The State Home Per Diem Program

1. The State Home Per Diem Program State Home Admissions Applications Processes Wayne A. Valey Acting Chief, State Home Per Diem Program prepared for the GEC 2010 Regional Conferences

2. Overview Basic Rules for State Home Admissions Basic Admission Process Flow for State Homes Eligibility for VA Aid for Care in State Veterans Homes SH Nursing Home Care Eligibility SH Domiciliary Care Eligibility SH Adult Day Health Care (ADHC) Processing State Home Admissions Applications Contacts

3. Basic Rules for State Home Admissions • State Veterans Homes are not open to the general public. • Admission is restricted to eligible Veterans and certain categories of Veteran-related family members • All non-Veteran residents must be: (1) spouses of Veterans; or (2) surviving spouses; or (3) gold star parents (all of whose children died while serving in the armed forces of the United States). A State home cannot admit or provide care to applicants other than those noted above.

4. Basic Rules for State Home Admissions • VA per diem payments to States are only paid for the care of eligible Veterans. • VA pays per diem to SVHs for the care of Veterans irrespective of whether the Veteran has wartime or peacetime service. • The Secretary of the Department of Veterans Affairs may adjust the per diem rates each year. • Non-Veteran residents are not entitled to payment of VA aid.

5. Basic Admission Process Flowfor State Homes . Applicant is an eligible veteran or an eligible Veteran-related category (spouse, surviving spouse, or gold star parent) Eligible for Admission Yes Yes Admissions Review No Can the home provide the level of care required? No Admission Denied Yes No Can the Applicant Pay? Yes Applicant Qualifies for Pay Sources (e.g., VA Per diem, Medicare, Medicaid, A&A, Private Pay, etc.)

6. Basic Admission Process Flowfor State Homes . Applicant Qualifies for Pay Source(s) Veteran Only Eligible Veteran-Related can be Admitted, but VA Per Diem is not Authorized for Payment (other pay sources may be used) Applies for VA per diem @ VAMC of Jurisdiction Meets Administrative Eligibility Criteria Admission not Approved, per diem cannot be paid No Reviewed by VA Physician Admission not approved, per diem cannot be paid Skilled Care Required No Per diem payments can be approved effective on the admission date when applications are received within ten days of admission. If received after ten days of admission, per diem payments begin on the day the application is received.

7. Eligibility for VA Aid for Care in State Veterans Homes General Eligibility Requirements • (1) VA aid may be paid for any Veteran who is eligible for care in a VA facility (38 C.F.R. 17.194 and 17.196). • (2) Not all Veterans are eligible for VA domiciliary care. The regulation governing eligibility for VA domiciliary care is 38 C.F.R. 17.46(b). • (3) A VA physician will determine the medical need of the applicant in accordance with 38 CFR §17.46 and §17.47.

8. Eligibility for VA Aid for Care in State Veterans Homes General Eligibility Requirements (continued) • (4) VA Medical Centers of Jurisdiction are directed to institute proper controls so that VA per diem payments are paid only for eligible Veterans. • VA has no authority to control the management or operation of state homes, including their admission practices.

9. SH Nursing Home Care Eligibility • A Veteran is deemed eligible for nursing home care if VA determines such care is needed by any Veteran in any of the following categories: • (1) Veterans with service-connected disabilities; • (2) Veterans who are former prisoners of war; • (3) Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty; • (4) Veterans who receive disability compensation under 38 U.S.C. 1151; • (5) Veterans whose entitlement to disability compensation is suspended because of the receipt of retired pay;

10. SH Nursing Home Care Eligibility(continued) • (6) Veterans whose entitlement to disability compensation is suspended pursuant to 38 U.S.C. 1151, but only to the extent that such Veterans' 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); • (8) Veterans of the Mexican border period or of World War I; • (9) 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 to the United States the applicable co-payment determined under 38 U.S.C. 1710(f) and 1710(g).

11. SH Domiciliary Care Eligibility Domiciliary care may be furnished when needed to: • (1) 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 • (2) Any Veteran who the Secretary determines had no adequate means of support. An additional requirement for eligibility for domiciliary care is the ability of the Veteran to perform the following: (a) Perform without assistance daily ablutions, such as brushing teeth, bathing, combing hair, or eliminating body waste. (b) Dress self with a minimum amount of assistance. (c) Proceed to and return from the dining hall without aid. (d) Feed self.

12. SH Domiciliary Care Eligibility(continued) • e) Secure medical attention on an ambulatory basis or by use of personally propelled wheelchair. • (f) Have voluntary control over body eliminations or control by use of an appropriate prosthesis. • (g) Share in some measure, however slight, in the maintenance and operation of the facility. • (h) Make rational and competent decisions as to his or her desire to remain or leave the facility.

13. SH Adult Day Health Care (ADHC) May be furnished to any Veteran who VA determines a Veteran is eligible for Per diem Adult Day Health Care in a state home if needs adult day health care, and is within one of the following categories: • (1) Veterans with service-connected disabilities; • (2) Veterans who are former prisoners of war; • (3) Veterans who were discharged or released from active military service for a disability incurred or aggravated in the line of duty;

14. SH Adult Day Health Care (ADHC)(continued) • (4) Veterans who receive disability compensation under 38 U.S.C. 1151; • (5) Veterans whose entitlement to disability compensation is suspended because of the receipt of retired pay; • (6) Veterans whose entitlement to disability compensation is suspended pursuant to 38 U.S.C. 1151, but only to the extent that such Veterans' continuing eligibility for adult day health 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);

15. SH Adult Day Health Care (ADHC)(continued) • (8) Veterans of the Mexican Border period or of World War I; • (9) 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); • (10) Veterans who agree to pay to the United States the applicable co-payment determined under 38 U.S.C. 1710(f) and 1710(g), if they seek VA (U.S. Department of Veterans Affairs) hospital, nursing home, or outpatient care.

16. Processing State Home Admissions Applications a. In order for an eligible Veteran to be considered for per diem payments, two forms are required to be submitted to VA when admission to a state Veterans home is sought. b. The Administrator will complete and submit a VA Form 10-10EZ, Application for Health Benefits and VA Form 10-10SH, State Home Program Application for Veteran Care Medical Certification, to the VA Medical Center Per Diem POC for each Veteran who is seeking admission to a SVH. These forms will be accompanied by proof of honorable discharge from the armed services and power of attorney, as applicable.

17. Processing State Home Admissions Applications • (1) For Veterans receiving nursing home care, domiciliary care, or adult day health care, the VA Form 10-10SH must contain sufficient medical information to justify the level of care that will be provided to the Veteran. • (2) For Veterans receiving domiciliary care, the VA Medical Center of Jurisdiction must obtain, maintain, and utilize income data to assure eligibility for VA per diem. Any changes from the 10-10EZ must be reported on VA Form 10-10EZR.

18. Processing State Home Admissions Applications • c. These admissions application forms will be date stamped in when they are received by the VA Medical Center of Jurisdiction’s Per Diem POC. • This is important because the effective date for payment of VA aid is determined based on the date the Veteran was admitted to a state home and the date that his/her admissions applications (VA Forms 10-10EZ and 10-10SH) were received by VA. • These forms must be received by VA within 10 days following admission, if VA is to approve payment of per diem from the first day of admission. If the forms are received more than 10 days after a Veteran’s admission to a state home, then per diem payments will be approved based on the date that complete and correct copies of VA Forms 10-10EZ and 10-10SH were received by VA.

19. Processing State Home Admissions Applications • For example: • (1) If a Veteran was admitted on May 1st and his applications forms were received by VA on May 10th, VA would approve per diem payments from May 1st. • (2) If a Veteran was admitted to a state home on May 1st and his applications forms were received by VA on May 17th, VA would not pay from the first day of admission (May 1st). In this case, VA would approve per diem payments from May 17th.

20. Processing State Home Admissions Applications • d. When these admissions application forms are received by the VA Medical Center of Jurisdiction’s Per Diem POC, two reviews will be conducted: • An administrative eligibility review will be conducted first to assure that the requirements in paragraph 8, above, are met. • At this time, VA will determine and specify whether the Veteran applicant is eligible for the higher per diem rate for service connected Veterans or the basic per diem rate. • This determination will form the future basis for calculating VA per diem for the applicant. • After the administrative eligibility review on the VA Form 10-10SH is conducted and verified (by signature by VA’s administrative reviewing official), the VA Form 10-10SH will be forwarded for a VA clinical review.

21. Processing State Home Admissions Applications • (2) For the clinical review, the medical need for the level of care applied for will be verified in writing by the signature of a VA physician on the basis of information furnished in the application for care. If the form lacks sufficient information to make a level of care determination, VA will ask the SVH to provide additional information (for example, a recent discharge summary and/or a history and physical narrative). • e. Reviews should be conducted expeditiously because the review can have an effect on the accurate and timely sub-mission of monthly SH per diem claims. The VA Medical Center of Jurisdiction POC will notify the state home if an approval will be delayed, and the reason(s) why. Prima facie determinations will be made pending verification of eligibility.

22. Processing State Home Admissions Applications • f. After the reviews have been conducted: • (1) The state home will be notified promptly on the admissions application decision rendered. VA Form Letter (FL) 10-356, Payment of Aid to State Homes by the VA, will be used for an approved application. A locally generated letter, which includes the reason(s) for disapproval will be used for admissions applications that were not approved. • (2) The VA Medical Center Per Diem POC will create or update a Veteran’s profile in the VAMC’s Veterans Health Information Systems and Technology Architecture (VistA) functionality. Information related to the veterans admission may also be entered into the VistA Fee state home program. Coordination will be required with VAMC facility enrollment staff to assure that records and eligibility information is properly input. This is important because not all Veterans who are admitted to state homes are eligible for enrollment in VHA health care.

23. Processing State Home Admissions Applications • g. Changes of status. The transfer of a Veteran to another level of care (e.g., from ADHC to domiciliary to nursing home) may occur and be more suitable to the Veteran's needs. These changes should be considered when a change in health or physical condition occurs. • (1) In cases where VA approval had not been previously granted, the state home should complete items necessary for a determination of legal eligibility for the transfer of a Veteran to a level of care. • (2) In cases where a Veteran who has been previously approved for and received nursing home care may be returned to that level of care without additional VA approval provided episodes occur during the same period of residency in the home and the information and the findings on VA Forms 10-10EZ and 10-10SH are still valid.

24. Contacts For additional information, please contact: Wayne A. Valey Acting Chief, State Home Per Diem Program wayne.valey@va.gov (303) 398-5908 Brenda Wiggins Program Analyst, State Home Division brenda.wiggins3@va.gov (202) 461-6757

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26. Content Developer Wayne Valey This training course or product was produced by the National Fee Program Office Communications and Training Division. It has been created for training purposes only and is not a replacement for policy information.