Dad receives, or plans to claim, VA pension with Aid and Attendance. A nursing facility says it accepts Medicaid. Do not treat those facts as separate files.

Before Dad commits to the bed, ask the facility when Medicaid coverage would begin, whether Dad will have dependents for VA purposes, and which VA payment the facility expects to count toward his cost of care. Then take those answers to an accredited Veterans Service Organization representative. VA has a special pension rule for a beneficiary without dependents who lives in a Medicaid-covered nursing facility, and that rule can change the expected payment substantially.[1]

The first question: Is this actually a Medicaid-covered nursing-facility stay?

Ask the admissions or billing office to answer in writing:

Is this placement in a nursing facility, or in assisted living, memory care, independent living, or another residential setting? Is Medicaid paying for Dad's nursing-facility care now, or is the family private-paying while a Medicaid application is pending? What coverage date will the facility report? Does the facility consider Dad to have a spouse or other dependent whose status affects the account?

The label matters. VA describes the reduced pension rule for a person who is living in a Medicaid-covered nursing facility and has no dependents.[1] A facility that merely accepts Medicaid is not the same as a particular resident whose nursing-facility care is being covered by Medicaid. Get the answer for Dad's account, not the building generally.

Run the three pension gates again

A nursing-home admission can help establish an age or disability condition, but it does not erase the other pension requirements. For Veterans Pension, VA still tests character of discharge, qualifying wartime active service, age or disability status, and household income and net worth.[2]

Put three headings on the intake sheet:

Service gate. Confirm the discharge and qualifying active service. Do not rely only on membership in a veterans organization or the statement that Dad served during wartime. VA applies minimum active-duty and wartime-service rules, with different service tests depending on when active duty began.[2]

Medical gate. Aid and Attendance is an increased pension amount, not a stand-alone care policy. VA may find the medical gate met when the claimant needs help with daily activities, is largely confined to bed because of illness, is in a nursing home because of loss of mental or physical abilities, or meets VA's stated eyesight criteria.[3]

Financial gate. VA considers yearly family income and net worth. VA says net worth includes the claimant's and spouse's assets and income for VA purposes, subject to exclusions and deductions under the pension rules.[2] Do not assume Medicaid approval proves VA financial eligibility. Give the VSO the actual income, assets, dependents, recurring care charges, reimbursements, and coverage dates.

Ask for two pension calculations, not one promise

Ask the representative to show the file in two periods: before Medicaid begins paying for the nursing-facility stay, and after it begins. Identify which medical expenses Dad actually paid in each period and which amounts Medicaid, insurance, or another source paid or reimbursed.

VA calculates pension using income for VA purposes and may deduct qualifying unreimbursed medical expenses under its rules.[4] A private-pay nursing-home bill and a Medicaid-covered stay therefore should not be entered as though Dad paid the same expense in both periods.

Bring the admission agreement, private-pay invoices, Medicaid notices, insurance explanations, proof of payment, and the facility's resident-account statements. Ask the VSO which expenses belong on VA Form 21P-8416, Medical Expense Report, and what evidence should accompany them.[5] The useful number is what Dad paid and was not reimbursed, not the facility's full charge.

The special Medicaid nursing-home rule

VA says a pension beneficiary without dependents who lives in a Medicaid-covered nursing facility may be subject to a $90 monthly VA pension rate.[1] VA also says this payment cannot be counted by the facility as income toward the cost of care, allowing the beneficiary to keep it for personal expenses.[1]

Do not apply that sentence by memory. Ask the VSO to confirm all three facts in Dad's file: the care is Medicaid-covered, the setting is a nursing facility, and VA considers Dad to have no dependents. If any answer differs, ask which pension rule VA will apply and what evidence supports that answer.

Check compensation before electing pension

If Dad receives VA disability compensation, do not cancel it because someone says Aid and Attendance pays more. VA generally does not pay pension and disability compensation at the same time.[1] VA specifically explains that an eligible resident of a Medicaid-covered nursing facility may receive the $90 pension payment instead of disability compensation, and that the pension payment replaces the compensation payment.[1]

Ask for a written comparison of the payment Dad receives now, the pension payment expected during any private-pay period, and the pension payment expected after Medicaid coverage begins. Also ask whether changing benefits could affect any added compensation Dad already receives. This is a benefit election, not merely another source of nursing-home money.

The forms to identify before admission

For a Veteran's original pension claim, the main application is VA Form 21P-527EZ.[6] A claim for Aid and Attendance generally uses VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance.[3] If Dad is a nursing-home patient, VA also identifies VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance.[3]

If the packet is not ready, ask whether VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or D.I.C., is appropriate. VA says an intent to file can secure the earliest possible effective date for retroactive payments for which the claimant may qualify while information is being gathered.[7]

If a VSO will represent Dad, VA Form 21-22 appoints a recognized Veterans Service Organization.[8] Both Dad and the representative must complete the appointment process. Do not leave the facility with a salesperson's assurance that somebody handles VA paperwork. Get the representative's name, organization, accreditation status, and confirmation that the appointment was submitted.

Who files it free in St. Louis

VA states that accredited VSO representatives provide representation on VA benefit claims free of charge.[8] Start with the offices listed in Local Help: St. Louis Offices. Ask whether the person who will handle the claim is individually VA-accredited, whether that person regularly handles pension and Medicaid-covered nursing-facility cases, and who will keep the submission receipt.

VA does not automatically assign a representative. VA also advises checking accreditation and contacting the representative to confirm availability.[8] For general pension questions or claim status, call VA benefits at 800-827-1000.[6]

Use the right VA door

The Veterans Benefits Administration door handles the pension claim, Aid and Attendance increase, forms, evidence, and payment decision. The Veterans Health Administration door handles enrollment in VA health care and possible VA long-term-care services. VA says some long-term-care services may be covered through VA health benefits, while other services may be paid through Medicaid, Medicare, private insurance, or private funds.[9]

Ask the VSO or VA benefits line about the pension file. Ask Dad's VA health-care team about VA-provided or VA-arranged care. An answer from one door does not decide eligibility at the other.

If Mom is the claimant

A surviving spouse uses VA Form 21P-534EZ to apply for Survivors Pension and related survivor benefits.[10] The same Medicaid-covered nursing-facility issue can matter for a qualifying survivor without dependents, and VA says the special pension payment may replace Dependency and Indemnity Compensation when VA determines that pension at that rate is payable.[1]

Before electing Survivors Pension, ask the accredited representative to compare the survivor's existing Dependency and Indemnity Compensation, if any, with the pension result. Do not reuse Dad's income, expenses, dependents, or benefit election as though they automatically transfer to Mom.

How long will the pension decision take?

VA gives no fixed decision time for Aid and Attendance. It says timing depends on the claim and that claims are generally processed in the order received unless priority processing applies.[3] A pending claim is not a promise that VA will reimburse every care bill or approve the amount used in the family's budget.

Care may begin on private pay while a VA claim is pending, but the admission decision must work without assuming a particular VA payment date or award. Before signing, write down who pays each bill, how long available funds last, what happens if Medicaid or VA asks for more evidence, and what the facility will do if either benefit is denied.

The decision sheet to finish before committing

Do not sign until the family can answer these questions:

What is the exact level of care and payment status on admission? When might Medicaid coverage begin? Does VA consider Dad to have any dependents? Which VA benefit does he receive now? Would pension replace compensation? Which expenses will Dad actually pay without reimbursement? Who will complete Forms 21P-527EZ, 21-2680, 21-0779, and any needed 21P-8416? Has an intent to file been submitted if the full claim is not ready? Which accredited VSO owns the file, and where is the submission receipt?

If those answers are still guesses, the VA side of the admission is not ready. The next step is not another sales presentation. It is a documented calculation with the facility's Medicaid facts, Dad's existing VA award, and an accredited representative at the same table.

VA.gov footnotes

[1] VA.gov, “$90 VA Pension Rate If You're in a Medicaid-Covered Nursing Facility.”

[2] VA.gov, “Eligibility for Veterans Pension.”

[3] VA.gov, “Aid and Attendance Benefits and Housebound Allowance.”

[4] VA.gov, “Veterans Pension Rates.”

[5] VA.gov, “Medical Expense Report, VA Form 21P-8416.”

[6] VA.gov, “Apply for Veterans Pension Benefits, VA Form 21P-527EZ.”

[7] VA.gov, “Intent to File Form for Certain VA Benefit Claims, VA Form 21-0966.”

[8] VA.gov, “Get Help From a VA-Accredited Representative or VSO.”

[9] VA.gov, “Does VA Cover Nursing Home, Assisted Living, or Other Long-Term Care?”

[10] VA.gov, “Application for DIC, Survivors Pension, and/or Accrued Benefits, VA Form 21P-534EZ.”