The VA State Home Per Diem Program State Home Admissions The Application Process Colette Alvarez, Chief State Home Per Diem Manager State Home Per Diem Program January 2015 Isabel Saunders

Objectives To understand the general eligibility criteria for State Veterans Home (SVH) Admissions To understand the eligibility criteria for each level of care To know the basic admission process flow To learn how to process the admission application To learn how to have your questions/concerns answered

General Eligibility Criteria for State Veterans Home Admissions SVH admission is only for eligible Veterans and certain categories of Veteran-related family members The homes are not open to the general public The categories of family members (non-Veteran residents) are: The spouses of Veterans; or The surviving spouses of Veterans; or Gold Star Parents The parents of children who have died while serving in the US Armed Forces

General Eligibility Criteria for State Veterans Home Admissions (cont’d) The SVH Per Diem Program provides per diem payments to SVHs for the care of eligible Veterans only. Per Diem is provided for the care of Veterans irrespective of whether the Veteran has wartime or peacetime service. The VA does not have authority to control the management or operation of State Homes, including their admission practices. VA Per Diem may be paid for a Veteran who is eligible for care in a VA facility, but it is very important to know that not all Veterans, on whose behalf VA pays per diem, are eligible for enrollment in VHA health care.

Nursing Home Care Eligibility A Veteran is eligible for nursing home care if the VA determines such care is needed by any Veteran, as defined in 38 U.S.C. 101(2), and meets one of the following criterion: Veterans with service-connected disabilities Veterans who are former prisoners of war (POW) Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty Veterans who receive disability compensation under 38 U.S.C. 1151 Veterans whose disability compensation is suspended because of the receipt of retired pay A Veteran is eligible for nursing home care if the VA determines such care is needed by any Veteran, as defined in 38 U.S.C. 101(2), and meets one of the following criterion: Veterans with service-connected disabilities Veterans who are former prisoners of war (POW) Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty Veterans who receive disability compensation under 38 U.S.C. 1151 Veterans whose disability compensation is suspended because of the receipt of retired pay

Nursing Home Care Eligibility (cont’d) 6) Veterans whose disability compensation is suspended according to 38 U.S.C. 1151, but only to the extent that a Veteran’s continuing eligibility for nursing home care is provided for in the judgment or settlement (described in 38 U.S.C. 1151) 7) Veterans who VA determines are unable to defray the expenses of necessary care as specified under 38 U.S.C. 1722(a), income thresholds Veterans of the Mexican Border period or World War 1; Veterans solely seeking care for a disorder associated with exposure to a toxic substance or radiation, or for a disorder associated with service in the Southwest Asia theater of operations during the Persian Gulf War (as provided in 38 U.S.C. 1710(e) 10) Veterans who agree to pay the United States the applicable co-payment determined under 38 U.S.C. 1710(f)(g)

Adult Day Health Care (ADHC) Eligibility ADHC may be furnished under 38 U.S.C. 1720(f)(1)(A). The Secretary may furnish adult day health care services to a veteran enrolled under section 1705(a) of this title who would otherwise require nursing home care. And to any Veteran who VA determines is not barred from receiving VA care, and meets the same eligibility requirements as nursing home level of care.  

Adult Day Health Care (ADHC) Eligibility (cont’d) Veterans who VA determines are unable to defray the expenses of necessary care as specified under 38 U.S.C. 1722(a), income thresholds Veterans solely seeking care for a disorder associated with exposure to a toxic substance or radiation or for a disorder associated with service in the Southwest Asia theater of operations during the Gulf War, as provided in 38 U.S.C. 1710(e) Veterans who agree to pay the United States the applicable co-payment determined under 38 U.S.C. 1710(f)(g) if they seek VA hospital, nursing home, or outpatient care

Domiciliary Care Eligibility Domiciliary care may be furnished, when needed, to: Any Veteran whose annual income does not exceed the maximum annual rate of pension payable to a Veteran in need of regular Aid and Attendance, or Any Veteran who the VA Secretary determines has no adequate means of support As defined in the State Veterans Home handbook (VHA Handbook 1601SH.01), the clinical provider will make this determination after it is determined that the Veteran’s income disqualifies him from previous criteria

Domiciliary Care Eligibility (cont’d) An additional requirement for eligibility for domiciliary care is the ability of the Veteran to perform the following: Without assistance, daily ablutions (hygiene), such as brushing teeth, bathing, combing hair, or eliminating body waste Dress self with a minimum amount of help Proceed to and return from the dining hall with aid Feed self Secure medical attention on the ambulatory basis or by use of personally propelled wheelchair Have voluntary control over body eliminations or control by use of an appropriate prosthesis Share in some measure, however slight, in the maintenance and operation of the SVH facility Make rational and competent decisions as to his or her desire to remain or leave the facility

Processing State Home Admissions Applications The Application Packet By law (38 CFR, Part 51.43), as a condition for receiving payment, the SVH must submit to the VA Medical Center (VAMC) of Jurisdiction for each Veteran a completed admissions application, consisting of: a completed VA Form 10-10 EZ, Application for Medical Benefits (or VA Form 10-10 EZR, Health Benefits renewal Form (if a VA Form 10-10 EZ is already on file at the VA) and a completed VA Form 10-10SH, State Home Program Application for Care – Medical Certification. These forms must be submitted to VA when admission to an SVH is sought, or with any request for a change in the level of care (domiciliary, nursing home, or adult day health care). This also includes when a veteran has been discharged for any reason, i.e. exceeding 10/12 day bed hold policy.

Processing State Home Admissions Applications (cont’d) The State Home will ensure a complete application package (VA Form 10-10EZ/EZR and VA Form 10-10SH) is submitted to the VAMC Per Diem POC for each Veteran within 10 calendar days of admission. For the 10-10EZ, use the new form dated July 2014 and do not use previous editions These forms will be accompanied by a power of attorney, if applicable If veteran signs with an "X", 2 people veteran knows must witness as he/or she signs. They must sign the form and print their names. A DD-214 or discharge document is no longer required with the admission packet, although the Veteran’s eligibility must be verified. If the Veteran is unable to provide documents of proof, the burden of verification lies with VA, and VA has the duty to assist the Veteran with finding the necessary information to file a claim for benefits, which includes information to determine Veteran status.

Processing State Home Admissions Applications (cont’d) For Veterans seeking nursing home, domiciliary, or adult day health care, VA Form 10-10SH must contain sufficient medical information to justify the level of care that is being recommended. The 10-10SH must be filled out entirely. For Part II, the History and Physical, you may use and attach a separate sheet if necessary, but be sure that each block on the form has been addressed. There are no optional blocks For all Veterans seeking domiciliary care, the VAMC of Jurisdiction must obtain, maintain, and utilize income data to assure eligibility for VA Per Diem.

Processing State Home Admissions Applications (cont’d) VA Form 10-10 EZ Since VA Form 10-10EZ was created as the application for health benefits and enrollment in the VA health care system, there are no instructions specific to State Home. The form is used to determine SVH per diem eligibility.   Applications for domiciliary care must provide financial disclosure. Nursing home care and adult day health care do not require financial disclosures. Veterans whose annual income does not exceed the maximum annual rate of pension payable to a Veteran in need of regular aid and attendance may be furnished domiciliary care when needed. Follow the guidance on the form 10-10EZ in Section V, revealing pension income.

Processing State Home Admissions Applications (cont’d) Both application forms (VA Form 10-10 EZ and VA Form 10-10 SH) must be date stamped (e.g. mailroom stamp, fax stamp) on the date received by the VAMC of Jurisdiction Per Diem POC. The date stamp is important because it plays a part in the determination of the first day that VA Per Diem payments start. In order for per diem payments to start the day that the Veteran was admitted, the complete application packet must be received by VA within 10 calendar days following admission. If the application packet is received after 10 calendar days of the Veteran’s admission, per diem payments will start on the date the complete and correct copies of VA Forms 10-10EZ and 10-10SH were received by VA.

Processing State Home Admissions Applications (cont’d) Date Stamp (Receipt Date of Application at VA And When to Start VA Payments) Here are a couple of examples: The Veteran is admitted on May 1st. His application was received by VA on May 10th. VA per diem payments start May 1st. The Veteran is admitted on May 1st. His application was received by VA on May 11th. Since the application was received more than 10 days after the Veteran’s admission, VA per diem payments start on May 11th (the date of receipt-date stamp).

Processing State Home Admissions Applications (cont’d) Eligibility for the Prevailing Rate (higher rate) of Per Diem VA processes two different nursing home per diem rates: The prevailing rate (higher rate) The basic rate There are three ways that a Veteran may qualify for the prevailing rate: The Veteran has a service-connected disability of 70% or greater and is in need of nursing home care The Veteran has a rating of total disability based on individual unemployability (TDIU or IU). Veterans rated for P&T are not eligible for higher per diem. To validate eligibility of TDIU or IU, verify with your local regional office. The Veteran is seeking care for a specific rated service connected disability that is less than 70% (0-60%) The State Home Per Diem POC may find the above qualifying information in VIS or in HINQ

Processing State Home Admissions Applications (cont’d) When the application packet is received by the VAMC of Jurisdiction’s Per Diem POC, two reviews will be conducted: An administrative eligibility review will be conducted first, to assure that all requirements that we previously discussed, both general and specific to the level of care that the Veteran is seeking, are met. For future reference, these requirements may be found in our handbook. At this time, VA will determine and specify whether the Veteran applicant is eligible for the prevailing per diem rate for service-connected Veterans, or the basic Per Diem rate. This determination forms the future basis for calculating VA per diem for the applicant.

Processing State Home Admissions Applications (cont’d) After the administrative eligibility review (on the VA Form 10-10SH) is conducted and verified (by signature of VA’s administrative reviewing official), VA Form 10-10SH will be forwarded for a VA clinical review. For the clinical review, the application should be sent for review to a designated VA physician or a qualified licensed physician assistant or nurse practitioner (all of whom should have knowledge of long term care). This clinician, in turn will review the application and determine the level of care, whether or not the admission is for a service connected disability, and sign the VA Form 10-10SH. The clinician will approve the level of care based on information furnished by the State Home.

Processing State Home Admissions Applications (cont’d) As far as specific requirements/items that must be present on the VA Form 10-10SH that the certifying medical official must/should use in making level of care recommendations, we do not, at this time have any guidance. If you need assistance, there are guidelines for nursing home care on the Medicare website. If the form lacks sufficient information to make a level of care determination, VA will ask the State Home to provide additional information (e.g. a recent discharge summary and/or a history and physical narrative). It is also recommended the VA Clinical Reviewer communicate directly with the SVH Clinical Reviewer.   VA has the final authority on the determination of the level of care.  One of the most important steps in the process is the timely communication of approval or denial decisions to the SVH. Both reviews should be conducted promptly, within 10 business days after the application is received by the VAMC. A delayed review can have an effect on the accurate and timely submission of monthly SVH Per Diem claims.

Processing State Home Admissions Applications (cont’d) If the application is denied, the VAMC of Jurisdiction POC should notify the SVH and advise them of the reason(s) why, and return the application.  A courtesy phone call to the SVH, letting them know the application is being returned may help reduce the delay. If, for example, the denial reason is the VA physician does not agree with the level of care recommendation, the VA physician should be providing specific reasons to the SVH for the denial so that they have the opportunity to appeal. 

Processing State Home Admissions Applications (cont’d) After the reviews have been conducted: The SVH will be promptly notified of the admission application decision. VA Form Letter (FL) 10-356, Payment of Aid to State Homes by the VA, may be used to communicate approved applications. The VAMC will develop a standard letter template to communicate denials. The denial letter will include the specific reason(s) the application was not approved. The VAMC Per Diem POC will create, or update an existing Veteran’s profile in the VAMC’s Veterans Health Information Systems and Technology Architecture (VistA). Coordination is required with VAMC facility enrollment staff to assure that records and eligibility information is properly input.

Processing State Home Admissions Applications (cont’d) Changes of Status: There will be times when a Veteran is transferred to another level of care (i.e. from ADHC to domiciliary, or domiciliary to nursing home). This will occur because it has been medically determined to be more suitable for the Veteran's needs. The SVH must complete a new application (VA Form 10-10EZ and VA Form 10-10SH) when there is a change in the level of care being considered.

How to Have Your Questions and Concerns Answered For more information on the State Home Admissions Application Process, there is information that may be found on our State Home Program web page: Intranet for VAMC: http://nonvacare.hac.med.va.gov/programs/state-homes.asp Internet for SVH: http://www.va.gov/PURCHASEDCARE/programs/veterans/nonvacare/statehome/index.asp Resources Include: State Veterans Home (SVH) Per Diem Payment Program Handbook, VHA Handbook 1601SH.01 Policies, Laws, and Regulations Forms Training Presentations If you find that you have exhausted all of these resources, then please send your questions/concerns to: VAMC Inquiry Group VHAStateHomePerDiemInquiries@va.gov SVH Inquiry Group CBOPCNASVH-VHAStateHomePerDiemInquires@va.gov