+-----------------------------------------+----------------------------+
| State of Washington                     | DSHS/ HRSA /Payment Review |
|                                         | Program                    |
| Department of Social & Health Services  |                            |
|                                         | Veteran's Benefit          |
| Health and Recovery Services            | Enhancement Project        |
| Administration                          |                            |
|                                         | PO Box 45511 Phone: 360    |
|                                         | 725-1020                   |
|                                         |                            |
|                                         | Olympia, WA 98504-5511 or  |
|                                         | 360-725-2077               |
+-----------------------------------------+----------------------------+

Veterans Benefit Enhancement

State of Washington's Method for Using PARIS VA File Data to Maximize
Veterans Benefits

![](media/image1.png){width="0.875in" height="1.625in"}
![](media/image2.png){width="1.9166666666666667in"
height="0.5819444444444445in"}

# MAXIMIZATION OF THE PARIS VETERANS MATCH 

#### Review State Code for Treatment of Certain Payments Made by Department of Veterans Affairs

Many veterans and survivors of veterans receive monthly payments from
Veterans Affairs (VA). Some of these recipients who need the regular
assistance of a caregiver receive an increased amount from VA. This
additional amount, added to the regular payment amount, is known as an
aid and attendance allowance. (A&A)[^1] According to
[§3705](http://www.acf.hhs.gov/exit_page.html?http://www.cms.hhs.gov/manuals/45_smm/sm_03_3_3700_to_3714.2.asp#_toc490889354)
of the State Medicaid Manual, VA allowances for aid and attendance may
not be considered **income** for eligibility purposes.

However, CMS has recognized the aid and attendance allowances from VA
payments as **third party payments** to be applied toward the cost of
Medicaid long term care services when paying claims for long term care
services. \[[see Estate of Krueger v. Richland
County](http://www.acf.hhs.gov/exit_page.html?http://www.court.state.nd.us/court/opinions/940128.htm),
Civil No. 940128 (N.D. 1994)\] A person is considered to be in need of
aid and attendance if the person "is (1) a patient in a nursing home or
(2) helpless or blind, or so nearly helpless or blind as to need or
require the regular aid and attendance of another person". 38 U.S.C.
1115(1)(E), 1311(c), 1315(g), 1502(b). See also 38 C.F.R. 3.351(b) and
(c). Additionally, Veterans Affairs have established regulations to
determine the need for an aid an attendance allowance, which include but
are not limited to: living in a nursing home, "inability of claimant to
dress or undress", and having an "incapacity, physical or mental, which
requires care and assistance on a regular basis". See 38 C.F.R.
3.351(c)(2) and 3.352(a). Under the third-party liability payment
scheme, a \"third party\" is broadly defined as \"any individual, entity
or program that is or may be liable to pay all or part of the
expenditures for medical assistance furnished under a State plan.\" See
42 C.F.R. 433.136(3). The court in Krueger ruled that

"aid and attendance allowances...are provided based on an assessment of
the veteran\'s physical and medical need for them and, when the veteran
is in need of, and in fact does receive, nursing home care, that care
substitutes for the purpose for which the aid and attendance allowance
was designed. When a veteran is in a nursing home, the aid and
attendance allowance is paid to cover the exact same services being paid
for by the Medicaid program."

Effective August 2004, the State of Washington implemented a policy
change to treat aid and attendance payments to long term care Medicaid
recipients as a third-party resource. While aid and attendance is not
considered income when determining eligibility and client participation
for long term care services, the portion of VA benefit constituting an
A&A allowance is applied to offset and reduce the state payment for long
term care services provided to a recipient of VA aid and attendance.

# Partnership with State Veterans Services Office 

Together, the Department of Social and Health Services and the
Washington Department of Veteran's Affairs identify veterans receiving
Medicaid benefits (especially long term care benefits) and review their
benefit structure. In some cases, clients have full long term care
coverage, either through VA, TRICARE[^2] or CHAMPVA[^3]. In other cases,
additional benefits are identified, such as aid and attendance allowance
and prescription drug coverage, of which the veteran or family members
are not aware.

Department of Social and Health Services (DSHS) partnered with
Washington State Veteran's Affairs (WDVA) through two (2) performance
based contracts, which measure savings resulting from VA benefits and
ensure sustainability. The focus of these contracts are outreach,
enrollment and advocacy of VA benefits to expand the number of Medicaid
clients receiving VA benefits and maximize the VA benefits to which they
are entitled.

One contract between DSHS and the WDVA addresses the need to review
current VA benefits for Medicaid recipients and facilitate the
enhancement of benefits for clients not receiving maximum entitlement,
as well as a plan to identify new applicants who may be entitled to VA
benefits.[^4] The other contract pertains to VA medical benefits and the
enrollment of Medicaid recipients into the VA health care system.[^5]
Also there are Medicaid recipients potentially eligible for but not
receiving VA benefits. The work to identify these clients and facilitate
VA claims will require an agreement and contract separate from the
current Performance Based Agreement that enhances benefits for those
that are already eligible for and receiving some VA related monetary
benefits.

When an increase in housebound/aid and attendance award is necessary,
WDVA initiates the process of increasing the entitlements. For the
majority of these clients, WDVA acts in the legal capacity of Client
Representative. This authorizes WDVA staff to represent the claimant
throughout the VA Adjudication process. Claims are developed and
processed more expeditiously in this manner. Staff associates within the
Seattle VA Regional Office assume the role of "attorney in fact" in
regards to VA claims representation. WDVA has access to the Master VA
file, which allows for review of client records and assistance to more
participants.

Direct VA benefit services and representation increases the awards to
the maximum amount possible under law and decreases the amount of time
it takes to receive a favorable rating. DSHS will thereby realize an
increase in client participation for long term care services, and a
correlating decrease in state reimbursement, at the earliest possible
date.

# Prepare PARIS VA File Data

#### Importing VA File

It\'s important to understand and identify the differences between
veterans **pension**, which is based on financial need, and
**compensation**, which is a non-needs-based benefit based on degree of
disability or service-connected death. For this reason, it may be
helpful to split the two character "Entitlement Code" (starting at
element position 467 in the VA File) into two distinct fields or
columns. The first position of the Entitlement Code designates the
period of service (e.g., WW I, WW II, Vietnam, etc.); the second
position the type of benefit (compensation, pension for veteran, pension
for survivor, DIC for survivor, etc.). By assigning a distinct code for
the VA benefit type, it is easier to group those clients receiving like
benefits, which will be helpful in identifying those who are eligible
for an increased payment.

# Join State Client Data with VA File Records

While the VA File provides a list of individuals associated with state
benefits and active VA claims, it does not necessarily provide all the
data needed to ascertain which clients should be receiving a greater
amount from VA.

It is helpful to add state client data to the VA File, such as
**financial responsibility** (i.e. whether the individual is a direct
recipient of state benefits, non-applying spouse, ineligible parent,
non-member, etc.), **marital status** and **living arrangement** (e.g.,
at home, in a nursing facility, assisted living, etc.). This information
could be retrieved from the state database and compiled with VA File
data after the VA File is received. Alternatively, this state data could
be included with the state information that is sent to PARIS for data
match (a better solution). Element positions 70-127 of the submitted
state information allow space for state optional data such as this.

If possible, collect individual client VA income figures from the state
database, to compare with income amounts provided by Veterans Affairs.
This provides an opportunity to identify those clients with unreported
and underreported VA income. Also, this provides a more precise basis
for measurement of cost savings due to identification of VA income.

# Use PARIS VA File and State Data to Maximize Veterans Benefits 

#### Assemble Groups of Clients Entitled to VA Benefit Increases

With the PARIS VA File and state data, one can sort out the various
groups of clients that should be receiving greater monthly payments from
Veterans Affairs. For example:

-   **Recipients of long term care services should receive an additional
    aid & attendance allowance with their VA benefit.** (Aid and
    attendance entitlement is represented in element position 229 of the
    VA File). This is an additional amount that should be considered as
    a third party payment, to offset Medicaid payment for long term care
    services. Aid and attendance is available to both veterans and
    surviving spouses, and to those receiving pension or compensation
    (including widow's DIC). Any long term care recipients from the
    PARIS VA File not coded for aid and attendance should be referred to
    the state or local Veterans Service Office for an enhancement claim.
    The exceptions to aid and attendance entitlement include: those not
    married, receiving VA pension, and residing in a nursing facility
    (they will receive only \$90 per month payment); and those receiving
    10-20% service-connected compensation (there is no aid and
    attendance payment available for this group).

-   **Long term care recipients not living in a nursing facility should
    not be receiving the reduced \$90 / month VA pension.** There may be
    many clients receiving only \$90 / month pension that do not reside
    in a nursing facility, but continue to receive this reduced payment
    because Veterans Affairs believes them to be institutionalized. This
    applies to those eligible for VA pension only, not to those clients
    entitled to compensation, who should continue to receive their
    compensation rate regardless of living arrangement. These clients
    not in nursing facilities receiving reduced pensions need to be
    referred to the state or local Veterans Service Office for
    enhancement claims.

-   **Some clients have a VA claim for benefits, but are receiving zero
    payment.** The PARIS VA File provides a Change Reason code (element
    position 430) which may indicate the reason for non-payment of VA
    benefits, including Failure to file an Income Questionnaire,
    Excessive Net Worth, and Whereabouts Unknown. The state or local
    Veterans Service Office can help determine which clients are
    correctly not receiving any payment, and file reinstatement claims
    for the others.

-   **Some veterans are receiving compensation based on a low degree of
    service-connected disability, but now have a worsened condition.**
    By collecting diagnostic data from Medicaid medical, institutional,
    and possibly pharmaceutical claim history, one can compile condition
    and disease profiles for these veterans receiving lower
    service-connected compensation rates and long term care services.
    This may be especially helpful when considering those veterans with
    Vietnam service, because there are ten diseases presumed by VA to be
    service-related for compensation purposes for veterans exposed to
    Agent Orange and other herbicides during that period.[^6]

[^1]: VA also pays a lesser additional benefit, known as housebound
    allowance, to some veterans and surviving spouses who are need a
    lower level of care

[^2]: TRICARE is the Department of Defense's worldwide health care
    program for active duty and retired uniformed services members and
    their families. TRICARE consists of TRICARE Prime, a managed care
    option; TRICARE Extra, a preferred provider option; and TRICARE
    Standard, a fee-for-service option. TRICARE For Life is also
    available for Medicare-eligible beneficiaries age 65 and over
    (effective Oct. 1, 2001). See the [TRICARE, Military Health System
    website](http://www.acf.hhs.gov/exit_page.html?http://tricare.osd.mil/mhshome.aspx)
    for more information.

[^3]: Families of veterans who have a 100 percent, permanent disability,
    or of veterans who died from a service-connected disability, may be
    covered by CHAMPVA as long as they are not eligible for TRICARE.

[^4]: see Appendix A for a copy of this contract (Interlocal Agreement)

[^5]: See the VA [Health Eligibility
    Center](http://www.acf.hhs.gov/exit_page.html?http://www.va.gov/healtheligibility/home/hecmain.asp)
    site for more information. All veterans are potentially eligible for
    VA medical care, but this effort focuses on veterans who are
    receiving aid and attendance allowance or service-connected
    compensation at a 50% disability rating or higher. These veterans
    need not obtain a prescription from a VA doctor to receive drugs and
    medicines from VA, but can have their own doctor provide a
    prescription to the VA pharmacy. See 38 USC 17.1712(d).

[^6]: See **Federal Benefits for Veterans and Dependents** (2004
    Edition), Benefit Programs, Disability Compensation.
    [PDF](http://www.acf.hhs.gov/exit_page.html?http://www1.va.gov/opa/vadocs/Fedben.pdf)
    file, [Web page
    version](http://www.acf.hhs.gov/exit_page.html?http://www.pueblo.gsa.gov/cic_text/fed_prog/va_benefits/).