If you claim miles traveled to a medical facility in a personal conveyance (car, motorcycle, other), VA will calculate the allowable expense amount based on the current mileage rate (41.5 cents per mile). A. MEDICAL FACILITY TO WHICH YOU TRAVELED B. TOTAL ROUNDTRIP MILES TRAVELED (Personal conveyance only) C. AMOUNT PAID BY YOU (Taxi, public transportation fares, tolls, parking fees, etc.) D. DATE PAID (Month/Day/Year) and E. FOR WHOM PAID (Self, spouse, child) IMPORTANT: Be sure to sign this form in Item 22A on the reverse side. Unsigned reports will be returned. VA FORM SUPERSEDES VA FORM 21P-8416, DEC 2011, FEB 2012 21P-8416 WHICH WILL NOT BE USED. (Continued on Reverse)

21. ITEMIZATION OF MEDICAL EXPENSES Report medical expenses that you paid between the dates and. If no dates appear on this line, refer to the accompanying letter or Eligibility Verification Report for the dates you should report medical expenses. A. MEDICAL EXPENSE (Physician or Hospital Charges, Eyeglasses, Oxygen Rental, Medical Insurance, etc.) B. AMOUNT PAID BY YOU C. DATE PAID (Month/Day/Year) D. NAME OF PROVIDER (Name of doctor, dentist, hospital, lab, etc.) E. FOR WHOM PAID (Self, spouse, child) MEDICARE (PART B) MEDICARE (PART D) PRIVATE MEDICAL INSURANCE CERTIFICATION: I have not and will not receive reimbursement for these expenses. I certify that the above information is true. 22A. SIGNATURE OF CLAIMANT (Do NOT print) 22B. DATE PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled. VA FORM 21P-8416, FEB 2012

REQUEST FOR NURSING HOME INFORMATION IN CONNECTION WITH CLAIM FOR AID AND ATTENDANCE OMB Approved No: 2900-0652 RESPONDENT BURDEN: 10 Minutes VA DATE STAMP (Do Not Write In This Space) INSTRUCTIONS: For free help in completing this form, call VA toll-free at 1-800-827-1000. (Hearing Impaired TDD line 1-800-829-4833.) Section I - IDENTIFICATION INFORMATION 1A. NAME OF NURSING HOME 1B. ADDRESS OF NURSING HOME 2. ADDRESS OF VA REGIONAL OFFICE 3. FIRST NAME - MIDDLE INITIAL- LAST NAME OF CLAIMANT 4. SOCIAL SECURITY NUMBER 5. VA FILE NUMBER SECTION II - NURSING HOME INFORMATION (To be completed by a Nursing Home Official) 6. DATE ADMITTED TO NURSING HOME (Month, Day, Year) 7. DATE MEDICAID BEGAN (Month, Day, Year) 8. AMOUNT PATIENT IS RESPONSIBLE FOR OUT OF POCKET $ 9. I CERTIFY THAT THE CLAIMANT IS A PATIENT IN THIS FACILITY BECAUSE OF MENTAL OR PHYSICAL DISABILITY AND IS RECEIVING: (Check one) SKILLED NURSING CARE INTERMEDIATE NURSING CARE 10. NURSING HOME OFFICIAL'S NAME (First & Last) (Please print) 11. NURSING HOME OFFICIAL'S TITLE (Please print) 12. NURSING HOME OFFICIAL'S OFFICE TELEPHONE NUMBER (Include Area Code) 13A. SIGNATURE OF NURSING HOME OFFICIAL 13B. DATE SIGNED PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. While you are not required to respond, your cooperation in providing this relevant and necessary information will help us determine the claimant's maximum benefit entitlement under the law. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining the claimant's eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of the claimant's participation in any benefit program administered by the Department of Veterans Affairs. RESPONDENT BURDEN: We need this information to determine eligibility for benefits and the proper rate of payment (38 U.S.C. 5503, 38 U.S.C. 1115 (1)(E)), 38 U.S.C. 1311(c), 38 U.S.C. 1315(h)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/ombinv.va.epa.html#va. If you desire, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM MAR 2010 21-0779 SUPERSEDES VA FORM 21-0779, MAR 2004, WHICH WILL NOT BE USED.

The list below shows many of the common allowable medical expenses. Note: This list is not all-inclusive. Allow all expenses that are directly related to medical care. Abdominal supports Acupuncture service Ambulance hire Anesthetist Arch supports Artificial limbs and teeth Back supports Braces Cardiographs Chiropodist Chiropractor Convalescent home (for medical treatment only) Crutches Dental service, for example, cleaning, x- ray, filling teeth Dentures Dermatologist Drugs, prescription and nonprescription Gynecologist Hearing aids and batteries Home health services Hospital expenses Insulin treatment Insurance premiums, for medical insurance only Invalid chair Lab tests Lip reading lessons designed to overcome a disability Lodging incurred in conjunction with out-of-town travel for treatment (to be determined on a facts-found basis) Long-term care insurance Medical insurance premiums Medicare premiums Neurologist Nursing services for medical care, including nurse s board paid by claimant Occupational therapist Ophthalmologist Optician Optometrist Oral surgery Osteopath, licensed Pediatrician examinations Physical examinations Physician Physical therapy Podiatrist Psychiatrist Psychoanalyst Psychologist Psychotherapy Radium therapy Sacroiliac belt Service animals and maintenance Speech therapist Splints Surgeon Telephone/teletype special communications equipment for the deaf Transportation expenses for medical purposes (plus parking and tolls or actual fares for taxi, buses) Vaccines Wheelchairs Whirlpool baths for medical purposes X-rays

Special Access to: Philadelphia PMC Advocacy Team Special Inquiry Phone Queue: 215 381 3762 Fax Number( VVA): 215 842 4410 Congressional E Mail Address VBAPHI.PMCCONGRESSIONAL@VA.GOV VSO E mail Addresses: PensionCtrVSO.VBAPHI@va.gov Fiduciary Hub (888) 407 0144 Option 2