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... 9 38 CFR 3.55 Marriage Was Void or Annulled... 9 Marriage Terminated Prior to November 1, 1990... 10 DIC Benefits for Terminated Remarriage... 10 Non--Married Relationship... 10 Benefits for a surviving spouse who remarries after age 57 (presumed married).. 10 Divorce or Annulment... 11 38 CFR 3.53 Continuous cohabitation... 12 Evidence for the Marriage... 12 Evidence for Death... 14 Death Determined by a Seven-Year Absence... 15 Accrued Benefits (benefits due at the death of the claimant)... 15 i
Appeals... 16 The Importance of Submitting a Fully Developed Claim... 16 CHAPTER 2 Pension and Death Pension (Commonly Called Aid and Attendance) 17 Defining What Pension Is... 17 The Disability and Medical Needs Tests....... 17 The Income Test........ 18 The Asset Test..... 19 38 CFR 3.274 Relationship of net worth to pension entitlement...... 21 38 CFR 3.275 Criteria for evaluating net worth... 22 38 CFR 3.276 Certain transfers or waivers disregarded........ 23 Death (Survivors) Pension for a Single Surviving Spouse.. 23 Reducing Income through Medical Expenses....... 24 The Importance of a Rating......... 25 Understanding an Original Application for Pension..... 26 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... 27 Denial of Pension Benefits after an Initial Award....... 29 The Importance of Keeping VA Informed....... 30 Criteria for Receiving a Rating for Aid and Attendance... 30 38 CFR 3.351 Special monthly dependency and indemnity Compensation death Compensation, Pension and spouse s Compensation ratings... 31 Housebound; improved Pension; death 31 3.352 Criteria for determining need for aid and attendance and permanently bed ridden.. 31 Interpreting the Regulations for the Requirement for Aid and Attendance... 32 Medical Deduction Rules for Personal Care Arrangements... 33 Medical Deduction Rules for Licensed Personal Care Services... 35 Medical Deduction Rules for Independent Living... 35 Medical Deduction Rules for Assisted Living......... 36 Medical Deduction Rules for Nursing Homes... 36 ii
Medical Deductions for the Unhealthy Spouse of a Healthy Living Veteran. 37 Examples of How Pension is Calculated.... 37 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...... 41 Single Veteran- Veteran in Assisted Living. 41 Sample Case #3 Veteran and Spouse - Veteran in a Nursing Home..... 41 Veterans and Spouse- Veteran in a Nursing Home.... 43 Sample Case #4 Single Surviving Spouse with Paid Home Care Services... 43 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... 44 Surviving Spouse of a Veteran With Large Offsetting Medical Costs 45 Sample Case #6 Healthy Veteran/Non-Veteran Spouse Generating Medical Costs... 45 Healthy Veteran with Non-Veteran Spouse Generating the Medical Costs... 45 Making Application for Pension or Death Pension on Your Own... 46 Three Types of Application for Pension.... 46 The Claim Support Data Disk..... 47 Description of the Necessary Forms for a Fully Developed Claim..... 49 SF 180 Request Pertaining to Military Records.... 50 VBA-21-527EZ-ARE Application for Pension... 51 VBA-21-534EZ-ARE Application for DIC, Death Pension, and/or Accrued Benefits.. 51 VBA-21-22a-ARE Appointment of Individual as Claimant's Representative..... 51 VBA-21-0845-ARE Authorization to Disclose Personal Information to a Third Party. 51 VBA-21-2680-ARE Exam for Housebound Status or Permanent Need for Regular Aid and Attendance...... 52 VBA-21-0779-ARE Request for Nursing Home Information in Connection with Claim for Aid and Attendance........ 52 FV12- Doctor Report Addendum....... 52 FV13- Care Provider Certification of Services 53 FV 16 Claimants Certification of Out of Pocket Expenses... 53 FV 22 Independent Living Community Certification of Services..... 53 iii
FV 11 Cover Letter for Submission..... 54 Other Necessary Forms.... 54 Filing an Intent to File, VBA Form 21-0966, 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... 63 Providing Information to VA.. 63 IRS Crosschecks... 63 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.......................................... 68 5121. Payment of certain accrued benefits upon death of a beneficiary. 68 Accrued Benefits and Final Expenses... 69 If the Claimant Dies before the Claim is Approved or Denied.. 70 The Appointment of a Fiduciary.... 71 Filling out VBA Form 21-0792... 72 The Fiduciary Hubs... 72 Notifying VA of Changes in Income, Assets and Medical Costs...... 72 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....... 77 Most Claimants Don t Know It s Hard to Do It Right...... 77 The Typical Claim Is Likely to Add to the Current Backlog.... 79 iv
An Incomplete Claim Will Languish for a Long Time and Likely Result in a Denial... 80 VA s Requirements under the Veterans Claims Assistance Act of 2000 81 Follow Our Instructions for Better Success through a Fully Developed Claim... 83 You Must Take the Initiative for Timely Decision through a Fully Developed Claim... 83 How to Use the Information in This Book to File a Fully Developed Claim... 83 SECTION B ABOUT DIC AND COMPENSATION 85 Description of DIC..... 85 Dependency and Indemnity Compensation for 2015-16.. 86 Description of Disability Compensation...... 87 Overview of Disability Compensation and Special Monthly Compensation.. 87 Individual Unemployability Benefits.. 87 Special Monthly Compensation (SMC)... 88 SMC for Assistance with Aid and Attendance or Housebound.... 89 A rating of SMC (1) would Include.. 89 Disability Compensation Rate Table for 2015-16.. 90 Special Monthly Compensation (SMC) Rate Table for 2015-16 90 Receiving Disability Benefit Payments..... 91 Concurrent Retirement and Disability Payments (CRDP)...... 91 Combat-Related Special Compensation (CRSC)...... 92 Housing Adaptability Grants..... 92 Special Benefit Allowances.... 93 Medal of Honor Pension....... 94 SECTION C UNDERSTANDING ADJUDICATION PROCESS FOR CLAIMS 95 The Four Necessary Elements of a Claim for Disability Compensation or DIC. 95 1. Understanding Service Requirements for Veterans Benefits....... 95 2. Establishing Evidence of the Illness, Injury or Aggravation incurred in Service.. 99 3. Establishing Evidence for a Current Disabling Illness or Condition. 101 4. Establishing a Link between the Current Disability and the Illness, Injury or Condition That Occurred in Service... 102 The Consequences of Incomplete Evidence or Failing for What VA Wants. 105 Understanding the Claims Process in the Regional Office.. 106 Overview of the Veterans Benefits Administration.... 106 v
How the Rating Activity in the Regional Office Makes a Decision... 110 The Job of the Rating Activity... 110 Rating Decisions Are Not Made by Individuals with a Medical Background... 110 Instructions for Raters from Adjudication Manual M21-1MR... 111 Assigning a Rating Level...... 123 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... 125 The Fully Developed Claim Is a Wonderfully Useful Procedure for Getting Results.. 125 1. Decide Whether the Condition Warrants Making a Claim.. 125 2. Always File an Intent to File, VA Form 21-0966.... 126 3. Get a Copy of Your Discharge and Locate Your Own Service Treatment Records 127 4. Obtain Your Own Private Medical Records...... 128 5. Have Your Private Doctors or Specialists Do Disability Evaluations.... 129 6. Have Your Doctors/Specialists Provide Opinion Letters If Service Connection Is Needed.... 130 7. Obtain or Produce Lay Evidence...... 131 8. Locate Records to Establish Assignment Location or Type of Duty Where Applicable...... 133 9. Make Sure the Evidence Conforms with Rating Decision Criteria in Section C... 133 10. Understand the Claim Forms and the Forms for Obtaining Records....... 133 11. Fill out the Fully Developed Claim Forms for the Claimed Benefit. 136 12. Check and Double Check Everything and Include All Necessary Forms. 137 13. Arrange for Representation and Third-Party Help If Needed...... 138 14. Provide a Cover Letter to Help the Service Representative Understand the Claim.. 138 15. Where to Submit Claims Claims Intake Center..... 138 16. Understand the Acknowledgment Letter from Your Veterans Service Center... 139 17. Use VA Form 21-4138 for Purposes of Correspondence on the Claim.... 139 18. Expect Scheduling of a Compensation and Pension Examination..... 139 19. Decide How to Proceed if the Claimant Dies before the Claim Is Adjudicated... 141 vi
SECTION B SUBMITTING APPLICATION FOR SPECIFIC TYPES OF CLAIMS Understanding the Disability Rating System...... 145 Disability Ratings............ 145 Disability Compensation Rate Table for 2015-16... 146 Combined Ratings........... 146 Disability Compensation Replaces the Earnings Capacity Lost Because of the Disability.......... 147 Identify below the Type of Claim or Claims That Fit Your Situation... 148 1. Submitting Application for an Intent to File, VA Form 21-0966...... 148 2. Application for Aid & Attendance or Housebound w/ Compensation & DIC. 150 Understanding Claims for Aid and Attendance or Housebound Allowances.. 150 Criteria for the Need for Aid and Attendance.......... 151 Definition of Housebound........... 153 Identifying the Various Allowances Available for Application..... 154 Applications for Aid and Attendance or Housebound for Spouses or Surviving Spouses.. 155 Application for Aid and Attendance or Housebound for Veterans Totally Disabled. 157 3. Application for an Original Claim for DIC..... 162 Understanding DIC..... 162 Different Types of Claims.... 163 Elements Common to Every Type of Claim for DIC..... 165 Elements Common to All Claims for DIC except the Automatic Benefit Claim.. 165 Elements of the Fully Developed Claim Process for DIC... 169 List of All Forms Needed for DIC Claims... 169 Procedures for the Application Types below... 170 1. Application for the Automatic Benefit... 170 2. Application for a Veteran Who Was on Claim for Compensation but Fails the Test for the Automatic Benefit... 171 3. Application for a Veteran Who Never Made a Claim for Compensation but Whose Death Could Be Presumed Service-Connected... 172 4. Application for a Veteran who Never Made a Claim and Whose Survivor Must Prove Service Connection... 174 145 vii
5. Application for a Veteran s Death that Could Be the Result of a Section 1151 Claim That Has Not yet Been Filed... 176 6. Application to include a Surviving Spouse Who Needs Aid and Attendance or Is Housebound... 177 The Rating Decision for DIC... 177 Offsets to DIC... 178 4. Reconsidering or Reopening a Claim for A & A, Compensation or DIC... 178 Reconsidering Evidence before a Final Decision is Made 178 Reopening a Claim after a Denial Decision Is Made... 179 5. Specific Chronic Conditions Presumed Service-Connected with a Time Limit 182 6. Prisoner of War Chronic Conditions, Service-Connected with No Time Limit... 185 7. Ionizing Radiation Chronic Conditions Presumed Service-Connected... 187 8. Agent Orange Chronic Conditions, Service-Connected with No Time Limit... 189 9. Disability Caused by Illness, Combat or Other Injury Incurred in the Service... 192 10. Secondary Service Connection or Aggravation of an Existing Condition 196 11. Exposure to Hazards, Chemicals and Harmful Environmental Conditions... 198 12. PTSD Posttraumatic Stress Disorder... 202 13. Hearing Loss with or without Tinnitus... 205 14. PTIU Permanent and Total Disability Due to Individual Unemployability. 209 15. Gulf War Disorders Service Connection Is Presumed with a Time Limit... 211 16. Request for Reevaluation or Change for an Existing Benefit... 213 17. Section 1151 Claim... 215 18. Tropical Diseases Service Connection Is Presumed with a Time Limit... 217 19. Special Monthly Compensation (SMC)... 219 20. Specific Special Allowances... 221 21. HISA Grants (Home Improvement and Structural Alterations... 221 CHAPTER 5 State Veterans Benefits 223 State Tax Discounts, Special Services and Other Savings for Veterans... 223 Generally Available in All States... 223 State Veterans Homes... 223 viii
Burial in State Veterans Cemeteries... 223 Motor vehicles and License Plates... 224 Other Available Benefits... 224 Locating Specific Benefits in Each State... 224 About State Veterans Homes... 226 The Appeal of Living in a State Veterans Home... 226 Challenges for State Veterans Homes... 228 History of State Veterans Homes... 229 Challenges Facing the Construction of New Homes... 229 Nursing Home Daily Rates... 230 Standard Per Diem Program.. 230 Alternate Per Diem Program.. 230 Medication Subsidy... 231 Type of Care Provided... 232 Eligibility and Application Requirements for State Veterans Homes... 232 Department Of Veterans Affairs Funding and Statistics for Veterans Care Programs... 233 CHAPTER 6 Veterans Health Care 237 The Best Health Care System in America... 237 Why the VA Health Care System Works so Well... 240 What is Veterans Health Care?... 241 Outpatient Pharmacy Services... 243 Veterans Health Administration Long Term Care Benefits... 243 Enrolling in the Veterans Health Care System... 247 Minimum Duty Requirements... 247 Women Veterans Eligibility... 247 Readjustment Counseling Services... 247 Priority Group 8 Enrollment Relaxation... 247 Enrollment Restriction... 248 Initial Enrollment... 248 Concurrent Enrollment in VA and Medicare... 250 ix
Availability of the Other Services... 250 Hearing Aids and Eyeglasses... 250 Dental Benefits for Veterans... 251 Emergency Care at a Non-VA Facility... 252 Copayments for Medical Services -- Veterans Means Testing... 253 Health Care for Families of Veterans... 257 Family Members of Veterans... 257 CHAMPVA... 257 Children of Women Vietnam Veterans (CWVV) Program... 257 Spina Bifida Healthcare Program... 257 Caregiver Program... 257 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)... 259 State Veterans Home (SVH) Per Diem Program 259 Indian Health Services (HIS)/Tribal Health Program (THP) Reimbursement Agreement Program... 259 CHAPTER 7 Burial Benefits 261 Where to Burial Benefits Claims Claims Intake Center 261 Burial Allowances... 261 What Are VA Burial Allowances?... 262 Who Is Eligible?... 262 How Much Does VA Pay?... 262 Burial and Memorial benefits... 263 Eligibility... 263 Burial in VA National Cemeteries... 263 Burial in Arlington National Cemetery... 264 Certain Eligible Parents for VA Burial... 267 Headstones, Markers and Medallions... 267 x
Inscription... 267 Private Cemeteries... 268 In Memory Of Markers... 268 Medallions in Lieu of Government Headstone/Marker... 268 Presidential Memorial Certificates... 268 Burial Flag... 268 Military Funeral Honors... 269 Veterans Cemeteries Administered by Other Agencies... 269 CHAPTER 8 Appeals 271 Where do I file and Appeal for a Denied Claim.... 271 Where to File an Appeal for a Denied Pension / Survivor/ Burial Claim 271 What Constitutes an Appeal? (Filing a Notice of Disagreement)... 272 Decision Review Officer (DRO)... 272 Statement of the Case (SOC)... 273 Substantive Appeal (VA Form 9)... 273 Final Review and Forward to BVA by the Office of Original Jurisdiction... 274 Board of Veterans Appeals (BVA)... 274 Additional Evidence... 275 Personal Hearing... 275 Further Defining a Notice of Disagreement and a Substantive Appeal... 276 Grounds for Request for Reconsideration... 276 Further Appeal to the Court Of Appeals for Veterans Claims (CAVC)... 276 Hiring a Representative for Appeal... 277 CHAPTER 9 Using the Claim Support Data Disk 279 Introduction and Contents... 279 1 Application for Pension and Death (Survivors) Pension... 279 2 Application for Compensation and DIC..... 279 3 Application for Health Care Benefits... 279 4 Application for Burial Benefits... 279 xi
APPENDIX 289 Contents... 289 Appendix Section 1 List of VA Regional Offices... 291 Appendix Section 2 List of State Veterans Nursing Homes 2015... 295 Appendix Section 3 Evidence of Marriage and Death... 303 Surviving Spouse... 303 Criteria for a Surviving Spouse... 304 38 CFR 3.50 Spouse and surviving spouse... 304 Marriage Deemed Valid... 303 Remarriage... 304 38 CFR 3.55 Marriage void, terminated or annulled... 304 Divorce or Annulment... 305 38 CFR 3.53 Continuous cohabitation... 306 Evidence for the Marriage... 307 Evidence for Death... 308 Death Determined by a Seven-Year Absence... 309 Appendix Section 4 Information on Individual Unemployability... 311 Appendix Section 5 Information on Posttraumatic Stress Disorder PTSD... 331 Criterion A: stressor... 331 Criterion B: intrusive recollection... 331 Criterion C: avoidant/numbing... 331 Criterion D: hyper-arousal... 332 Criterion E: duration... 332 Criterion F: functional significance... 332 New Diagnostic Criteria for PTSD to Be Released: DSM-5... 333 PTSD History and Overview : Matthew J. Friedman, MD, PhD... 335 Criteria for a PTSD diagnosis... 336 Assessing PTSD... 337 xii
Treatment for PTSD... 338 References.. 339 Complex PTSD... 340 What types of trauma are associated with Complex PTSD?... 340 What additional symptoms are seen in Complex PTSD?... 340 What other difficulties are faced by those who experienced chronic trauma?... 341 Treatment for Complex PTSD... 341 References... 342 Epidemiology of PTSD: Jaimie L. Gradus, DSc, MPH... 343 What is epidemiology?... 343 What is prevalence?... 343 Prevalence of PTSD... 343 U.S. National Comorbidity Survey Replication... 343 PTSD among children and adolescents... 344 PTSD in other countries... 344 National Vietnam Veterans Readjustment Study... 344 Gulf War Veterans... 344 Operation Enduring Freedom/Operation Iraqi Freedom... 345 Commonly-used epidemiologic terms (12)... 345 What is cumulative incidence?... 345 What is a cumulative incidence ratio?... 345 What is the incidence rate?... 345 What is an incidence rate ratio?... 345 What is an odds ratio?... 346 References... 346 Overview of Psychotherapy for PTSD: Hamblen, PhD, Schnurr, PhD, Rosenberg, MA, & Eftekhari, PhD... 347 Exposure-based treatments... 347 Cognitive approaches... 347 Adding components... 348 EMDR... 348 Other approaches... 349 xiii
Conclusion... 349 References. 349 Clinician's Guide to Medications for PTSD: Matt Jeffreys, MD... 353 Overview... 353 What core PTSD symptoms are we trying to treat?... 353 What are some of the biological disturbances found in PTSD?... 354 How do medications help regulate these responses?... 354 How do we measure the effects of treatment?... 354 What is the evidence base for the specific groups of medications used for PTSD treatment?... 355 Selective Serotonin Reuptake Inhibitors (SSRIs)... 355 Other newer antidepressants for PTSD... 355 Mood stabilizers for PTSD... 356 Atypical antipsychotics for PTSD... 357 Other medications for PTSD... 357 Benzodiazepines and PTSD... 358 Developing new medications for PTSD... 358 Common barriers to effective medication treatment in PTSD... 359 A final word regarding medications and treatment for PTSD... 359 Important Considerations... 360 References... 360 Appendix Section 6 Hearing Loss Probability Chart... 363 Appendix Section 7 Agent Orange... 367 AGENT ORANGE STORED IN THE US 367 VA AGENT ORANGE NEWSLETTERS... 381 xiv