Aid And Attendance

[sixthscents]

Since I am undergoing this process for R2 or R1 (whichever they decide) I thought it might be a good idea to start a topic and discuss what others went thru to receive it....

Currently my VA Primary Care doctor has stated that I would require skilled care 24-7 at home, or a referral to a nursing home. I filed the claim stating that if they couldn't provide the necessary funding, or some sort of home healthcare providers.. well they would need to place me in a nursing facility.

They came back with this huge list of claims... I was actually shocked.

I wrote them back stating that no I was not attempting to claim this or that... (I thought that listing my claims 1-5 and printing them in bold would be clear enough).. and restated my case. I then went to the medical C&P, and a VERY nice doctor did the eval. I had my primary care person (a CNA I pay for myself) present, and my sister.. a director of nursing at the closest VA contract nursing home.. also an RN. We had a care plan, etc.... and I gotta say the doctor was really really incredible. Now you never know exactly what they type until you pull the record, but she said things like "I not going to check that... its obvious and isnt going to improve" etc. etc... She had a LONG list of things she was supposed to check though, and with my sister/RN and the CNA I am paying a fortune for... $12 hr... (sigh) she was able to answer them without asking me almost anything. I do know that for all the rotation questions she answered no rotation possible due to injury and pain... or at least most of them.

I didn't realize that the VA does not provide home health care except for short periods. This is looking to be a long term issue, and I am honestly debating going into a nursing home. The ONLY thing stopping me right now is my 8 year old daughter.... (sigh)

Anyway, they also set up a psych C&P... thats going to be a joke though, they have me in weekly counseling now so they should have a fairly clear picture with me walking-wheeling in, but I expect a million and one questions. Just me and the wife for this one though.

Like I said its an issue between R1 & R2... I wondered if anyone had any experience with the differences... the applicable reg is CFR 38 3.350 and 3.352, but they are a bit vague to be honest I meet all the critrea for both. Obviously for those who know me this is all new. I have been out of the loop for quite a while, and am only VERY slowly poking around again from my bed (hey it gave me an excuse to buy the 22 inch LCD monitor and wireless keyboard etc.).

Anyway... just wondering. I am classed as "skilled" care if I was in a nursing home... so I wonder if that would make a difference?

Mmmm... probably need to know the new injuries... rupture at L5-S1/L4-L5 L2-L3... incontinence/w indwelling catheter... major pain major muscle spasms constant... (the doctor actually saw and felt them - I thought that was a good thing)in legs and lower back. Loss of ability to balance, loss of memory (pain meds I guess) etc etc..... loss of streangth, mobility, inability to dress or put on ortho aplliances by myself, bath etc. The CNA cooks, cleans -lightly, etc. Rehab has written me off not Voc-rehab... rehab. They say until this is fixed or the muscle spasms reduced physical therapy will do more harm than good. They even annotated this into my records so as to make sure no one tries...

How did it happen? You got me. One day I was bad but stable (had been for 2-3 years)... next morning I woke up with this... go figure.

Anyway... opinions accepted.

[sixthscents]

the vet meets the maximum or a rate equal to the "O" award.and

Actually this is a bit vague in CFR 38... but I, with my new problems qualify for "o" simply by having loss of use of 2 limbs and incontinence/loss of bladder and bowel... this is grounds for automatically awarding a rate of o.

Thats not even taking into consideration the loss of 3 extremeties now (which entitles to the next higher stuatory rate M in my case, and the schedular rating for incontinence, as well as the other stuff. Inceased loss of function I guess they'll cover under IVDS... not sure.

The biggy here is that my primary care doc, and this C&P doc both "seem" to agree that its needed... I just havent dealt with it before and am worried since I am going out tons of money each month on this. It simply a matter of them either providing it or a nursing home - thats it.

Thanks for the input.

Edited November 22, 2007 by sixthscents

[sixthscents]

I need some info on this subject; I'm totally confused. I seemed to have been misled by a VSO in that he said it is based on personal finacial income. WOW, I even called the VA 1-800 number and they said the same.

I have the 2006 VBM.... and can't get definitive info on basis for financial data. But, I did read it in the VA Benefits Manual, 2007. Thus, we were discouraged to file a claim for it and did not do so. My Aunt and Uncle paid zero ($0.00) income tax for the past 3 years because of their low income.

HELP, pls....

Again.. icome is NOT a factor in A/A or SMC... period. I am certain of that. SMC is based upon need established by loss of use etc. Not income, nor does income play a deciding factor in eligability... only the rquirement outlined in CFR38.

[sixthscents]

How do you apply for SMC?

Like anything else you send a letter stating that you are requesting compensation for... and would further like to request an evaluation for increased SMC. Give the details of his situation.. i.e. falling, heart condition etc.

Yes a letter from SOME doctor anyway, requesting consideration of SMC for bedridden, or whatever is normally the first thing required to start a claim. As I stated my PCP (VA) wrote a consult with home health, hiospice care stating that either I would need 24/7 care or admission into a nursing care facility for the following reasons.... etc. The VA does NOT provide home health care 24/7... trust me, I spoke with their care coordinator. It's not even a program they offer... only hospice, or skilled short term care. So SMC is the ONLY route except for admittal to a nursing facility.

I suppose you could fill out a claim form but I never have for any other claim, so I doubt this is any different, and I've done hundreds. A clear, consice letter is sufficient stating WHAT you are claiming and why... and then attaching all necessary evidence in support. It's is no different than filing any other claim.

You can always try to get some senator to get the claim pushed to the top of the stack (at that point it normally falls off the stack, lands on the floor and is forgotten - but hey why not try huh?) (sigh)... I cant really answer this because its really dependent upon too many issues, and honestly pisses me off since I'm in the same freakin stack.

It takes how long the VA takes. Depressing but true. Lets see I filed my stuff in July.... and unless the rater wants MORE c&p stuff.. well I expect something by January sometime... or Feb, March... heck who knows.... honestly I do expect something within the next 60 days unless they want more C&P exams... well see, if they dont than thats what 6-7 months? I'd say thats fast too. Id normally give the VA 10 months or so for an additional claim.

I dont mean to be depressing, but... I am kinda burned out now. Personally my own money is on me going into a nursing home... but you never know. If your uncle says no, well that's on him isn't it? For crying out loud I'm 40 with a 8 year old daughter.. do you think I want to go into a nursing home?..... Your uncle is 92... his wife is 88, mines 38... how long do you think she will stay MY wife HUH?

I am putting out roughly $3K a MONTH (and thank God... honestly, thank you God... that I CAN) paying out of pocket for my care... without even a freakin nurse to come and bath me... except for the ones I pay for... (I cant do this forever though... eventually It will affect our savings etc... my daughters college money, our land and assets... nope at that point it stops and I go into a nursing home... no matter how much my family objects, my daughters college is too important and she doesn't see daddy all that much now anyway since I am either stoned in bed, or at a doctors appointment and I cant deal with watching her watch me come unglued, co if no answer by say March, you all will not hear from me until I can get DSL installed in my room in Overton County Nursing Home, or tap into their system.. doubtful)

The real funny thing here is that if the VA refuses my claim they are going to pay out the nose for "skilled" care in a contract facility run by my sister. And they dont have much they CAN say about that.... except to say they want me in another facility instead, and even then they are on shakey ground. My sister's facility just went thru their annual check by the VA and passed with flying colors...

So, file the stuff for your uncle but dont expect any answer SOON, and being housebound is NOT enopugh to qualify for R1 or R2... even bedridden at their own choice, or under doctors orders for healing is a no-go... like I said read CFR 38 3.350-3.362. So while I feel some empathy.. tell him he can room with me.

I mean you lookes at the C&P right? I odnt know what the lady could have said more to support my claim... and my PCP (VA) is saying the exact same stuff. That's why I posted it... I wanted an experts opinion on it, like Vike.... or someone who had dealt with it before, because I THINK that C&P was great, but it's only what I think....

The simple truth here dude, is sometime we just dont get to pick and choose. Your uncle is 92... he's had a long and fruitful life. If he has to go into a home, well at least he can say that. File the claim, and maybe they'll approve it, and maybe not but at least you tried.

Again though... and for the last time

IT is NOT income based, in any way shape or form. It's supposed to be based upon need. It is INTENDED to SAVE the VA money, as compared to a nursing home. You would think they would jump at the chance. I'll let you know how my stuff goes, but I am only able to do the computer for short periods...

If this came out sarcastic, and uncaring I am sorry.... it's just that to get rushed treatment means SOMEONE gets slower treatment... and on this subject I am inexperienced. Ask me about any other tyoe of claim and I can go on for days, but this ine is new to me (R1-R2 that is).....

It's like this issue of priority care for the new war vets... that means us older vets get less priority.. even if we are rated massivly higher %'s.... to me that's simply unfair.

Your uncle should qualify for some level of SMC, even if its not R1 or R2.... heck if he really is rated at 170% for differing conditions... read 3.350 "other 50% ratings" he should qualify for some... an "s' rating is housebound and thats approved at 100%+60%... of different etiology - like I said.. read the reg.

Bob Smith

Edited November 23, 2007 by sixthscents

[sixthscents]

The highest levels of SMC are- R-1 and R-2-

this might be a little off the main topic but it pays to explain these levels-

R-1 (aka Special Aid and Attendance)

Requirments for award:

1. the veterans is receiving the maximum rate or an equal rate to the "O" award and

2. the veteran meets the basic eligibility for regular A & A.

In my particular case I think they are going to HAVE to approve "o" rate because of the loss of use of 2 limbs and incontinence... this is think though, not know but thats what cfr 38 says... plus there's all the other junk... ED so now missing 3 appendages... periods of disorientation - disconnected or disorganized thought (meds probably - heck hopefully)

R-1 6164 per month for single vet no dependents

R-2 Special Aid and Attendance at a Higher Level of Care

Requirements for award:

1. the vet meets the maximum or a rate equal to the "O" award.and

2. the vet meets the requirements of regular Aid and attendance criteria

and

3.the vet needs a higher level of care as defined within 38 CFR 3.352( (2)

these involve needing the services of daily care provided by a licensed health care professional or by someone directly under supervision of a licenced health care professional.

The R-2 rate is $7,070 per month for single veteran-

RNs or LPNs etc are licensed professionals- this could involve the need for daily injections, catheter inplacements, changing of sterile dressings , physical therapy---etc

I fall in here for several reason, I have a foley catheter (indwelling in other words), I also "straight" cat 5-7 times a day if not wearing foley. physical therapy as well, but they are having a bit of trouble deciding WHAT physical therapy I CAN do... pads have to be changed as well as other... protective garments (what a world we live in huh?)... thats not skilled though... meds are though, I have massive narcotices, and a massive amount of other meds that I simply cant keep track of... there are just too many now. I am borderline type II diabetes as well, and hypertension, etc etc etc... lets just say if I go into a nursing home it will HAVE to be under a "skilled" care bed

[sixthscents]

Honestly, I think that the time frame is simply dependent upon where you live and the case load of the raters. If you live in a state with few military installations, then it seems your claim is handled much more quickly than in a state with a lot of bases. More bases means more vets in that area, means more time for a rating...

I think it is that simple. You can try and get them to move quicker on a case, but that normally requires some congressional interest.. and that doesn't always do it.

I think you Uncle is probably very eligable for some level of A/A... and I'd certainly file for it. Further, it sounds like he qualifies for adaptive vehicle grant, so he CAN go to his doctor... and probably a wheelchair.

Now.. make sure your uncle is not a pensioned vetrean but a compensated one... since you said he was rated at 100% or greater I assumed this, but make sure in any case because the rules DO change for pensioners, versus compesationed veterans.

Like I said I posted the C&P because I wanted some expert opinion, like Vike or some others. Sadly I have discovered that most of them no longer post on Hadit. Obviously some things happened while I was gone. I have discussed the issue with some of them and know some of their reasons.....

(sigh)... thats enough computer for me today. Thanks all.

[theotherguy]

the vet meets the maximum or a rate equal to the "O" award.and

Actually this is a bit vague in CFR 38... but I, with my new problems qualify for "o" simply by having loss of use of 2 limbs and incontinence/loss of bladder and bowel... this is grounds for automatically awarding a rate of o.

Thats not even taking into consideration the loss of 3 extremeties now (which entitles to the next higher stuatory rate M in my case, and the schedular rating for incontinence, as well as the other stuff. Inceased loss of function I guess they'll cover under IVDS... not sure.

The biggy here is that my primary care doc, and this C&P doc both "seem" to agree that its needed... I just havent dealt with it before and am worried since I am going out tons of money each month on this. It simply a matter of them either providing it or a nursing home - thats it.

Thanks for the input.

Sorry for not getting back to you in a more timely manner. I'm glad to see that you have a handle on things and frankly understand that getting to "O" or "N 1/2 + K" is a requirement for you to be evaluated at "R-1." If your impairments are related to your IVDS getting this level of SMC should not be problematic if the evidence is how you have described it. Basically, if you need A&A at even the basic level and are at "O" or "N 1/2 + K" you will be bumped up to R-1.

To reach "R-2" the VA has a requirement that a higher level of care must be certified. I know that there is more information available on this in their M21-1 MR and I will do some more research and get back to you tonight.

theotherguy