Do I qualify for SMC? Is it automatic?

[LKF050813]

Hi all,

I was originally awarded 80% rating upon medical retirement. Recently filed for an increase and just received the notification letter. I’m at 100% for mental health, and then I have combined ratings for other things that total another 90%. Do I qualify for SMC-S? If so, do I have to file for it or is it added automatically because of my rating?

[ShrekTheTank]

Welcome,  To answer your question, they should do it automatically.  The issue is they don't always do it.  So you might need to ask for a review to get it to trigger.  

I am currently at the BVA with a review, and we will see how it pans out.  It does not hurt to as the regional office or call Peggy.  

[Lemuel]

I am at the BVA with CCK for SMC for both me and my deceased wife.  Did not know spouses also qualify for SMC until I picked up the form.  VA Form 21-2680VA Form 21-2680

I took it to our primary care doctors as instructed by the Benefits Counselor when I tried to take it there.  Wife was hospitalized at the time.  CCK says they are up on both for me at the BVA.  I have had "higher level of care" qualifying for SMC-t since mid 2023.  My wife should have had the same but did not because of CHAMPVA.  MEDICARE and MEDICADE pay for the same in home higher level of care I am receiving.  The VAMC at Cheyenne tried to transfer my care to a housekeeping contractor which does not have employees qualified to watch for signs of partial and complex partial seizures, notify primary care and record them.

My advice to those who have CHAMPVA, if your wife has Part B Medicare, ignore CHAMPVA when being referred to a specialist.  Tell her primary care not to include CHAMPVA as the insurance source.  Only MEDICARE part B with co-pay. 

We did not and it cost my wife her life because a cardiologist reduced her seizure medication without consulting a neurologist.  She died in status epilepticus after not being able to get any neurologist clinic to take her. 

Extremely difficult to find a neurologist with CHAMPVA probably because they do not pay for that specialist regularly causing the neurology clinics to give you an excuse that they cannot take any more patients at this time.  

CHAMPVA  is essentially a MEDICARE advantage plan.  They can only charge MEDICARE approved rates.  Better to pay a little co-pay as I found out and save your wife's life or at least extend it longer.  A lesson learned too late.

You will find that true of any MEDICARE advantage plan.  They are not worth it even if they are free and you get to even not have to pay the part B charge.

@Tbird.  Something to research, explore and write a blog on.

Edited June 12 by Lemuel
left out definitive phrases

[LKF050813]

1 hour ago, ShrekTheTank said:

Welcome,  To answer your question, they should do it automatically.  The issue is they don't always do it.  So you might need to ask for a review to get it to trigger.  

I am currently at the BVA with a review, and we will see how it pans out.  It does not hurt to as the regional office or call Peggy.  

Any harm in asking for a review? My VSO keeps scaring me with horror stories of people that have a good rating and then get reduced because they didn’t leave well enough alone. I understand that completely, but also would like to get the SMC if I rate it.

[Lemuel]

57 minutes ago, LKF050813 said:

Any harm in asking for a review? My VSO keeps scaring me with horror stories of people that have a good rating and then get reduced because they didn’t leave well enough alone. I understand that completely, but also would like to get the SMC if I rate it.

My suggestion is to fill out the form.  Take it to your primary care for their input.  It then stays in VAHA is my understanding and is handled the same way as PCAFC.  I could be wrong about that.  But nothing you ask for should affect your current rating unless you are actually improved over what you were when you got the rating or did some stretching to get the rating.

Key is to look at your decision.  If it says P & T (permanent and total)  and the effective date to see if you meet the 5-10-20 year rules.  Not all ratings can be corrected.  Ratings for Rehab are always revisited no matter what you do usually annually.  Initial ratings are handled the same way.  No matter what you do they will be reassessed.  SMC is also reassessed regularly.  

If you do not qualify for no reassessment, then you will likely be reassessed.  Might as well draw the SMC and deal with the reassessments as they come.  If you rate it you rate it and an attorney will help.

SMC can eventually get to the BVA.  Prior to recent decisions it was very difficult because it is based upon VAHA medical reports which were unchallengeable.  C&P exams and challengeable with second opinions is my understanding of the difference.  A recent decision by the CAFC made the VAHA records challengeable for PCAFC and that should apply also to SMC.

 

Edited June 12 by Lemuel

[ShrekTheTank]

1 hour ago, LKF050813 said:

Any harm in asking for a review? My VSO keeps scaring me with horror stories of people that have a good rating and then get reduced because they didn’t leave well enough alone. I understand that completely, but also would like to get the SMC if I rate it.

If I would have listened to this I would still be at 30%.  I really don't like when they tell stories like this, it happened to one person who was probably not telling the truth, so now they do this to scare us I think.  

I was told by a guy at the DAV to not push anymore, and that the conditions I was going after would never be awarded.  I started with 2 condtions rated and I now have 12 or 13.  I have been to the CAVC twice and the BVA 4 times.  I have won everyone of the ones i pushed for and felt were service connected and they agreed.  

I now get full benefits and my family does also, and it makes it a bit easier to live each day.  It really sucks to live with these conditions, and it would suck more with more stress if we didn't get something.  My advice and this is just my opinion is to fight them as far as you need too, as no one else will do it for you.  Stand up to them and use the veterans here to help you.  Each one of us has a story of how we won our cases against the VA.  

Keep pushing and never give up!

[broncovet]

LKF...posted:

Quote

Any harm in asking for a review? My VSO keeps scaring me with horror stories of people that have a good rating and then get reduced because they didn’t leave well enough alone. I understand that completely, but also would like to get the SMC if I rate it.

Great question, even tho I have answered it before..its hard to find sometimes.  

In short, 

Quote

NO!

This is a myth perpetuated by the VA and assisted by VSO's..   Remember, your VSO ultimately gets paid (mostly) through VA.  So they owe their loyalty to the same VA that doctors owe their loyalty to VA:  Since the VA signs their checks, they dont want to bite the hand that feeds them.    I have thoroughly read the regulations on reductions at least 10 times.  NOWHERE does it say, "When the Veteran applies for an increase, then do a reduction instead".  

Instead, the VA has rather strict rules they must go by to reduce your rating.  While I will provide a link to the exact regulations, in summary the VA cant reduce Veterans (who are P and T, or have been rated 5 years or more) unless the Veteran has "actually improved under ordinary conditions of life".  Further, to make a reductions "stick" the improvement needs to be "sustained", and not just you had a good day when you went to your daughters birthday party.  So, one "good day" is not enough for the VA to reduce your benefits.  

Now, sometimes the VA will try to hornswaggle you.  They may do a proposed reduction, as they did to me.  But I simply wrote a letter and provided evidence that I did not meet criteria for reduction.  Since they tried to reduce (aka take off) my spouse from my award, I simply wrote a letter explaining I was still married, and had my wife do the same.  Reduction proposal was quashed easily.    

Here are some of the rules VA must adhere to be able to try to reduce you:

Quote

§ 3.344 Stabilization of disability evaluations.

(a) Examination reports indicating improvement. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and Department of Veterans Affairs regulations governing disability compensation and pension. It is essential that the entire record of examinations and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. This applies to treatment of intercurrent diseases and exacerbations, including hospital reports, bedside examinations, examinations by designated physicians, and examinations in the absence of, or without taking full advantage of, laboratory facilities and the cooperation of specialists in related lines. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings on account of diseases subject to temporary or episodic improvement, e.g., manic depressive or other psychotic reaction, epilepsy, psychoneurotic reaction, arteriosclerotic heart disease, bronchial asthma, gastric or duodenal ulcer, many skin diseases, etc., will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Ratings on account of diseases which become comparatively symptom free (findings absent) after prolonged rest, e.g. residuals of phlebitis, arteriosclerotic heart disease, etc., will not be reduced on examinations reflecting the results of bed rest. Moreover, though material improvement in the physical or mental condition is clearly reflected the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. When syphilis of the central nervous system or alcoholic deterioration is diagnosed following a long prior history of psychosis, psychoneurosis, epilepsy, or the like, it is rarely possible to exclude persistence, in masked form, of the preceding innocently acquired manifestations. Rating boards encountering a change of diagnosis will exercise caution in the determination as to whether a change in diagnosis represents no more than a progression of an earlier diagnosis, an error in prior diagnosis or possibly a disease entity independent of the service-connected disability. When the new diagnosis reflects mental deficiency or personality disorder only, the possibility of only temporary remission of a super-imposed psychiatric disease will be borne in mind.

(b) Doubtful cases. If doubt remains, after according due consideration to all the evidence developed by the several items discussed in paragraph (a) of this section, the rating agency will continue the rating in effect, citing the former diagnosis with the new diagnosis in parentheses, and following the appropriate code there will be added the reference “Rating continued pending reexamination ______ months from this date, § 3.344.” The rating agency will determine on the basis of the facts in each individual case whether 18, 24 or 30 months will be allowed to elapse before the reexamination will be made.

(c) Disabilities which are likely to improve. The provisions of paragraphs (a) and (b) of this section apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.

[26 FR 1586, Feb. 24, 1961; 58 FR 53660, Oct. 18, 1993]