Denied

Discussion in 'General Discussion' started by phauwarine, May 23, 2013.

  1. phauwarine

    phauwarine Newbie

    Mom is in an Independent Living Facility receiving help from a third party provider to help with showers and meds. VA did count the fees paid to the Private Care provider as a medical expense, but not the room and board. The denial was because without the room and board deduction she is $1,123.00 over per year in income.

    In the Dept. of Veterans Affairs "Fast Letter" of Oct. 26, 2012 that went out from the Director of VA regional offices and Center to all pension management center and veterans service center personnel it states "If the facility does not provide the claimant custodial care, or the claimant's physician does not prescribe care by a third-party provider in that facility, VA will not deduct room and board paid to the facility but will deduct the cost of any medical or nursing services obtained from a third-party provider."

    So I can assume that since the showers and med help are provided through a private care company and not the ILF , room and board is not counted against income. (The company does have an office, etc. in the ILF and all residents use this company). On that note, the claimaint's doctor did fill out the VA form in very much detail stating that she needs assistance with self care, etc. as she is not able to stand for any length of time due to severe arthritis,pain, balance and depth perception (no vision in one eye..included optometrist's report) and also mild cognitive impairment due to age (90)...I thought this would fulfil the requirement of "physician prescribing", but evidently not?? actually what would the dr. have to write or do to fulfill this requirement?

    The denial letter states "You claimed special monthly pension (aid and attendance or housebound allowance) because of your health conditions. A formal rating is required to determine your eligibility for special monthly pension. No rating has been done at this time, because your income exceeds the income limit. We used the aid and attendance income limit when denying your pension, because it is higher than the income limit without special monthly pension. However, this does not guarentee that you would have been granted Aid and Attendance if a rating had been done" WHAT IS MEANT BY "RATING'.... DOES THIS MEAN THEY DID NOT TAKE THE DOCTORS LETTER INTO CONSIDERATION AND PERHAPS IF THEY HAD THEY WOULD HAVE SEEN THAT THE DR. STATED THE NEED FOR HER TO LIVE IN THE FACILITY WITH HELP WITH MEDICAL ADL'S?

    What does the dr. need to provide to meet the quote of the VA regarding that the claimant must live in that facility to separately contract for custodial care with a third - party provider?

    Sorry this is so long....but I would so like to help my mom get this as she is truly in need.

    Thank you in advance for anyone who can help me .
     
  2. vetadmin

    vetadmin Administrator Staff Member

    The VA has taken a very hard stance on IL's as they are not licensed care facilities, and if your Mom falls, or chokes on something, they will not touch her. They will call 911, but not going to lay a hand on her. They aren't going to dose her medications, or assist her with bathing, so no the rent is not covered.

    I am sending you a personal email for a resource.
     
  3. dilebeau

    dilebeau Newbie

    I had a similar response from the VA. My mom is 91, legally blind and receiving care in her Retirement facility where she is registered as in the "independant" living wing. The VA called to verify how she was registered.
    My mom's income was 1,000.00 above the $13,128.00 per year that VA said was the minimum threshold. If I understood the denial letter correctly. We are in a Catch 22 here. My mom needs more services. Ideally, we would like to have her meds distributed because she frequently forgets. This would cost us 1,000.00 per month to have her medication given to her by a Care Service 2x per day.
    She has congestive heart failure and recently fell fracturing her hip. She has $4,000.00 left in her savings. We could increase the care services to 1,860.00 per month incuding the medication which should put her under the $13K amount the VA mentioned in their response to me. But she/we can't afford that amount. We would be willing to use the rest of her money if we knew for sure she would get approved, but we waited 6 months for the denial.

    Any suggestions or thoughts on next steps would be greatly appreciated.
     
  4. vetadmin

    vetadmin Administrator Staff Member

    You are in a catch-22 situation. She is obviously in need of more care and services. You can either move her to the ALF side of the facility or bring in the outside services to bring her countable income down in order to qualify. Nobody can promise that the VA will come through in the timeframe that you need by using her savings, but I don't think you have much choice.

    You can do the VA form 21-4138 Statement in Support of Claim letting the VA know her expense have gone up. Since she is now in the system, it should be a much faster response, but again no guarantee.
     
  5. Cslcs25

    Cslcs25 Newbie

    Our situation is very similar to that of the original poster. My mom is in an independent living facility and the VA basically said that they (the ILF) do not provide any "medical" services. What exactly would "medical" services be?

    She is 89, blind, needs assistance bathing, assistance going to dining room, they "manage" her meds.

    Trying to decide whether to appeal or move her to an actual assisted living facility and start over hoping everything else would meet the needed criteria.
     
  6. vetadmin

    vetadmin Administrator Staff Member

    You would be better off moving her to an actual "licensed care" facility. IL's are not that. If she falls, they will not pick her up. They will call 911.

    You would have to be paying someone to come in and provide the additional services as IL's don't assist with bathing, toileting etc.

    You would not have to appeal. You would simply do a VA form 21-4138 Statement in Support of Claim updating them she now resides in an ALF, and provide a Statement of Occupancy.
     
  7. phauwarine

    phauwarine Newbie

    Since my mom received the denial letter, I visited a couple of assisted living facilities (she is now in an Independant living facility receiving help with showers and meds). The lowest priced assisted living facility I could find was $3,900 monthly. So even if I moved her to the assisted living facility and she received the full aid and attendance amount, she would be paying more out of pocket than she is now without the pension. So, the assisted living facility is not the solution for every case denied. In the "fast letter" it states:
    Does a third-party contractor provide the individual assistance with two or more ADLs in the residental facility?
    If yes, is there a statement of record from the individual's physician that the individual must reside in that facility to receive the contractor's assistance with ADLs?
    If yes, VA will deduct as a UME the cost of room and board based on custodial care.
    If no, VA will not deduct as a UME the cost of room and board based on custodial care.

    That is where I am confused......what exactly would the Dr. have to write in the statement to meet that criteria?

    I am also confused about "partial awards". How does VA decide if a partial award is given? Since she is only $100 over per month is countable income, with no savings, I would think a partial award would be given?
     
  8. vetadmin

    vetadmin Administrator Staff Member

    The problem is the VA is not giving her any credit for the Independent facility.

    The Dr's statement would have to outline that she needs to live in a modified environment and state as to why.

    I am sending you a private message.
     
  9. Cathy

    Cathy Newbie

    Oops, I guess I should have read/posted over here. Initial post: http://www.veteranaid.org/forums/index.php/topic,2466.msg10081.html#new

    I would say I have the same question as Concerned Daughter: Does a third-party contractor provide the individual assistance with two or more ADLs in the residental facility?
    If yes, is there a statement of record from the individual's physician that the individual must reside in that facility to receive the contractor's assistance with ADLs?
    If yes, VA will deduct as a UME the cost of room and board based on custodial care.
    If no, VA will not deduct as a UME the cost of room and board based on custodial care.

    That is where I am confused......what exactly would the Dr. have to write in the statement to meet that criteria?


    I'm not even looking for room and board but perhaps just some portion of board as she cannot prepare here own meals. Or perhaps I am over complicating things as her yearly countable income looks like it would be about 5 or 6 K ? (with 60K in assets) ?
     
  10. Max

    Max Hero Member

    Nothing. The VA is not going to count an independent living facility as a medical expense. Its right in the name "independent" means that the facility leaves their residents to live independently. I really hate to sound harsh, but at this point either she's going to have to live without the VA benefit or move to a licensed assisted living facility.
     
  11. Cathy

    Cathy Newbie

    No prob VSR; I appreciate any feedback. Let's ask this another way; forget carving out any expenses from IL. :-X
    At age 95 , with 60 K in the bank and a positive delta of $500/month(Income-expenses), what is the probabilty of getting the A&A benefit ?
     
  12. vetadmin

    vetadmin Administrator Staff Member

    Hate to say it, and if VSR disagrees, he can jump in here, but I would not hold out much hope for a positive decision. Sorry.
     
  13. Max

    Max Hero Member

    It depends on what you're defining as expenses and income. Without knowing that, I couldn't tell you.
     
  14. Cathy

    Cathy Newbie

    Expenses= Home Health(shower/grooming,escort to meals or meals brought to her by HH-she's in a wheelchair and can't go anywhere without someone pushing her in a wheelchair); Part D drug monthly premium; premium for Medicare Supp ins., monthly meds out of pocket. Income = Social Security check

    Let's assume the expenses are allowable; I'm most concerned about the asset level...
    [and maybe given that asset level the maximum monthly delta(Inc -Expenses) to still get the benefit--can it be positive(and if so by how much) or does it have to be zero or negative ?].
     
  15. kwinkle

    kwinkle Newbie

    My mom just got denied after 1 year and 6 months - they said she makes too much money a year with her SS and survivor benefits they said in the letter that she could appeal if she pays out money for her care that reduces her income. She did not know she could do that and I can help her. She falls under the Housebound so if I understand correctly she can claim anything she pays out because she is housebound, is that correct? i am confused reading some of the posts because you talk about some facilities care not being counted because they are not licensed but in the explanation for the A and A it says that the care giver can even be a family member and does not need to be licensed. My mother has very little savings and cannot afford an expensive licensed caregiver. Where can I find clarification about all of this and how do we appeal the denial?

    Thank you
     
  16. vetadmin

    vetadmin Administrator Staff Member

    Mom would have to be paying you or someone else for her care. It does not have to be a medical professional, but she has to be able to show an expense. The facilities that are referenced are Independent or Retirement properties which does not apply to your Mom.
     

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