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Attachment H: Veterans Health Administration Opportunity for 

ADRCs 

Special Opportunity To Expand HCBS Access for Veterans 

Summary 

The Veterans Health Administration (VHA), within the Department of Veterans 

Affairs (VA) has a long standing partnership with the U.S. Department of Health and 

Human Services (HHS) and partners with the Aging and Disability networks to 

provide Veteran Directed Home and Community Based Services (VD-HCBS). The 

VHA plans to build on the existing partnership with ACL by purchasing the services 

of ADRC Options Counselors to work with veterans and their families as they 

determine how to use their flexible HCBS service budgets to meet their LTSS needs, 

goals and preferences. 

The VHA recognizes the ADRC Options Counseling Program as the front door to 

LTSS and will have estimated expenditures of up to $9 million each year over the 

project period across states who receive the “The Enhanced Aging and Disability 

Resource Center Options Counseling Program” Award. Flexible HCBS service 

budgets and the services of an ADRC Options Counselor will be offered, no matter if 

the Veteran chooses Veteran Directed HCBS or non-veteran directed HCBS. The 

VAMC will directly purchase Options Counseling from the ADRCs. Veterans may 

choose to self-direct their services or purchase traditional HCBS services. 

This Attachment provides guidance to states interested in pursuing this "Special 

Opportunity to Expand HCBS Access for Veterans." 

Background 

The VA’s mission is to fulfill President Lincoln's promise “To care for him who shall 

have borne the battle, and for his widow, and his orphan” by serving and honoring 

the men and women who are America’s veterans. Last year approximately $6.3 

billion was invested to provide LTSS. The number of veterans in need of LTSS is 

projected to increase commensurate with the number of veterans with serviceconnected disabilities. Much like the general population, veterans prefer to receive 

their care and services in the least restrictive setting, desire to be engaged in family 

and community life and value an option to direct their care and services including 

hiring family, friends and neighbors to provide HCBS. Anticipating the growing 
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need for LTSS, the FY 2013 President’s Budget, includes a proposed increase of the 

VA LTSS by $500 million to strategically expand access to both institutional and 

non-institutional LTSS.1 HCBS is a mandated benefit for all Veterans enrolled in the 

VA system, 38 CFR Part 17.38. 

As of September 30, 2010 the total veteran population 17 years of age and older was 

22.72 million. Of these veterans 40%3 are age 65 or older while 1.4%4 are under age 

25. While the total number of veterans is decreasing, the number of veterans with a 

service-connected disability is increasing. A service-connected disability means the 

disability was a result of disease or injury incurred or aggravated during active 

military service. These disabilities are evaluated according to the Department of 

Veterans Affairs’ (VA) Schedule for Rating Disabilities in 38 CFR Part 4. Since 1990 

there has been a 46% increase in the number of veterans with a service connected 

disability.5 In FY 2010 more than 3.2 million veterans or 14% of the total veteran 

population had a service connected disability.6 Service-connected disability ratings 

are graduated based on the degree of the veteran’s disability on a scale of 0 to 100% 

in increments of 10%. The growth in the number of veterans with a serviceconnected disability is concentrated among those rated 50% or higher.7 The graph 

below by Dr. Stephen Kaye show that the number of community-resident veterans 

reported as needing help in 2 or more of the basic activities of daily living (ADL) is 

also increasing.8

 

1

 VA 2013 Budget Fast Facts. 

http://www.va.gov/budget/docs/summary/Fy2013_Fast_Facts_VAs_Budget_Highlights.pdf 

2

 US Department of Veterans Affairs, Office of the Actuary, Veteran Population Projections Model 

(VetPop), 2007, Table 5L. 

3

 US Department of Veterans Affairs, Office of the Actuary, Veteran Population Projection Model 

(VetPop), 2007. Prepared by the National Center for Veterans Analysis and Statistics. 

4

 Department of Veterans Affairs, Office of the Actuary, Veteran Population Projection Model (VetPop), 

2007. Prepared by the National Center for Veterans Analysis and Statistics. 

5

 Department of Veterans affairs, Veterans Benefits Administration Annual Benefits Reports, 1985-2010; 

Office of Policy & Planning, Office of the Actuary, Veteran Population Projection Model (VetPop), 2007. 

Prepared by the National Center for Veterans Analysis and Statistics. 

6

 Department of Veterans affairs, Veterans Benefits Administration, Annual Benefits Reports, 1985 to 

2010. Prepared by the National Center for Veterans Analysis and Statistics. 

7

 Department of Veterans affairs, Veterans Benefits Administration Annual Benefits Reports, 1985-2010. 

Prepared by the National Center for Veterans Analysis and Statistics. 

8

 H.Stephen Kaye, Ph.D., Center for Personal Assistance Services University of California San Francisco; 

PAS Center funded by National Institute on Disability & Rehabilitation Research. Feb 2012. 
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Last year more than 100,000 veterans received LTSS and approximately 60% were 

provided HCBS while 40% received their LTSS in a nursing home. From 1995 to 

2011, the total number of veterans receiving LTSS has increased 64%. 

 

9

 H.Stephen Kaye, Ph.D., Center for Personal Assistance Services University of California San Francisco; 

PAS Center funded by National Institute on Disability & Rehabilitation Research. Feb 2012. 
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From 2007-2011, VA’s LTSS expenditures increased by $1.2 billion. This amount 

represented a 22% increase in total expenditures in LTSS. During this time period 

nursing home expenditures increased by $1 billion and HCBS expenditures 

increased by roughly $300 million. In 2011 HCBS expenditures represented 19% of 

total LTSS expenditures. 

Another way to look at expenditures is by reviewing annual expenditure per LTSS 

recipient. Of note, throughout the period, per-resident nursing home expenditures 

were much greater than those for HCBS; in 2011, the ratio was 5.3 to 1. Despite the 

increasing per-resident nursing home expenditure, the total LTSS expenditure per 

veteran remains relatively steady, at roughly $80,000 in 2010 dollars, over the 

period because of increasing utilization of less-costly HCBS.11

 

10 H.Stephen Kaye, Ph.D., Center for Personal Assistance Services University of California San Francisco; 

PAS Center funded by National Institute on Disability & Rehabilitation Research. Feb 2012. 

11 H.Stephen Kaye, Ph.D., Center for Personal Assistance Services University of California San Francisco; 

PAS Center funded by National Institute on Disability & Rehabilitation Research. Feb 2012. 
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The VHA is seeking to expand access to HCBS to honor veteran’s preferences to 

remain engaged members of the community and to increase the numbers of 

veterans that may receive LTSS. The VHA has a long standing partnership with the 

ACL and partners with the Aging and Disability networks to provide Veteran 

Directed Home and Community Based Services (VD-HCBS). The VHA plans to build 

on the existing partnership with ACL by purchasing the services of NWD/ADRC 

Options Counselors to work with veterans and their families as they determine how 

to use their flexible HCBS service budgets to meet their LTSS needs, goals and 

preferences. 

Over the last 4 years more than 38 VAMCs across 15 VISNs have been purchasing 

Options Counseling services via the VD-HCBS from 91 AAA/CIL/ADRCs. Options 

Counselor’s work with veterans and their families to identify their functional needs, 

develop a service plan to meet those needs, activate the service plan and follow-up 

to assure the plan is working as the veteran envisioned. More than 17% of the 

individuals served through the VD-HCBS program are under 60, many having 

returned from current conflicts including Operation Iraqi Freedom, Operation 

Enduring Freedom and Operation New Dawn. 

Starting in 2008, ACL has collaborated with the VHA to deliver a veteran-directed 

option to veterans in need of home and community based services. HHS, through 

the ACL, continues to work closely with VHA to provide an additional opportunity to 

SUAs and AAAs to serve veterans of all ages at risk of nursing home placement. ACL 

and VHA’s long-range national vision is to have a long-term service and supports 

system that is person-centered, consumer-directed and helps people at risk of 

institutionalization to continue to live at home and be engaged in community life. 

The VHA will increase access to HCBS to serve the growing demand of veterans who 

desire home care and prefer independence at home over living in a nursing facility. 

Current research shows that on average, the Medicaid dollars that are required to 

support one adult in a nursing home are almost enough to support three adults with 

physical disabilities in the community.12 As the need of veterans for LTSS continues 

to grow, increasing access to HCBS strategically through an ADRC is essential to 

meeting the current and future needs of veterans and their families. 

How Do I Apply? 

States interested in pursuing this additional opportunity will be required to submit 

the following as an Addendum to their ADRC application: 

 

12 Kassner E, Reinhard S, Fox-Grage W, Houser A, Accius J, Coleman B, et al. A balancing act: state long-term care 

reform [Internet].Washington (DC): AARP Public Policy Institute; 2008 Jul [cited 2011 Jan 25]. (Research Report).
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I. Letters of Commitment from: 

1. Leadership at VAMC (e.g. CEO, CMO or CFO) 

2. VISN Director 

If there are multiple VISNs in your state wishing to participate 

please submit LOC’s from each participating VISN. 

II. Approach. Each applicant should describe the approach your state will take to 

develop and deliver VDHCBS services to Veterans statewide by the end of the 3 year 

project period. 

Applicant should describe:

1. After receipt of VDHCBS funds how soon implementation will begin. 

2. Any relationships, formal or otherwise, that exists at the state or local 

level between ADRCs and VAMCs. 

3. Demonstrated experience in the delivery of a consumer directed 

program(s). 

4. Any current relationship that exists between a state or local ADRC and 

an FMS vendor in the deliver VDHCBS. 

Reviewers will look favorably upon applications that: 

1. Include a Letter of Support from the State Office of Military and 

Veterans Affairs 

2. Have minimal or no delay in the delivery of VDHCBS upon 

receipt of funds

VISN/VAMCs serving veterans in the state shall indicate their interest in applying 

for the VA HCBS Expansion Program via letters of commitment that are included 

with the state’s application. VISNs/VAMCs will agree in the letters of commitment 

that they will use funds to purchase the ADRC Options Counseling Program and 

provide each veteran with a flexible HCBS budget. Similar to previous funding 

opportunities, the VA HCBS Program application shall be made by including in 

the ADRC grant application letters of commitment from the VISNs/VAMCs that 

serve veterans living in the state. 

Within 6 Months After Receipt of ADRC Options Counseling Award
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States receiving this funding opportunity and who select to participate in these joint 

VHA activities will work with their local ADRCs/VAMCs to submit the following 

project management information to ACL, CMS and VHA: 

Number of Veterans served through VDHCBS to Date: _________ 

(as of __/__/____)

Number of Veterans expected to be served through VDHCBS in Year 1: 

_____

Number of Veterans expected to be served through VDHCBS in Year 2: 

_____

Number of Veterans expected to be served through VDHCBS in Year 3: 

_____

Number of Veterans expected to be served over 3 year project period 

_____ at a total estimated cost of $_____ 

What is the VISN/VAMC and ADRC Options Counseling role in the delivery of 

the VA HCBS Expansion Program? 

For the selected States participating in this funding opportunity, the Designated 

State Agencies by the Office of the Governor will provide an Options Counseling 

program through ADRC sites. The VAMC will screen veterans that are eligible for 

HCBS and determine the case-mix category that is most appropriate based on the 

veterans functional needs. The VAMC will refer eligible veterans with a flexible 

HCBS service budget to the ADRC. Upon referral from their VAMC colleagues, the 

ADRC Options Counselors will conduct comprehensive person-centered 

assessments, work with the veteran and their family caregiver to develop HCBS 

service plans, provide consumer directed models of care when selected, work with 

the veteran to activate HCBS services and provide on-going options counseling to 

veterans and their family caregivers in partnership with their local VA Medical 

Center(s). 

Options counseling enables individuals to understand the services available in their 

communities, evaluate the utility of these services, make informed decisions about 

the services that best meet their needs and preferences, and make the best use of 

their own personal and financial resources over time. Options Counseling also helps 

ensure that people receive services they choose, including streamlined access to 

services to ensure that an individual’s service plan is activated. Options Counseling 

connects individuals to appropriate services using person-centered planning 

methods. 
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Options counseling involves self direction of services. Self direction enables access 

to services and supports that are controlled by the individual; self directed services 

are also a key requirement of the Older Americans Act of 1965 as Amended In 2006 

(Public Law 109-365) (OAA). The OAA requires the Assistant Secretary for Aging to 

promote coordinated systems of care that enable individuals to receive long term 

services and supports in home and community-based settings “in a manner 

responsive to the needs and preferences of older individuals and their family 

caregivers.” Flexible spending accounts, which are integral to successful self 

direction, are a vehicle by which individuals directly hire their workers and directly 

purchase goods and services. A large, randomized-controlled trial of self direction 

provided evidence of the efficacy of this approach. Results included greater 

satisfaction with quality of services, satisfaction with quality of life, sense of 

empowerment, and decreased unmet needs.13

Based on the number of veterans that will be referred to the ADRC Options 

Counselors, the local VA Medical Centers will provide funding to the ADRCs so that 

Options Counselors are available and ready to serve veterans as they are referred by 

the VAMC. The estimated monthly budget for HCBS services for each enrolled 

veteran will be supported by ongoing VA HCBS funding. Similar to the VD-HCBS 

program, the VAMC will pay for both the VA HCBS Administrative component and 

the HCBS services. The ADRC Options Counseling program will submit bills to the 

VAMC on a monthly basis. If the veteran chooses to receive traditional HCBS 

services, the HCBS service agencies selected by the veteran will bill the ADRC OC 

program for HCBS services provided. If the veteran chooses VD-HCBS, the ADRC 

will provide the funds for the flexible service budget and bill the VA for both the VDHCBS Administrative component and the authorized services at the end of each 

month. 

Agency Contacts: 

Daniel J. Schoeps 

Director, Purchased Long Term Services and Supports 

Geriatrics and Extended Care 

VA Central Office 

Daniel.Schoeps@va.gov

Kevin Foley 

Center for Disability & Aging Policy 

 

13 Brown, R et al: 2005. Cash and Counseling: Improving the Lives of Medicaid Beneficiaries Who Need 

Personal Care or HCBS Princeton NJ: Mathematica Policy Research Inc 
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Office of Integrated Programs 

Administration for Community Living 

Kevin.Foley@aoa.hhs.gov