What counts as unreimbursed medical expenses on a VA pension, and why paying for care can change the math

What counts as unreimbursed medical expenses on a VA pension?

38 CFR 3.278, current on eCFR as of September 9, 2026, identifies medical expenses VA may deduct from countable income for pension (and two other needs-based programs). The first sentence that matters: payments for such medical expenses must be unreimbursed to be deductible from income. If insurance, Medicare, or anyone else paid you back, it is not unreimbursed.

The regulation defines the words people argue about:

• Activities of daily living (ADLs): bathing or showering, dressing, eating, toileting, transferring, and ambulating within the home or living area. Transferring means moving from one position to another, such as getting in and out of bed.
• Instrumental activities of daily living (IADLs): independent living activities such as shopping, food preparation, housekeeping, laundering, managing finances, handling medications, using the telephone, and transportation for non-medical purposes.
• Custodial care: regular assistance with two or more ADLs, or supervision because an individual with a physical, mental, developmental, or cognitive disorder requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to his or her daily environment.

Generally, medical expenses for these VA programs are payments for items or services that are medically necessary, that improve a disabled individual's functioning, or that prevent, slow, or ease an individual's functional decline. The regulation then lists care by a health care provider, medications and supplies, adaptive equipment, transportation for medical purposes, health insurance premiums including Medicare Parts A, B, and D and long-term care insurance, and institutional and in-home care under paragraph (d). Vacations and dance classes are on the non-medical list. Do not get creative.

Do in-home attendant payments count?

Paragraph (d)(2) is the one a son in Chesterfield actually needs. Payments for assistance with ADLs and IADLs by an in-home attendant are medical expenses as long as the attendant provides the disabled individual with health care or custodial care. Payments must be commensurate with the number of hours that the provider attends to the disabled person. The attendant must be a health care provider unless one of these is true:

• The disabled individual needs A&A or is housebound, or
• A physician, physician assistant, certified nurse practitioner, or clinical nurse specialist states in writing that, due to a physical, mental, developmental, or cognitive disorder, the individual requires the health care or custodial care that the in-home attendant provides.

That is why Form 21-2680 and this expense rule talk to each other. If VA has already found that he needs Aid and Attendance or is housebound, the attendant does not have to be a licensed clinician for those ADL and IADL payments to be medical expenses under this paragraph. If VA has not so found, you need the written statement from one of the clinicians the regulation names. Do not invent the letter. Ask the doctor. The 21-2680 briefing is the exam page.

Aid and Attendance, again, is the monthly add-on for qualified Veterans and survivors who need help with daily activities or are housebound. The add-on and the expense deduction are related. They are not the same switch.

What form reports these expenses?

VA Form 21P-8416, Medical Expense Report, is the page VA's 21P-527EZ family points to: report medical or dental expenses you have paid for yourself or for a family member living in your household. These must be expenses you were not reimbursed for and do not expect to be reimbursed for. Keep invoices. Keep a simple hour log with dates, hours, and who came. If you pay a company, the company's statements are better than a notebook, but a notebook is better than nothing.

Net worth still matters. From December 1, 2025, to November 30, 2026, the net worth limit is $163,699. For a Veteran with no dependents, VA lists MAPR of $17,441 without Housebound or Aid and Attendance, $21,313 with Housebound, and $29,093 with Aid and Attendance. This desk does not compute the gap between his Social Security and that table. A VSO will. A consultant who computes it as a sales tool is not a VSO.

The IRS is a different system. Topic 502 allows a medical expense deduction to the extent expenses exceed 7.5 percent of adjusted gross income, and only to the extent not compensated by insurance or otherwise. Do not mix the 7.5 percent floor into a VA pension worksheet. They are not the same math.