Geriatrics and Extended Care

What is Long Term Care?

Long Term Care

• Includes a wide range of services such as help with everyday tasks and support for managing an illness.
• Is provided for an extended period when someone is not able to do everyday tasks themself.
• Can be provided in many settings, such as a person’s home, community sites, residential settings, and nursing homes.
• May include support for family members or other caregivers who help people who are ill or disabled.

Please review the Home and Community Based Services and Nursing Home and Residential Settings sections of the Guide for a detailed description of long term care services and settings.

You may be able to pay for long term care services through VA, Federal and State programs (Medicare and Medicaid), and through insurance or your private funds. Click on the tabs in this section of the Guide for more information about these sources of funding.

Your eligibility for long term care services, provided in any long term care setting, will be determined based on your need for ongoing treatment, personal care, and assistance, as well as the availability of the service in your location. Other factors, such as financial eligibility, your service-connected (VA disability) status, insurance coverage, and/or ability to pay may also apply.

If you still have questions after reading this section of the Guide to Long Term Care, call toll-free, 1-877-222-VETS (8387), Monday through Friday, 7 a.m. to 7 p.m. (CST). Or, contact your VA social worker.

VA Health Care Standard Medical Benefits Package

Standard Medical Benefits

Veterans must be enrolled in VA health care before applying for VA long term care services. Enrolled in VA health care means you have applied for VA health care benefits, and receive care through a VA facility on a regular basis. Receiving financial compensation for a VA disability does NOT automatically enroll you in VA health care.

You may be eligible for VA health care services (known as the Standard Medical Benefits Package) if you served in the military and were discharged for any reason other than dishonorable.

Detailed eligibility information can be found on the main VA Health Benefits website.

To Enroll in Health Care Services

• Visit your local VA medical center’s New Patient Registration office to complete and submit the VA Application for Health Benefits, or
• Enroll online: Online Application for Health Benefits

Factors that Affect Your Costs for VA Services

When you enroll in VA health care, your (1) VA service-connected disability status and (2) income will be reviewed to determine whether or not you are charged a copay for VA health care services and VA long term care services. Long term care copays are different from standard VA health care copays because they are not charged until the 22nd day of care. Copays are NOT charged for Hospice Care provided in any setting.

The VA is required by law to bill any other health insurance you may have (except Medicare) for treatment of conditions that are not service-connected. Payments received from your insurance company will reduce the copays that VA bills to you.

VA Long Term Care Services

Home and Community Based Services are part of the VA Medical Benefits Package. All enrolled Veterans are eligible for these services. However, to get the service you must have a clinical need for it, and the service must be available in your location. Services in the VA Standard Benefits Package include:

• Geriatric Evaluation to assess your care needs and to create a care plan
• Adult Day Health Care
• Respite Care
• Skilled Home Health Care

Some Home and Community Based Services may be prioritized based on your level of VA service-connected disability.

Nursing Home and Residential Settings have different eligibility requirements for each setting. The VA does not pay for room and board in residential settings such as Assisted Living or Adult Family Homes. However, you may receive some Home and Community Based Services while you are living in a residential setting.

The VA will provide Community Living Center (VA Nursing Home) or community nursing home care IF you meet certain eligibility criteria involving your service connected status, level of disability, and income.

Service-Connected Disability and Special Monthly

Service-Connected Disability

A “service-connected disability” is a disability that is related to your active military service. Your disability is assigned a rating (0% to 100%) based on how severely it impacts your daily life. The greater your disability, the higher your rating.

VA Disability Compensation

VA Disability Compensation is a monthly tax-free payment to Veterans who have a service-connected disability. The higher your rating, the higher monthly payments will be.

However, having a disability caused by your active military service does NOT automatically start disability compensation payments. You need to APPLY for those benefits. It is important to do this because your service-connected disability status has an effect on how much you pay for VA health care services, what programs you are eligible for, and your priority in receiving certain services.

Special Monthly Compensation

If you receive VA compensation for a service-connected disability, you may be eligible to receive additional monthly monetary benefits if you ALSO:

• Require significant help with your personal care needs by another person because of your disability, or
• Are bedridden because of your disability

You can use your Special Monthly Compensation payments to help pay for services that you need.

Helpful Website

The VA Disability Compensation website contains information about:

• Eligibility and how to apply
• Payment rates
• Special monthly compensation

Veterans Pension

Veterans Pension

Veterans Pension is a tax-free monetary benefit paid to low-income war-time Veterans who are ALSO:

• 65 or older, or
• Totally and permanently disabled, or
• Living in a nursing home receiving skilled nursing care, or
• Receiving Social Security Disability Insurance, or
• Receiving Supplemental Security Income

Low-income guidelines are set by Congress. A single Veteran, with no dependents, must have an annual income of less than $12,465 to be considered low-income in 2013. Additional income is allowed if you have dependents. A chart of income limits can be found on the Maximum Annual Pension Rate website.

How much does it pay?

Your payments will raise your income to the Maximum Annual Pension Rate, and not exceed it. For example, if you are a single Veteran who earns $10,000 per year, then your monthly payment would be about $205 ($12,465 maximum annual pension rate - $10,000 current annual income, divided by 12 months). Pension benefits are paid monthly.

How do I apply?

• Complete and mail VA Form 21-526 to your Veterans Benefits Administration (VBA) regional office. To find your VBA regional office, visit the facility locator site, or
• Complete the application online using an eBenefits account, or
• Work with an accredited representative or agent, such as a Veterans Service Officer. You can search for representatives here, or visit your local VBA office for assistance.

Helpful Website

The VA Pension website covers information about supplemental income for wartime Veterans:

• Eligibility and how to apply
• Payment rates

Aid and Attendance/Housebound

Aid and Attendance Allowance

If you receive a VA pension, you may be eligible to receive additional monthly monetary benefits from the VA, IF you:

• Require the help of another person for everyday personal care needs (such as bathing, dressing, toileting), or
• Are bedridden, or
• Live in a nursing home and are physically or mentally incapacitated, or
• Have poor eyesight (5/200 corrected visual acuity or less in both eyes)

You can use your Aid and Attendance payments to help pay for the services that you need.

Housebound Allowance

If you receive a VA pension, you may be eligible to receive additional monthly monetary benefits from the VA, IF you are significantly restricted to your residence because of a permanent disability. You can use your Housebound Allowance payments to help pay for the services that you need.

How do I apply for Aid and Attendance or Housebound benefits?

Send a written statement to your Veterans Benefits Administration regional office that includes a report from your doctor that describes your need for these benefits. The report should include:

• The reasons your condition makes it difficult for you to manage your personal care needs (such as bathing, dressing, toileting, moving around)
• That your condition makes it difficult for you to leave your home (or residential setting)
• What activities you are able to do in a typical day

Helpful Website

The VA Aid and Attendance and Housebound Allowance website provides information for Veterans and caregivers about:

• Eligibility and how to apply
• Payment rates

>What is Medicare?

What is Medicare?

Medicare is the federal health insurance system for people:

• 65 years or older
• Under 65 with certain disabilities
• Of all ages with End Stage Renal Disease

You can enroll in “Original Medicare” or a “Medicare Advantage Plan.”

Original Medicare

Once you enroll, you receive services from any organization or provider that accepts Medicare as long as the services are ordered by your doctor, approved by Medicare as being medically necessary, and covered by your plan.

Medicare Advantage Plan

Once you select a plan and enroll, you receive services from any organization or provider that accepts your plan’s coverage as payment as long as the services are approved by your plan as being medically necessary and covered by your plan.

Helpful Website

The Medicare website provides information to Veterans and caregivers, including:

• Medicare eligibility tool
• Help with enrollment
• List of covered services
• Tips on selecting a Medicare plan
• How to get help paying Medicare costs
• Directory of Medicare-certified providers
• The publication Your Guide to Choosing a Nursing Home

>Medicare Benefits

Medicare Benefits

Original Medicare

There are 3 components, or “parts,” of Original Medicare services:

1. Hospital Insurance (Part A)
2. Medical Insurance (Part B)
3. Prescription Drug Coverage (Part D)

If you enroll in Part A, you can also enroll in Parts B and D. Here is a summary of the long term care services provided in each of these parts:

• Hospital Insurance (Part A) provides coverage for services in a hospital, skilled nursing facility, hospice care, and some home health care services. Most people over 65 have paid Medicare taxes while working and will automatically receive this coverage without having to pay a monthly premium. 
• Medical Insurance (Part B) provides coverage including doctor’s services, outpatient hospital care, and some home health care. Part B enrollment is voluntary and you will be charged a monthly premium for this coverage. Your premium can vary based on your income, and when you signed up for the coverage.
• Prescription Drug Coverage (Part D) is provided by insurance companies and private companies approved by Medicare. Part D enrollment is voluntary and you will be charged a monthly premium for this coverage. Your premium can vary based on when you signed up for the coverage.

Medicare Advantage Plans

These plans provide coverage for the same services as hospital insurance (Part A) and medical coverage (Part B) of the Original Medicare plan. Most of these plans also include prescription drug coverage (Part D). Here are the most common types of Medicare Advantage Plans. Review the different plans to find one that best fits your needs.

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Private Fee-for-Service (PFFS)
• Special Needs Plans (SNPs)

How do I enroll in Original Medicare (Part A and Part B) benefits?

How do I enroll in Original Medicare (Part A and Part B) benefits?

Automatic Enrollment

Many people are automatically enrolled in Medicare benefits (Part A and B) because they are already receiving Social Security benefits or Railroad Retirement Board benefits. In this case, Part A and Part B enrollment starts the first day of the month you turn 65.

If you are under 65 and disabled, Part A and Part B enrollment starts after you receive disability benefits from Social Security or certain RRB disability benefits for 24 months.

If you are enrolled automatically you will receive a red, white, and blue Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability benefits if under 65 years old. Instructions will be included with your card to decline Part B coverage if you do not want it.

Sign up for Benefits

Some people who are eligible are not automatically enrolled and need to sign up for Part A and Part B benefits. Most often these are people who are 65 or older but not receiving Social Security or Railroad Retirement Board benefits.

To sign up for benefits:

• Visit your local Social Security Office, or
• Apply at www.SocialSecurity.gov, or
• Call Social Security at 1-800-772-1213
• If you worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772

Is there help for me to pay my Medicare out-of-pocket costs?

• If you are low-income, you may qualify for Medicaid to assist you with your Medicare costs.
• You can purchase a Medigap policy from a private company. Medigap supplemental Medicare insurance policies can help you pay for Medicare costs such as Part A and Part B deductibles, copays, and coinsurance.

Long Term Care Benefits

Long Term Care Benefits

Original Medicare will pay for services in a Skilled Nursing Facility and some home health services. Medicare Advantage Plans are required to provide the same benefits, however, they may charge different copays and/or change the eligibility standards.

Skilled Nursing Facility (SNF)

You can receive care in a skilled nursing facility for a limited number of days (Original Medicare helps pay costs for up to 100 days in a benefit period) if your doctor decides that you require skilled care after a hospital stay. The facility must be certified by Medicare. Skilled care means services are provided by skilled nursing or rehabilitation staff, such as a nurse or physical therapist.

Your Skilled Nursing Facility Costs under Original Medicare

• $0 for the first 20 days of your stay and care
• 20% of your care costs (about $150/day in 2013) for days 21 to 100 of your stay and care
• All costs for each day after day 100

If you selected a Medicare Advantage Plan, your costs will vary based on that specific plan.

Home Health Services

If your doctor decides that you are home-bound (your condition keeps you from leaving home without significant effort), then you may be eligible for home health services under hospital insurance (Part A) and medical coverage (Part B). Covered services may include (but are not limited to):

• Intermittent skilled nursing care  
• Rehabilitation (physical/occupational therapy/speech therapy)
• Assistance with activities of daily living
• Medical supplies/equipment to use at home

Services must be ordered by a physician and provided by a Medicare-certified home health agency for Original Medicare enrollees. Medicare Advantage Plan members must use a home health agency that accepts their plan’s payment.

What is NOT covered by Medicare?

Custodial care is help with personal care needs such as dressing or bathing. If the ONLY type of care you need is custodial, then Medicare will not pay for your care in a nursing home or in your own home. Medicare may cover medical and rehabilitation services provided in an Assisted Living Facility, but typically will not cover the costs of the facility – such as rent and meals.

What is Medicaid?

What is Medicaid?

Medicaid is the joint federal/state insurance program that helps people with low incomes pay for their medical costs. This may include help with Medicare premiums, copays, and deductibles. Medicaid can also pay for some services not covered by Medicare.

Specific eligibility criteria will vary by state. The information provided is a general guide to eligibility. Speak with your VA social worker or state Medicaid office to determine your eligibility.

How do I enroll in Medicaid benefits?

To apply for Medicaid benefits in any state you need to:

• Complete an application
• Provide documentation of general and financial eligibility requirements being met
• Complete a functional eligibility assessment

Where do I get an application?

The application can be found at your local state Medicaid office. Many states also provide Medicaid applications at aging/disability assistance agencies throughout the community.

Helpful Website

The Medicaid website provides information about:

• Eligibility and how to apply
• How to locate a state office
• How to use Medicare and Medicaid at the same time (dual enrollment)

Medicaid Eligibility

Medicaid Eligibility

You must meet the requirements of all three eligibility categories listed below to qualify for Medicaid coverage of long term care services: General, Functional, and Financial.

1. General Eligibility:
   • Be 65 or older, OR under 65 with a permanent disability, OR be blind
     AND
   • Be a U.S. citizen or meet certain immigration rules and be a resident of the state where you apply
2. Functional Eligibility: An assessment of your need for assistance with activities of daily living (also known as ADLs) will be completed by a medical professional. This assessment will review your functional eligibility for long term care, and whether that care should be provided in the home and community or a nursing home. Examples of ADLs include:
   • Eating
   • Bathing
   • Dressing
   • Transferring to a bed or chair
   • Using the toilet
   • Caring for incontinence
3. Financial Eligibility: Your income and items of value you may have (your assets with the exception of the home where you live, one motor vehicle and personal belongings), determine whether or not you are eligible for Medicaid. Income levels and allowable assets vary by state. The income level is usually set at about the poverty level, and the assets level is usually set at about $2,000 per person. Many people must pay for long term care services with their own resources until they spend enough so that they become eligible for Medicaid. This is also known as “spending down.”

Long Term Care Benefits

Long Term Care Benefits

Medicaid covers Nursing Home services for all eligible people age 21 and older. Medicaid will also cover Home and Community Based Services for eligible people IF they would need to be in a Nursing Home without those services.  Covered Home and Community Based Services vary by state. For example, some states cover Assisted Living Facility costs, while other states do not. Many states cover services to help you remain in your home, such as help with personal care needs or some chores (laundry, cleaning). Specific services should be discussed with your state Medicaid office or your social worker.

Your Costs Under Medicaid

Based on your income, you may be eligible for Medicaid coverage of some portion of your Medicare premiums/copays. Your state may also require you to pay for some of your Medicaid covered services, if you have enough income to do so. This varies by state. Talk with staff in your state Medicaid office to find out how this works in your state.

Helpful Website

The National Clearinghouse for Long Term Care website provides details about:

• Average costs of long term care services in each state
• Options to help pay for long term care services
• How to apply for Medicaid benefits in your state

Personal Contributions and Long Term Care Insurance

Personal Contributions and Long Term Care Insurance

Private Pay: Even though VA, Medicare, Medicaid and other funding sources cover the costs of some long term care services and settings, many people need to use their own income or savings to pay part of the costs for long term care services or settings they need or prefer.

For example, people often use their own resources to pay for:

• Living in an Assisted Living Facility or Adult Family Home
• Paid caregiver assistance with personal care needs, chores, or meals in their home

Long Term Care Insurance can also be used to pay for long term care services and settings. Since long term care policies vary, do your homework and choose wisely.

• Most policies will cover long term care services for a pre-set number of years, after which time you become responsible for the costs of your care.
• Policies often include an “elimination period” of 30, 60, or 90 days before your benefits begin. This means you agree to pay for all of your necessary care for the first 30, 60, or 90 days.  
• Premiums are based in part on your age at the time of enrollment in a policy. They become more expensive as you get older.

If you already live in a Nursing Home or Assisted Living Facility, or you already need help with activities of daily living such as bathing, dressing, or using the toilet, then you probably will not qualify for a long term care policy.