What is the Special Case of Recurring Long Term Care Medical Costs?

An initial application for Pension and Survivor's Pension allows for certain future monthly recurring medical costs to be subtracted from income in order to generate a benefit even though those costs have not currently been incurred.

The Special Case of Long Term Care, Recurring Medical Expenses

A special provision for calculating Pension income allows household income to be reduced by 12 months of future, recurring medical expenses. Normally, income is only reduced by medical expenses incurred in the immediate months prior to application. These allowable, annualized medical expenses are such things as health insurance premiums, the cost of home care, the cost of paying any person to provide care, the cost of adult day care, the cost of assisted living and the cost of a nursing home facility.

This special provision can allow households earning more than the annual MAPR to qualify. For example, a veteran household earning $6,000 a month could still qualify for Pension if the veteran is paying $4,500 to $6,000 a month for nursing home costs. The claimant must submit appropriate evidence for a rating and for recurring costs in order to qualify for this special provision.

Rationale for Allowing Future, Annualized Deductions

The following is quoted from VA manual 21-1:

"The basic theory underlying improved Pension is that during any given month a beneficiary's IVAP plus VA Pension benefits will establish a given level of income (the MAPR). To make the program conform more closely to its basic theory, certain expenses paid by a beneficiary are taken into consideration in arriving at the individual's IVAP. Most deductible expenses are allowed as deductions from otherwise net countable income. However, certain deductible expenses are allowed only as deductions from specific income. See paragraph 16.35."

"Then unreimbursed medical expenses that exceed 5 percent of the applicable maximum annual Pension rate (MAPR) are deductible. Note: In determining the 5 percent deductible, include additional benefits for dependents and the WWI/MBP supplement in the MAPR. Do not include additional benefits for Aid and Attendance or Housebound status in the MAPR. ..."

"In most instances, the medical expense deduction is allowed after the fact. However, if a claimant has consistently recurring unreimbursed medical expenses (for example, a nursing home patient), it may be possible to allow the medical expense deduction on a continuing basis."

(This means certain recurring expenses can be counted for the 12-month future benefit period.)

Authority for Allowing Prospective, Annualized, Recurring Medical Expenses

38 CFR 3.272 (g) Exclusions from income; Medical Expenses. Within the provisions of the following paragraphs, there will be excluded from the amount of an individual's annual income any unreimbursed amounts which have been paid within the 12-month annualization period for medical expenses regardless of when the indebtedness was incurred. An estimate based on a clear and reasonable expectation that unusual medical expenditure will be realized may be accepted for the purpose of authorizing prospective payments of benefits subject to necessary adjustment in the award upon receipt of an amended estimate, or after the end of the 12-month annualization period upon receipt of an eligibility verification report.

In order to receive a deduction for unreimbursed medical expenses and to adjust the claimant's countable income the following must apply.


Evidence of Medical Expenses

Proof of all medical expenses including recurring expenses to be annualized for the 12-month future benefit period must be submitted to the regional office. Photocopies of invoices or statements on the provider's letterhead are acceptable, but copies of canceled checks are not. Evidence of payment should include the following:


The application form for Pension provides only a few lines for detailing medical costs. The form suggests adding a separate page if more detail is required. In actuality, the application form provides no information and no hints that certain medical costs can be annualized to calculate the Pension benefit. One simply has to know that this is the case and how to do it. This is one of the well-kept secrets of applying for Pension.

Generally, evidence for out-of-pocket medical costs need only be provided for the month of application. VA will examine the application and determine whether this expense appears to be the type of expense that will recur from month-to-month for the next 12 months. If there is a question that this is only a temporary cost and not ongoing, more information will be requested.

In Some Cases, Medical Expenses Are Only Annualized if There Is Also a Rating.

Medical evidence for a rating for "aid and attendance" or "housebound" should be submitted with the application to avoid a delay in the approval process. Waiting for the regional office to order medical records is a time-consuming process, mainly because doctors offices don't respond quickly to these kinds of requests.

VA has a form for this purpose -- VA Form 21-2680

Ratings are requested by checking the appropriate box for aid and attendance or housebound on VA Form 21p-527ez or VA Form 21p-534ez.

As a restatement of the requirements above: In addition to medical evidence submitted for a rating, applicants must also submit evidence of actually paying for care in assisted living or at home and for the recurring costs of insurance premiums. In other words, arrangements for providing care or insurance costs must already be implemented and contract for payment or actual payment must have been arranged before the regional office will consider allowing claims for unreimbursed medical expenses.

Most families make the mistake of applying too soon -- before care arrangements have been made -- and may end up with a denial of the claim or drag out the process many months longer than it should take.

Pension -- Maximum Annual Pension Rates (MAPR) 2019-20

These amounts increased by 1.6% on 12 / 01 / 2019

For a Living Veteran

 

Yearly

Monthly

Without Spouse or Child

 

$13,752

$1,127

Medical Deduction

 

$687

$57

With One Dependent

 

$18,008

$1,500

Medical Deduction

 

$900

$75

Housebound Without Dependents

 

$16,805

$1,400

Housebound With One Dependent

 

$21,063

$1,755

Aid and Attendance Without Dependents

 

$22,939

$1,911

Aid and Attendance With One Dependent

 

$27,195

$2,266

Add for Each Additional Child

 

$2,351

$195

 

Survivors Pension -- Maximum Annual Pension Rates (MAPR) 2019-20

For a Surviving Spouse

 

Yearly

Monthly

Without Dependent Child

 

$9,224

$768

Medical Deduction

 

$461

$38

With One Dependent Child

 

$12,072

$1,006

Medical Deduction

 

$603

$50

Housebound Without Dependents

 

$11,273

$939

Housebound With One Dependent

 

$14,116

$1,176

Aid and Attendance Without Dependents

 

$14,742

$1,228

Aid and Attendance With One Dependent

 

$17,586

$1,465

Add for Each Additional Child

 

$2,351

 

MAPR FOR CHILD ALONE

 

$2,351