TABLE OF CONTENTS. Getting Started: Applying for the Right Benefit. About the Author. Introduction. CHAPTER 1 Important Information 1 III

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1 TABLE OF CONTENTS Getting Started: Applying for the Right Benefit About the Author Introduction I III V CHAPTER 1 Important Information 1 Submitting Claims and Communicating with VA 1 VA s Duty to Assist... 1 The Fully Developed Claim Concept... 2 Requirement for Service... 2 Effective Date of Your Claim... 4 Signatures and Power Of Attorney... 5 How VA Makes Decisions Approving or Denying Benefits... 6 VA s Principle of Reasonable Doubt... 6 Responding to Denials... 8 Marriage... 9 Marriage Deemed Valid... 9 Remarriage CFR 3.55 Marriage Was Void or Annulled... 9 Marriage Terminated Prior to November 1, DIC Benefits for Terminated Remarriage Non--Married Relationship Benefits for a surviving spouse who remarries after age 57 (presumed married).. 10 Divorce or Annulment CFR 3.53 Continuous cohabitation Evidence for the Marriage Evidence for Death Death Determined by a Seven-Year Absence Accrued Benefits (benefits due at the death of the claimant) i

2 Appeals The Importance of Submitting a Fully Developed Claim CHAPTER 2 Pension and Death Pension (Commonly Called Aid and Attendance) 17 Defining What Pension Is The Disability and Medical Needs Tests The Income Test The Asset Test CFR Relationship of net worth to pension entitlement CFR Criteria for evaluating net worth CFR Certain transfers or waivers disregarded Death (Survivors) Pension for a Single Surviving Spouse.. 23 Reducing Income through Medical Expenses The Importance of a Rating Understanding an Original Application for Pension Applying Income, Assets, Medical Expenses to 12 Month Prospective Period.. 26 General Medical Costs Eligible for the 12 Month Prospective Deduction. 27 Medical Costs Eligible for Ongoing Receipt of Pension after Initial Application Denial of Pension Benefits after an Initial Award The Importance of Keeping VA Informed Criteria for Receiving a Rating for Aid and Attendance CFR Special monthly dependency and indemnity Compensation death Compensation, Pension and spouse s Compensation ratings Housebound; improved Pension; death Criteria for determining need for aid and attendance and permanently bed ridden.. 31 Interpreting the Regulations for the Requirement for Aid and Attendance Medical Deduction Rules for Personal Care Arrangements Medical Deduction Rules for Licensed Personal Care Services Medical Deduction Rules for Independent Living Medical Deduction Rules for Assisted Living Medical Deduction Rules for Nursing Homes ii

3 Medical Deductions for the Unhealthy Spouse of a Healthy Living Veteran. 37 Examples of How Pension is Calculated Maximum Annual Pension and Annual Death Pension Rates. 38 Sample Case #1 Veteran & Spouse - Veteran Receiving Long Term Care at Home 39 Veterans and Spouse- Veteran Receiving Paid Long Term Care at Home.. 40 Sample Case #2 Single Veteran - Veteran in Assisted Living Single Veteran- Veteran in Assisted Living. 41 Sample Case #3 Veteran and Spouse - Veteran in a Nursing Home Veterans and Spouse- Veteran in a Nursing Home Sample Case #4 Single Surviving Spouse with Paid Home Care Services Single Surviving Spouse with Paid Home Care Services. 44 Sample Case #5 Surviving Spouse of a Veteran - No Large Offsetting Medical Cost 44 Surviving Spouse of a Veteran No Large Offsetting Medical Costs Surviving Spouse of a Veteran With Large Offsetting Medical Costs 45 Sample Case #6 Healthy Veteran/Non-Veteran Spouse Generating Medical Costs Healthy Veteran with Non-Veteran Spouse Generating the Medical Costs Making Application for Pension or Death Pension on Your Own Three Types of Application for Pension The Claim Support Data Disk Description of the Necessary Forms for a Fully Developed Claim SF 180 Request Pertaining to Military Records VBA EZ-ARE Application for Pension VBA EZ-ARE Application for DIC, Death Pension, and/or Accrued Benefits.. 51 VBA-21-22a-ARE Appointment of Individual as Claimant's Representative VBA ARE Authorization to Disclose Personal Information to a Third Party. 51 VBA ARE Exam for Housebound Status or Permanent Need for Regular Aid and Attendance VBA ARE Request for Nursing Home Information in Connection with Claim for Aid and Attendance FV12- Doctor Report Addendum FV13- Care Provider Certification of Services 53 FV 16 Claimants Certification of Out of Pocket Expenses FV 22 Independent Living Community Certification of Services iii

4 FV 11 Cover Letter for Submission Other Necessary Forms Filing an Intent to File, VBA Form , formerly known as an Informal Claim 54 Making Application for Pension or Death Pension Using Our Checklists. 55 Checklist 1 Pension Unhealthy Veteran Facility or Home Care. 56 Checklist 2 Veteran Unhealthy Spouse Facility or Home Care.. 56 Checklist 3 Surviving Spouse Facility or Home Care. 56 Paying Attention to Potentially Disastrous Pitfalls in the Application Process Providing Information to VA.. 63 IRS Crosschecks Financial Issues to be Aware Of.. 65 Evidence for Medical Costs 67 What Documents Not to Submit with the Claim.. 67 If the Claimant Dies While the Application Is Pending or VA owes the Claimant Money Payment of certain accrued benefits upon death of a beneficiary. 68 Accrued Benefits and Final Expenses If the Claimant Dies before the Claim is Approved or Denied.. 70 The Appointment of a Fiduciary Filling out VBA Form The Fiduciary Hubs Notifying VA of Changes in Income, Assets and Medical Costs Pension Management Centers 72 Formal Claim Submission.. 73 Claims Involving Independent Living Facilities (ILF). 75 CHAPTER 3 Understanding Compensation and DIC 77 SECTION A HOW TO FILE A SUCCESSFUL CLAIM FOR BENEFITS 77 The Dilemma Presented to Your Regional Office Most Claimants Don t Know It s Hard to Do It Right The Typical Claim Is Likely to Add to the Current Backlog iv

5 An Incomplete Claim Will Languish for a Long Time and Likely Result in a Denial VA s Requirements under the Veterans Claims Assistance Act of Follow Our Instructions for Better Success through a Fully Developed Claim You Must Take the Initiative for Timely Decision through a Fully Developed Claim How to Use the Information in This Book to File a Fully Developed Claim SECTION B ABOUT DIC AND COMPENSATION 85 Description of DIC Dependency and Indemnity Compensation for Description of Disability Compensation Overview of Disability Compensation and Special Monthly Compensation.. 87 Individual Unemployability Benefits.. 87 Special Monthly Compensation (SMC) SMC for Assistance with Aid and Attendance or Housebound A rating of SMC (1) would Include.. 89 Disability Compensation Rate Table for Special Monthly Compensation (SMC) Rate Table for Receiving Disability Benefit Payments Concurrent Retirement and Disability Payments (CRDP) Combat-Related Special Compensation (CRSC) Housing Adaptability Grants Special Benefit Allowances Medal of Honor Pension SECTION C UNDERSTANDING ADJUDICATION PROCESS FOR CLAIMS 95 The Four Necessary Elements of a Claim for Disability Compensation or DIC Understanding Service Requirements for Veterans Benefits Establishing Evidence of the Illness, Injury or Aggravation incurred in Service Establishing Evidence for a Current Disabling Illness or Condition Establishing a Link between the Current Disability and the Illness, Injury or Condition That Occurred in Service The Consequences of Incomplete Evidence or Failing for What VA Wants. 105 Understanding the Claims Process in the Regional Office Overview of the Veterans Benefits Administration v

6 How the Rating Activity in the Regional Office Makes a Decision The Job of the Rating Activity Rating Decisions Are Not Made by Individuals with a Medical Background Instructions for Raters from Adjudication Manual M21-1MR Assigning a Rating Level CHAPTER 4 The Claims Process for Compensation, DIC and SMC 125 SECTION A ELEMENTS OF THE FULLY DEVELOPED CLAIM PROCESS 125 Where to Submit Claims Claims Intake Center The Fully Developed Claim Is a Wonderfully Useful Procedure for Getting Results Decide Whether the Condition Warrants Making a Claim Always File an Intent to File, VA Form Get a Copy of Your Discharge and Locate Your Own Service Treatment Records Obtain Your Own Private Medical Records Have Your Private Doctors or Specialists Do Disability Evaluations Have Your Doctors/Specialists Provide Opinion Letters If Service Connection Is Needed Obtain or Produce Lay Evidence Locate Records to Establish Assignment Location or Type of Duty Where Applicable Make Sure the Evidence Conforms with Rating Decision Criteria in Section C Understand the Claim Forms and the Forms for Obtaining Records Fill out the Fully Developed Claim Forms for the Claimed Benefit Check and Double Check Everything and Include All Necessary Forms Arrange for Representation and Third-Party Help If Needed Provide a Cover Letter to Help the Service Representative Understand the Claim Where to Submit Claims Claims Intake Center Understand the Acknowledgment Letter from Your Veterans Service Center Use VA Form for Purposes of Correspondence on the Claim Expect Scheduling of a Compensation and Pension Examination Decide How to Proceed if the Claimant Dies before the Claim Is Adjudicated vi

7 SECTION B SUBMITTING APPLICATION FOR SPECIFIC TYPES OF CLAIMS Understanding the Disability Rating System Disability Ratings Disability Compensation Rate Table for Combined Ratings Disability Compensation Replaces the Earnings Capacity Lost Because of the Disability Identify below the Type of Claim or Claims That Fit Your Situation Submitting Application for an Intent to File, VA Form Application for Aid & Attendance or Housebound w/ Compensation & DIC. 150 Understanding Claims for Aid and Attendance or Housebound Allowances Criteria for the Need for Aid and Attendance Definition of Housebound Identifying the Various Allowances Available for Application Applications for Aid and Attendance or Housebound for Spouses or Surviving Spouses Application for Aid and Attendance or Housebound for Veterans Totally Disabled Application for an Original Claim for DIC Understanding DIC Different Types of Claims Elements Common to Every Type of Claim for DIC Elements Common to All Claims for DIC except the Automatic Benefit Claim Elements of the Fully Developed Claim Process for DIC List of All Forms Needed for DIC Claims Procedures for the Application Types below Application for the Automatic Benefit Application for a Veteran Who Was on Claim for Compensation but Fails the Test for the Automatic Benefit Application for a Veteran Who Never Made a Claim for Compensation but Whose Death Could Be Presumed Service-Connected Application for a Veteran who Never Made a Claim and Whose Survivor Must Prove Service Connection vii

8 5. Application for a Veteran s Death that Could Be the Result of a Section 1151 Claim That Has Not yet Been Filed Application to include a Surviving Spouse Who Needs Aid and Attendance or Is Housebound The Rating Decision for DIC Offsets to DIC Reconsidering or Reopening a Claim for A & A, Compensation or DIC Reconsidering Evidence before a Final Decision is Made 178 Reopening a Claim after a Denial Decision Is Made Specific Chronic Conditions Presumed Service-Connected with a Time Limit Prisoner of War Chronic Conditions, Service-Connected with No Time Limit Ionizing Radiation Chronic Conditions Presumed Service-Connected Agent Orange Chronic Conditions, Service-Connected with No Time Limit Disability Caused by Illness, Combat or Other Injury Incurred in the Service Secondary Service Connection or Aggravation of an Existing Condition Exposure to Hazards, Chemicals and Harmful Environmental Conditions PTSD Posttraumatic Stress Disorder Hearing Loss with or without Tinnitus PTIU Permanent and Total Disability Due to Individual Unemployability Gulf War Disorders Service Connection Is Presumed with a Time Limit Request for Reevaluation or Change for an Existing Benefit Section 1151 Claim Tropical Diseases Service Connection Is Presumed with a Time Limit Special Monthly Compensation (SMC) Specific Special Allowances HISA Grants (Home Improvement and Structural Alterations CHAPTER 5 State Veterans Benefits 223 State Tax Discounts, Special Services and Other Savings for Veterans Generally Available in All States State Veterans Homes viii

9 Burial in State Veterans Cemeteries Motor vehicles and License Plates Other Available Benefits Locating Specific Benefits in Each State About State Veterans Homes The Appeal of Living in a State Veterans Home Challenges for State Veterans Homes History of State Veterans Homes Challenges Facing the Construction of New Homes Nursing Home Daily Rates Standard Per Diem Program Alternate Per Diem Program Medication Subsidy Type of Care Provided Eligibility and Application Requirements for State Veterans Homes Department Of Veterans Affairs Funding and Statistics for Veterans Care Programs CHAPTER 6 Veterans Health Care 237 The Best Health Care System in America Why the VA Health Care System Works so Well What is Veterans Health Care? Outpatient Pharmacy Services Veterans Health Administration Long Term Care Benefits Enrolling in the Veterans Health Care System Minimum Duty Requirements Women Veterans Eligibility Readjustment Counseling Services Priority Group 8 Enrollment Relaxation Enrollment Restriction Initial Enrollment Concurrent Enrollment in VA and Medicare ix

10 Availability of the Other Services Hearing Aids and Eyeglasses Dental Benefits for Veterans Emergency Care at a Non-VA Facility Copayments for Medical Services -- Veterans Means Testing Health Care for Families of Veterans Family Members of Veterans CHAMPVA Children of Women Vietnam Veterans (CWVV) Program Spina Bifida Healthcare Program Caregiver Program Non-VA Medical Care Program. 258 Emergency Care Services. 258 Prior Approval for Veteran Care 258 Patient-Centered Community Care (PC3). 258 Project ARCH (Access Received Closer to Home) State Veterans Home (SVH) Per Diem Program 259 Indian Health Services (HIS)/Tribal Health Program (THP) Reimbursement Agreement Program CHAPTER 7 Burial Benefits 261 Where to Burial Benefits Claims Claims Intake Center 261 Burial Allowances What Are VA Burial Allowances? Who Is Eligible? How Much Does VA Pay? Burial and Memorial benefits Eligibility Burial in VA National Cemeteries Burial in Arlington National Cemetery Certain Eligible Parents for VA Burial Headstones, Markers and Medallions x

11 Inscription Private Cemeteries In Memory Of Markers Medallions in Lieu of Government Headstone/Marker Presidential Memorial Certificates Burial Flag Military Funeral Honors Veterans Cemeteries Administered by Other Agencies CHAPTER 8 Appeals 271 Where do I file and Appeal for a Denied Claim Where to File an Appeal for a Denied Pension / Survivor/ Burial Claim 271 What Constitutes an Appeal? (Filing a Notice of Disagreement) Decision Review Officer (DRO) Statement of the Case (SOC) Substantive Appeal (VA Form 9) Final Review and Forward to BVA by the Office of Original Jurisdiction Board of Veterans Appeals (BVA) Additional Evidence Personal Hearing Further Defining a Notice of Disagreement and a Substantive Appeal Grounds for Request for Reconsideration Further Appeal to the Court Of Appeals for Veterans Claims (CAVC) Hiring a Representative for Appeal CHAPTER 9 Using the Claim Support Data Disk 279 Introduction and Contents Application for Pension and Death (Survivors) Pension Application for Compensation and DIC Application for Health Care Benefits Application for Burial Benefits xi

12 APPENDIX 289 Contents Appendix Section 1 List of VA Regional Offices Appendix Section 2 List of State Veterans Nursing Homes Appendix Section 3 Evidence of Marriage and Death Surviving Spouse Criteria for a Surviving Spouse CFR 3.50 Spouse and surviving spouse Marriage Deemed Valid Remarriage CFR 3.55 Marriage void, terminated or annulled Divorce or Annulment CFR 3.53 Continuous cohabitation Evidence for the Marriage Evidence for Death Death Determined by a Seven-Year Absence Appendix Section 4 Information on Individual Unemployability Appendix Section 5 Information on Posttraumatic Stress Disorder PTSD Criterion A: stressor Criterion B: intrusive recollection Criterion C: avoidant/numbing Criterion D: hyper-arousal Criterion E: duration Criterion F: functional significance New Diagnostic Criteria for PTSD to Be Released: DSM PTSD History and Overview : Matthew J. Friedman, MD, PhD Criteria for a PTSD diagnosis Assessing PTSD xii

13 Treatment for PTSD References Complex PTSD What types of trauma are associated with Complex PTSD? What additional symptoms are seen in Complex PTSD? What other difficulties are faced by those who experienced chronic trauma? Treatment for Complex PTSD References Epidemiology of PTSD: Jaimie L. Gradus, DSc, MPH What is epidemiology? What is prevalence? Prevalence of PTSD U.S. National Comorbidity Survey Replication PTSD among children and adolescents PTSD in other countries National Vietnam Veterans Readjustment Study Gulf War Veterans Operation Enduring Freedom/Operation Iraqi Freedom Commonly-used epidemiologic terms (12) What is cumulative incidence? What is a cumulative incidence ratio? What is the incidence rate? What is an incidence rate ratio? What is an odds ratio? References Overview of Psychotherapy for PTSD: Hamblen, PhD, Schnurr, PhD, Rosenberg, MA, & Eftekhari, PhD Exposure-based treatments Cognitive approaches Adding components EMDR Other approaches xiii

14 Conclusion References. 349 Clinician's Guide to Medications for PTSD: Matt Jeffreys, MD Overview What core PTSD symptoms are we trying to treat? What are some of the biological disturbances found in PTSD? How do medications help regulate these responses? How do we measure the effects of treatment? What is the evidence base for the specific groups of medications used for PTSD treatment? Selective Serotonin Reuptake Inhibitors (SSRIs) Other newer antidepressants for PTSD Mood stabilizers for PTSD Atypical antipsychotics for PTSD Other medications for PTSD Benzodiazepines and PTSD Developing new medications for PTSD Common barriers to effective medication treatment in PTSD A final word regarding medications and treatment for PTSD Important Considerations References Appendix Section 6 Hearing Loss Probability Chart Appendix Section 7 Agent Orange AGENT ORANGE STORED IN THE US 367 VA AGENT ORANGE NEWSLETTERS xiv