VA ENHANCED 

MONTHLY BENEFITS

Recipient Population 

Is Changing, and 

Awareness Could Be 

Improved

Report to the Ranking Member, 

Committee on Veterans’ Affairs, 

U.S. Senate

December 2011

GAO-12-153

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-153, a report to the 

Ranking Member, Committee on Veterans’ 

Affairs, U.S. Senate

December 2011

VA ENHANCED MONTHLY BENEFITS

Recipient Population Is Changing, and Awareness 

Could Be Improved

Why GAO Did This Study

The Department of Veterans Affairs 

(VA) offers Aid and Attendance (A&A)

benefits to individuals who need 

regular assistance and the attendance 

of another person or Housebound 

benefits to individuals who are 

substantially confined to their homes. 

These benefits, which increase

recipients’ monthly disability 

compensation or pension payments,

are called enhanced compensation or 

enhanced pension, respectively—

collectively referred to as enhanced 

monthly benefits. This report describes 

(1) characteristics of enhanced 

monthly benefit recipients; (2) how the 

benefits help veterans obtain needed 

services, and the associated difficulties 

they face in obtaining these services;

and (3) VA’s efforts to educate 

veterans and their family members 

about the availability of the benefits. 

GAO’s work included analyzing VA

case-level demographic data from 

fiscal years 2000 to 2010 on 

enhanced monthly benefit recipients, 

conducting facilitated focus groups with 

veterans and their family 

representatives, and interviewing VA 

headquarters and regional officials on 

VA’s outreach efforts for enhanced 

monthly benefits, as well as reviewing 

relevant federal laws and regulations.

What GAO Recommends

GAO recommends that VA conduct 

more focused outreach to better 

educate potential recipients about 

enhanced monthly benefits. VA agreed 

with the recommendation and 

described a number of actions it would 

take or explore to address it, such as 

including more detailed information in 

its printed material on enhanced 

monthly benefits. 

What GAO Found

According to VA data during fiscal years 2000 to 2010, most enhanced monthly 

benefit recipients were veterans, over age 65, and receiving the A&A 

enhancement as part of their pension benefit. The recipient population is 

changing, however. In particular, the percentage of enhanced monthly benefit 

recipients age 65 or younger increased from 18 percent to 24 percent over the 

decade. Also, the percentage of recipients paid benefits under the disability 

compensation program increased from 15 percent to 26 percent. The cost of 

enhanced monthly benefits has increased from $124 million in fiscal year 2000 to 

$409 million in fiscal year 2010; however, VA does not know what portion of 

these costs was paid specifically for A&A and Housebound benefits. VA

maintains data on enhanced monthly benefit recipients’ total payments but does 

not separately identify the amount awarded as an A&A or Housebound benefit. 

VA officials stated that under its current system, separately tracking the costs of 

these benefits would be complicated and difficult.

Characteristics of Enhanced Monthly Benefit Recipients, Fiscal Years 2000 and 2010

Enhanced monthly benefits helped veterans obtain services to perform everyday 

living activities in different ways, but high service costs and limited service 

availability in some areas can make it difficult to acquire the services. Benefit 

recipients GAO spoke with said that they used their benefits to pay for in-home 

services by private providers, offset lost income from family members who 

provided care for them, or defray the costs of an assisted living facility. However, 

obtaining services from private providers can still pose difficulties for some 

recipients because of the generally higher cost of services in large urban areas 

or the limited availability of services in rural areas.

VA conducts a number of outreach activities to educate veterans and their family 

members about available benefits; however, a large number of elderly veterans 

may not be aware of their potential eligibility for enhanced monthly benefits. A VA 

study found that of pension recipients—who are mainly elderly veterans—62 

percent might be eligible for enhanced monthly benefits but only 22 percent 

received them, which the study primarily attributed to lack of awareness about 

the benefits. VA’s outreach efforts may not be sufficient to inform elderly veterans 

about enhanced monthly benefits because outreach activities do not typically 

focus on these benefits, some printed material lacks information on eligibility and 

application requirements for these benefits, and the extent to which regional 

offices conduct elderly outreach varies, among other reasons.

View GAO-12-153 or key components.

For more information, contact Daniel Bertoni 

at (202) 512-7215 or bertonid@gao.gov.
Page i GAO-12-153 VA A&A and Housebound Benefits

Letter 1

Background 3

Enhanced Pension 5

Enhanced Monthly Benefit Population Is Changing and Costs Are 

Growing 7

Enhanced Monthly Benefits Help Veterans Obtain Needed Services, 

but High Service Costs and Limited Availability of Services in 

Some Locations Can Pose Difficulties 14

Many Elderly Veterans May Be Unaware of Enhanced Monthly 

Benefits Despite VA’s Outreach Efforts 20

Conclusions 27

Recommendation for Executive Action 27

Agency Comments and Our Evaluation 28

Appendix I Objectives, Scope, and Methodology 30

Appendix II Qualifying Periods of War for VA’s Pension Program 37

Appendix III Comments from the Department of Veterans Affairs 38

Appendix IV GAO Contact and Staff Acknowledgments 41

Related GAO Products 42

Tables

Table 1: 2010 Maximum Annual Pension Benefit Limits 6

Table 2: Characteristics of Participants in Focus Groups and Oneon-One Interviews 36

Contents
Page ii GAO-12-153 VA A&A and Housebound Benefits

Figures

Figure 1: Examples of Everyday Living Activities for Which 

Individuals May Require Assistance to Perform 3

Figure 2: Characteristics of Veteran and Survivor Enhanced 

Monthly Benefit Recipients, Fiscal Years 2000-2010 8

Figure 3: Age of Veterans Receiving Enhanced Monthly Benefits 9

Figure 4: Type of Enhanced Monthly Benefits Received by Veterans 

by Age 10

Figure 5: Primary Periods of Service for Veterans Receiving 

Enhanced Monthly Benefits 11

Figure 6: Characteristics of Survivor Enhanced Monthly Benefit 

Recipients from Fiscal Years 2000-2010 13

Figure 7: Types of Assistance Needed by Focus Group Participants 15

Figure 8: Types of Providers Veterans Used to Help Perform 

Everyday Living Activities 16

Figure 9: Regional and State Differences in Costs of Home-Based 

Care Services, 2010 18

Abbreviations

A&A Aid and Attendance

TBI traumatic brain injury 

VA Department of Veterans Affairs 

VBA Veterans Benefits Administration

VHA Veterans Health Administration 

VSO Veterans Service Organizations

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-12-153 VA A&A and Housebound Benefits

United States Government Accountability Office

Washington, DC 20548

December 14, 2011

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

Dear Senator Burr:

Every day, thousands of veterans and their family members who are 

disabled from illnesses, injuries, or aging must rely on others to help them 

perform basic functions of everyday life such as bathing, feeding, and 

dressing themselves or to assist them with other needs such as 

transportation. As an enhancement of basic disability compensation and 

pension benefits, the Department of Veterans Affairs (VA) offers Aid and 

Attendance (A&A) and Housebound benefits, which help these individuals 

obtain needed services.1 A&A benefits are paid to severely disabled 

individuals who require regular aid and attendance of another person. 

Housebound benefits, which are generally smaller than A&A benefits, are 

paid to disabled individuals who are substantially confined to their homes.

Depending on whether the veteran is receiving disability compensation or 

pension benefits, the combined payment is called an enhanced disability 

compensation or enhanced pension, which we collectively refer to as 

enhanced monthly benefits. Provided as a single monthly payment in 

combination with the disability compensation or pension benefit, 

enhanced monthly benefits can help defray the cost of obtaining needed 

daily living support services.2

 1

These benefits are not stand-alone benefits; they increase recipients’ monthly disability

compensation or pension payments.

Enhanced monthly benefits are 

administered by VA’s Veterans Benefits Administration (VBA). Recipients 

of these benefits have generally been among the oldest and most 

severely disabled veterans. Although enhanced monthly benefits have 

existed for decades, there are questions about whether those who may 

be eligible for and need the benefits are aware of them.

2

Although spouses, surviving spouses, children, and parents may qualify for these 

benefits, the focus of our report is primarily on veterans receiving these benefits. 
Page 2 GAO-12-153 VA A&A and Housebound Benefits

As requested, this report examines (1) characteristics of enhanced 

monthly benefit recipients; (2) how the benefits help veterans obtain 

needed services, and the associated difficulties they face obtaining these 

services; and (3) VA’s efforts to educate veterans and their family 

members about the availability of the benefits. To conduct our work, we 

analyzed VA data from fiscal years 2000 to 2010 on the characteristics of 

recipients of enhanced monthly benefits, such as age and disabling 

conditions. We also conducted focus group discussions with veterans and 

their family representatives to obtain their views on how enhanced 

monthly benefits helped them obtain needed assistance. We conducted 

phone interviews with veterans or their family representatives who could 

not attend a focus group discussion. We held focus group discussions in 

San Antonio, Texas; St. Petersburg, Florida; and Norfolk, Virginia. We 

selected these locations because they had high concentrations of 

veterans who were receiving enhanced monthly benefits. We randomly 

selected 33 focus group participants based on VA data on veterans 

receiving these benefits during fiscal year 2009. We also gathered data 

from MetLife and Genworth on the cost of providing services to assist 

individuals with disabilities. We interviewed officials from VA’s Veterans 

Health Administration (VHA) about other benefits and services VA 

provides to help veterans perform everyday activities. In addition, we 

reviewed relevant federal laws and regulations, as well as prior GAO and 

other reports that addressed outreach efforts and best practices. We 

interviewed veterans and their family members regarding their 

experiences in learning about and applying for enhanced monthly 

benefits, the effectiveness of VA’s outreach efforts, and possible 

improvements to such efforts. We also interviewed VA officials in 10 VBA 

regional offices to discuss their outreach activities. These offices were 

selected based on several factors, including their size and geographic 

location. In addition, we gathered data from VBA on elderly outreach 

activities by regional offices during fiscal year 2010.

We conducted this performance audit from December 2009 through 

December 2011 in accordance with generally accepted government 

auditing standards. These standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. Additional 

information on our scope and methodology is provided in appendix I.
Page 3 GAO-12-153 VA A&A and Housebound Benefits

Various disabilities prevent many veterans from independently performing 

everyday living activities (see fig. 1).

Figure 1: Examples of Everyday Living Activities for Which Individuals May Require Assistance to Perform

VA offers enhanced monthly benefits that help such individuals obtain 

needed services. These services can be provided at home, in an assisted 

living facility, or a nursing home and can be provided by private providers, 

family and friends, and VHA. VA is required to ensure that potential 

recipients are informed about available benefits and to the maximum 

extent possible are offered assistance applying for them.3 VBA 

administers enhanced monthly benefits as well as other monetary and 

nonmonetary benefits, and conducts outreach through its 57 regional 

offices and Benefits Assistance Service and other VA offices.4

 3

38 U.S.C. § 6303. 

4

VA established the Benefits Assistance Service in 2010 to facilitate outreach conducted 

by VBA regional offices, as well as coordinate with other VA offices, federal agencies, and 

national organizations.

Background
Page 4 GAO-12-153 VA A&A and Housebound Benefits

Veterans may be eligible for A&A benefits if they

• establish a factual need for A&A, when considering many factors, 

including an ability to perform everyday personal functions such as 

bathing, dressing, eating, adjusting prosthetic devices, and protecting 

themselves from hazards or dangers in their daily environment;

• are a patient in a nursing home;5

• are bedridden; or

• are blind or nearly blind.

Veterans may be eligible for Housebound benefits if they have

• a disability rated at 100 percent and, as a result, are permanently or 

substantially confined to their homes, or

• a disability rated at 100 percent, and at least one other disability rated 

at 60 percent or more—although these individuals are legally 

classified as Housebound, they may be able to leave their homes.6

A&A and Housebound benefits both offer assistance that helps veterans 

function more independently, but A&A benefits are only for those who are 

in need of regular aid and attendance of another person, whereas 

Housebound benefits are for those who may be substantially confined to 

their homes. In addition to individual requirements specific to A&A and 

Housebound benefits, individuals have to meet the eligibility requirements 

for basic disability compensation or pension benefits.

When A&A or Housebound benefits are received as part of disability 

compensation benefits, the combined payment is called enhanced 

disability compensation. To qualify for disability compensation benefits, 

veterans must have disabling injuries or illnesses that occurred or were 

 5

Certain veterans who receive nursing home or domiciliary care at the government’s 

expense may have their pension benefits reduced to no more than $90 per month, 

depending on their length of stay. Our review did not include these veterans.

6

The disability rated at 60 percent must be separate and distinct from the disability rated 

at 100 percent and must involve different anatomical segments or bodily systems.

Enhanced Disability 

Compensation
Page 5 GAO-12-153 VA A&A and Housebound Benefits

made worse by their active military service. Such veterans must also 

have received a discharge or release under conditions other than 

dishonorable.7

The total monthly enhanced disability compensation benefit amount for 

A&A varies based on the veteran’s level of disability and family 

composition, whereas the amount of the Housebound benefit varies 

based only on the veteran’s family composition. For example, depending 

upon a veteran’s level of disability, the total monthly enhanced disability 

compensation payment for a single veteran receiving A&A benefits can 

range from approximately $3,300 to approximately $7,700 while the 

monthly payment for a veteran with a spouse and one child can range 

from approximately $3,600 to approximately $7,900. In contrast, the total 

monthly payment with Housebound benefits is approximately $3,000 for a 

single veteran and approximately $3,300 for a veteran with a spouse and 

child. For veterans receiving either A&A or Housebound benefits, the 

monthly amount is increased by $136 if the spouse requires A&A, by $75 

for each child in excess of one, and by $240 for each school child over 

the age of 18.

Per VA’s policy manual, VA is supposed to automatically 

consider the need for the A&A or Housebound benefit when awarding 

veterans a disability rating of 100 percent and may grant the benefit when 

there is sufficient medical evidence to support the individual’s need for aid 

and attendance.

When veterans receive A&A or Housebound benefits as part of a VA 

pension, the combined payment is called an enhanced pension. Veterans 

who served during a period of war8 and meet other service requirements 

may receive a VA pension if they are 65 or older, or at any age if they 

have disabilities unrelated to their military service that render them 

permanently and totally disabled, among other requirements.9

 7

To receive disability compensation benefits, veterans must first obtain a rating for their 

disability. VA assigns a rating from 0 percent to 100 percent based on the severity of the 

veteran’s disability. Veterans may qualify to receive A&A or Housebound benefits in 

addition to their regular compensation payment if they meet the requirements for those 

benefits.

Because 

8

Although we list all qualifying war periods in appendix II, there are no living veterans from 

the Indian wars, Spanish-American War, Mexican border period, and World War I. 

9

38 U.S.C. §§1513 and 1521(a). Also, as with disability compensation, to qualify for the 

pension, veterans’ disabilities must not have been the result of their own willful 

misconduct. 

Enhanced Pension
Page 6 GAO-12-153 VA A&A and Housebound Benefits

VA pension benefits are offered to help veterans or their surviving 

spouses of limited means, potential recipients must not exceed certain 

income and asset thresholds. Table 1 shows the differences in the 

maximum annual pension benefit limits for 2010 based on family 

composition for a VA pension recipient without enhanced benefits, with 

the A&A benefit, and with the Housebound benefit.

Table 1: 2010 Maximum Annual Pension Benefit Limits 

Type of 

benefit

Limit for 

veteran with no 

dependents

Limit for 

veteran with one 

dependent

Limit for 

surviving 

spouse with no 

dependents a

Limit for 

surviving 

spouse with 

one dependent

Pension 

without A&A or 

Housebound 

benefit

$11,830 $15,493 $7,933 $10,385

Pension with 

A&A benefit

$19,736 $23,396 $12,681 $15,128 b

Pension with 

Housebound 

benefit

b

$14,457 $18,120 $9,696 $12,144

Source: Federal Benefits for Veterans, Dependents and Survivors, 2011 Edition, U.S. Department of Veterans Affairs.

a

For both veteran and surviving spouses, the annual benefit limits are increased by $2,020 for each 

additional child.

b

Surviving spouses of veterans of the Spanish-American War are allowed a higher level of A&A 

benefits.

Veterans may have other sources of income, such as Social Security 

disability and retirement benefits, Medicaid, and private insurance, some 

of which may be counted in determining whether a veteran meets income 

eligibility requirements for a pension. For example, Social Security 

retirement benefits are counted as part of a veteran’s income, whereas 

public assistance benefits such as Social Security’s Supplemental 

Security Income is not. In addition to income, VA considers the net worth 

of individuals, excluding the value of the person’s home and vehicle. The 

standard that VA uses to determine eligibility for these benefits is whether 

the individuals’ resources are sufficient to meet their basic needs without 

assistance from VA. While there is no specified limit on the amount of 

resources individuals may have, if they have assets of $80,000 or more, 

per VA’s policy manual, VA is supposed to conduct an assessment to 

determine if their assets are sufficient to meet their basic needs. Assets 

counted toward the “sufficient means” figure of $80,000 include bank 

accounts, certificates of deposit, money market accounts, investment 

accounts, annuities, retirement accounts, and life insurance cash 
Page 7 GAO-12-153 VA A&A and Housebound Benefits

surrender values. To assess ongoing eligibility and benefit levels, VA 

requires pensioners who have income other than Social Security to file an 

annual income report.

In addition to enhanced monthly benefits, VA provides other benefits to 

help veterans perform daily living activities. For example, VBA provides 

benefits to help veterans purchase or convert an automobile to 

accommodate their disability. VHA offers other services, including the 

Home-Based Primary Care program, adult medical foster care, and adult 

day health care.

VA data at the end of fiscal year 2010 showed that for the overall enhanced 

monthly benefit population (including veterans and survivors), most 

recipients were veterans, over age 65, receiving the benefit as part of their 

monthly pension benefit, and receiving the A&A supplement, but the 

composition and characteristics of the recipient population is changing (see 

fig. 2).10

 10We were unable to examine the gender of enhanced monthly benefit recipients because 

VA told us that gender is not a required data field. 

According to VA’s data, more than 271,000 veterans and survivors 

received enhanced monthly benefits at the end of fiscal year 2010—a 52 

percent increase since the end of fiscal year 2000. While veterans over age 

65 comprised the majority of the overall enhanced monthly benefit 

population from fiscal years 2000 to 2010, there was an increased share of 

survivors, recipients age 65 or younger, those receiving the benefits under 

the disability compensation program, and those receiving the Housebound 

benefit enhancement. These changes were primarily driven by veterans 

age 65 or younger receiving these benefits—particularly those ages 46 to 

65—-as well as younger veterans receiving enhanced compensation 

benefits that included the Housebound enhancement.

Other Available Benefits 

and Services

Enhanced Monthly 

Benefit Population Is 

Changing and Costs 

Are Growing
Page 8 GAO-12-153 VA A&A and Housebound Benefits

Figure 2: Characteristics of Veteran and Survivor Enhanced Monthly Benefit Recipients, Fiscal Years 2000-2010

Note: Data from each fiscal year reflect individuals who were actively receiving benefits as of 

September 30, the last day of the fiscal year. Anyone who received benefits for only part of the year 

and was not actively receiving them on that date is not included in the analysis. See appendix I for 

more information.
Page 9 GAO-12-153 VA A&A and Housebound Benefits

Changes in the characteristics of the overall population of veterans and 

survivors who received enhanced monthly benefits were also mirrored in 

the population of veteran recipients. For example, the data showed that 

younger veterans are an increasing share of the veteran enhanced monthly 

benefit population. Although veterans over age 65 continued to comprise 

the majority of enhanced monthly benefit recipients at the end of fiscal year 

2010, their share of the veteran enhanced monthly benefit population has 

decreased steadily. Specifically, at the end of fiscal year 2010, veterans 

over age 65 who received enhanced monthly benefits accounted for a 64 

percent share of all veterans receiving these benefits compared with a 76 

percent share in fiscal year 2000. Meanwhile the share of veteran 

enhanced monthly benefit recipients age 65 or younger increased from 24 

percent to 36 percent over this time period (see fig. 3). While this increase 

was primarily driven by veterans ages 46 to 65, there was also a 

substantial increase in the percentage of veterans ages 18 to 45.

Figure 3: Age of Veterans Receiving Enhanced Monthly Benefits

Also for veterans who received enhanced monthly benefits, VA data 

showed that most received enhanced pension benefits that included the 

A&A benefit. This was particularly true for veteran recipients over age 65, 

although their share of these benefits declined from 62 percent in fiscal 

year 2000 to 50 percent in fiscal year 2010. For veterans age 65 and 
Page 10 GAO-12-153 VA A&A and Housebound Benefits

under receiving enhanced pension benefits with the A&A benefit, their 

share remained about the same—14 percent in fiscal year 2000 

compared with 13 percent in fiscal year 2010 (see fig. 4). By the end of 

fiscal year 2010, the percentage of veteran recipients age 65 or younger 

who received enhanced disability compensation benefits that included the 

Housebound benefit almost tripled from 6 percent in fiscal year 2000 to 

17 percent in fiscal year 2010.

Figure 4: Type of Enhanced Monthly Benefits Received by Veterans by Age

VA’s data also showed that most veterans receiving enhanced monthly 

benefits served during earlier war periods, but the number of recipients 

from more recent war periods is growing. The majority of recipients 

served during World War II, the Korean Conflict, and the Vietnam War 

(see fig. 5). Although Persian Gulf War (Gulf War) veterans comprised a 

relatively small proportion of veteran recipients, their numbers increased 

at a greater rate during fiscal years 2000 to 2010 (from less than 1,300 to 
Page 11 GAO-12-153 VA A&A and Housebound Benefits

nearly 11,000—more than a sevenfold increase) than veterans from any 

other period of service.11

Figure 5: Primary Periods of Service for Veterans Receiving Enhanced Monthly Benefits

Appendix II provides more information on the 

periods of service that qualify veterans for enhanced monthly pension 

benefits.

Note: Veterans can receive disability compensation for injuries suffered or diseases 

contracted in the line of duty even if such injury occurred during a peace time era.

 11The Gulf War period includes conflicts such as the Persian Gulf War, Operation Iraqi 

Freedom, and Operation Enduring Freedom.
Page 12 GAO-12-153 VA A&A and Housebound Benefits

In addition to analyzing the overall characteristics of veterans who 

received enhanced monthly benefits, we specifically analyzed the 

disabling conditions of Gulf War veterans.12 Consistently, the most 

common categories of disabling conditions during that time period were

skeletal conditions, neurological conditions and convulsive disorders, and 

mental and eating disorders.13 However, there were significant changes 

among other disabling conditions and categories of disabling conditions. 

For example, ear conditions increased from ninth most common in 2000 

to fourth most common in fiscal year 2010, while cardiovascular 

conditions went from sixth most common in fiscal year 2000 to eighth 

most common in fiscal year 2010. In addition, the proportion of Gulf War 

veteran enhanced monthly benefit recipients reporting diagnoses of Post

Traumatic Stress Disorder grew dramatically from 8 percent at the end of 

fiscal year 2000 to 28 percent at the end of fiscal year 2010. Additionally, 

7 percent of veteran enhanced monthly benefit recipients from the Gulf 

War reported diagnoses of traumatic brain injuries at the end of fiscal 

year 2010.14

Similar to the veteran population who received enhanced monthly 

benefits, the characteristics of survivors who received these benefits have 

also changed between the end of fiscal years 2000 and 2010. Over this 

period, most survivor recipients of enhanced monthly benefits were over 

age 65, and there was a slight decrease—from 6 percent to 3 percent—in 

the share of survivors age 65 or younger. Survivors primarily received 

enhanced pension benefits, and the share of such recipients increased 

from 77 percent in fiscal year 2000 to 84 percent in fiscal year 2010. Also, 

the percentage of survivor recipients of enhanced monthly benefits that 

included A&A benefits increased from 91 percent to 96 percent from fiscal 

 12Due to limitations we identified in VA’s data, we restricted our analysis of disabling 

conditions to veterans from the Gulf War period. See app. I for more information on data 

limitations.

13We grouped VA’s disabling conditions into 23 categories based on body system. 

14Effective in October 2008, the Veterans Affairs’ Schedule for Rating Disabilities—a 

guide for evaluating disabilities resulting from or incidental to military service—was revised 

to change the title of an existing diagnostic code to “Residuals of traumatic brain injury”

(TBI). Because veterans rated prior to this change were rated under different criteria and 

were not automatically reclassified at the time of the change, there may be undercounting 

of the number of veterans with TBI.
Page 13 GAO-12-153 VA A&A and Housebound Benefits

years 2000 to 2010. Figure 6 shows the characteristics of survivor 

recipients at the end of each fiscal year from 2000 to 2010.

Figure 6: Characteristics of Survivor Enhanced Monthly Benefit Recipients from Fiscal Years 2000-2010
Page 14 GAO-12-153 VA A&A and Housebound Benefits

For fiscal years 2000 to 2010, the total VA paid for enhanced benefits 

increased from approximately $124 million to $409 million; however, VA 

does not know the portion of enhanced benefit costs paid specifically for 

A&A and Housebound benefits. VA stated that it does not separately 

compile and monitor costs specifically attributable to A&A and 

Housebound benefits because they are not “stand-alone” benefits. The 

agency also stated that it would be complicated and difficult to track these 

costs separately in the agency’s current system and that it would take a 

considerable amount of resources to determine the costs and benefits of 

tracking this type of data.

Veterans and family members who participated in our focus groups and 

one-on-one interviews said that enhanced monthly benefits help them 

obtain needed assistance in different ways.15 For example, these benefits 

helped them pay for in-home services by private providers, offset lost 

income of family members who provide care, or defray the costs of an 

assisted living facility. One veteran told us that enhanced monthly 

benefits help him afford the home-based care that enables him and his 

wife to remain in their home. Another veteran told us that these benefits 

help replace some of the family income that was lost when his wife retired 

early from her job to care for him, rather than having him stay in a nursing 

home. Among the veterans we contacted, the activities they most 

frequently reported needing help with were bathing, dressing, and 

toileting (see fig. 7).16

 15Hereinafter, the term “veterans” refers to veterans or their family members who 

represented them in focus groups and one-on-one interviews. 

16We collected information from a total of 33 veterans through focus groups or one-on-one 

telephone interviews. However, since all veterans did not provide information on all topics, 

the total number of veterans providing information on a certain topic varied. These 

variations are noted as necessary. 

Enhanced Monthly 

Benefits Help 

Veterans Obtain 

Needed Services, but 

High Service Costs 

and Limited 

Availability of 

Services in Some 

Locations Can Pose 

Difficulties
Page 15 GAO-12-153 VA A&A and Housebound Benefits

Figure 7: Types of Assistance Needed by Focus Group Participants

Note: This figure reflects responses from 17 veterans who were receiving enhanced monthly benefits 

or the veterans’ family members.

In addition, 12 of the veterans we contacted said that enhanced monthly 

benefits also help them obtain other services, including transportation, 

doing laundry, preparing meals, and managing medications.

The veterans we spoke with also used their enhanced monthly benefits to 

obtain services from one or more of three sources—private providers, 

family members or friends, and VHA. They obtained services from each 

of these sources with similar frequency17

 17Private providers refer to those providers for which veterans are responsible for 

payment.

(see fig. 8).
Page 16 GAO-12-153 VA A&A and Housebound Benefits

Figure 8: Types of Providers Veterans Used to Help Perform Everyday Living 

Activities

About half of the veterans we spoke with (16 of 33) obtained home-based 

services from VHA. VHA offers various home-care services, including its 

Home-Based Primary Care Program, adult day health care, and adult 

medical foster care. The Home-Based Primary Care Program provides 

services such as rehabilitation and coordination of care to veterans who 

need assistance with daily living activities, among other health-care 

needs. One veteran we contacted said that the Home-Based Primary 

Care Program provided all needed services to help him meet his in-home 

health care needs. However, as we have noted in prior work, these 

services were not available in certain areas—especially rural locations, 

where approximately 40 percent of the veteran population enrolled in the 

VA health care system lives, according to VA.18

 18For example, GAO, VA Long-Term Care: Service Gaps and Facility Restrictions Limit 

Veterans’ Access to Noninstitutional Care, 

These gaps could make it 

difficult for some veterans to access VHA home-based care. VHA officials 

said that as of July 2010, there were still a limited number of home-based 

care service providers to contract with in some rural areas. However, 

according to VHA officials, one step the agency has taken to address this 

GAO-03-487 (Washington, D.C.: May 9, 2003).
Page 17 GAO-12-153 VA A&A and Housebound Benefits

problem is to collaborate with local area agencies on aging to help 

arrange for needed services.19

Some veterans may need to purchase services from private providers to 

assist them in performing daily living activities, which could make it 

difficult for veterans living in higher-cost regions of the country to obtain 

services. Private providers may offer a variety of services, such as 

housekeeping provided by home care aides and administration of oral 

medication by home health aides. The cost of these services varies 

among and within states. Nationally, our analysis of MetLife and 

Genworth data showed that the hourly cost for obtaining services from 

home care aides ranges from $9 to $38, and the national median hourly 

cost is $18.25.

Also, VA is planning to expand its HomeBased Primary Care Program, which currently operates in 15 VA medical 

centers.

20 Generally, service costs are lowest in Southern states.

The median hourly cost of obtaining services from home health aides was 

less than the national median for all but one Southern state. Figure 9 

shows regional and state differences in service costs. The cost of care 

also varies within states. For example, the median hourly cost of 

obtaining services from a home care aide in California ranges from 

$18.86 in Los Angeles to $24.38 in San Francisco, or about a 29 percent 

cost difference. Also, services are less available in some rural areas, 

which can limit recipients’ ability to obtain them. In addition, according to 

a study by the National Association for Home Care and Hospice, 

providers nationwide are finding it difficult to hire and retain a sufficient 

number of home health aides and home care aides to provide assistance 

to individuals needing them.21

 19Local area agencies on aging provide a variety of services for elderly individuals, 

including transportation, homemaker services, and family caregiver support.

20Our analysis took the average of the median costs as reported by Genworth and 

MetLife. See appendix I for more information on how we conducted this analysis.

21National Alliance for Caregiving, in collaboration with the American Association of 

Retired Persons, Caregiving in the U.S., Executive Summary (November 2009).
Page 18 GAO-12-153 VA A&A and Housebound Benefits

Figure 9: Regional and State Differences in Costs of Home-Based Care Services, 2010

Note: The depiction of states within geographic areas—Eastern, Southern, Central, and Western—

corresponds to VBA’s organization of states into four service areas.
Page 19 GAO-12-153 VA A&A and Housebound Benefits

Family members and friends are also called upon to help veterans 

perform daily activities but can face difficulties in doing so. About half of 

the veterans we contacted (17 of 33) relied on family members or friends 

to help them, and in some cases these individuals were their sole source 

of care. For example, the spouse of one veteran said that she had to 

attend to him 24 hours a day—including bathing and dressing him, and 

taking him to dialysis treatment—which prevented her from getting a job. 

An August 2009 study of veterans who received assistance from family 

caregivers found that persons with disabilities who had more restrictions 

in performing daily living activities and more health care needs were less 

likely than people with fewer restrictions to obtain home-based care, 

placing additional stress on their caregivers.22 According to a November 

2010 study, some of the major difficulties family members and others face 

in providing caregiver support for veterans include a lack of knowledge 

about the veterans’ medical condition as well as a lack of skills to help 

caregivers perform various activities.23

Last year, Congress passed the Caregivers and Veterans Omnibus 

Health Services Act of 2010 in part to provide assistance to family 

caregivers of veterans.

Some of the caregivers we 

contacted said they were unable to provide all of the assistance needed 

to perform everyday living activities. For example, one veteran relied on 

his spouse for assistance, but she was not always able to perform certain 

tasks. The veteran relies on a device to lift him, but when he falls, he told 

us that his spouse has to call the fire department to lift him.

24 The legislation directs VA to provide specified 

benefits and services to the caregivers of certain Post 9/11 veterans who 

have serious service-connected injuries and are in need of personal care 

services.25 As required by the new legislation,26

 22Joshua M. Thorpe, Courtney Harold Van Houtven, Betsy L. Sleath, “Barriers to 

Outpatient Care in Community-Dwelling Elderly With Dementia: The Role of Caregiver Life 

Satisfaction,” Journal of Applied Gerontology (August 2009). See also G. Dejong, S. E. 

Palsbo, P. W. Beatty, G. C. Jones, T. Knoll, and M. T. Neri, “The Organization and 

Financing of Health Services for Persons With Disabilities,” Milbank Quarterly (2002).

VA developed an 

implementation plan to guide its provision of benefits and services to 

23National Alliance for Caregiving, Caregivers of Veterans: Serving on the Homefront

(Bethesda, MD: November 2010).

24Pub. L. No. 111-163, 124 Stat. 1130.

25Id. § 101(a), 124 Stat.1132.

26Id. § 101(b), 124 Stat.1137.
Page 20 GAO-12-153 VA A&A and Housebound Benefits

caregivers of eligible veterans. Additionally, VA has begun to offer 

additional caregiver services to the families of seriously injured Post 9/11 

veterans, such as monthly stipends, training, medical-related travel cost 

reimbursements, and respite care. The legislation also requires VA to 

report to Congress on the feasibility of expanding the family caregiver 

benefits to veterans whose injuries were incurred before 9/11.27

VA’s data for fiscal years 2000 to 2010 indicate that elderly veterans and 

their surviving family members are the primary recipients of enhanced 

monthly benefits, although many other potentially eligible elderly veterans 

likely are unaware of these benefits. VA has previously acknowledged 

that enhanced pensions, whose primary recipients are elderly veterans, 

are underused and that not all potential recipients are aware of these 

benefits. Also, a 2004 VA study found that while 62 percent of pension 

recipients might be eligible for these benefits, only about 22 percent 

received them.28

 27Id. § 101(d), 124 Stat. 1139.

This study estimated that, in 2010, between 565,000 and 

925,000 veterans and between 940,000 and 1.38 million surviving family 

members would be eligible for, but would not be receiving, VA pension 

benefits. A portion of these veterans and surviving family members were 

expected to also qualify for enhanced monthly benefits. The study found, 

however, that the lack of awareness about the VA pension is the primary 

reason eligible veterans and their surviving family members may not be 

applying for enhanced monthly benefits. Some VA officials and Veterans 

Service Organizations (VSO) representatives we spoke with also said that 

28VA Pension Program Final Report, ORC Macro Economic Systems Inc., Hay Group, 

Evaluation of VA Pension and Parents’ DIC Programs (Dec. 22, 2004).

Many Elderly 

Veterans May Be 

Unaware of Enhanced 

Monthly Benefits 

Despite VA’s Outreach 

Efforts

Many Elderly Veterans 

Reportedly Lack 

Awareness of Enhanced 

Monthly Benefits
Page 21 GAO-12-153 VA A&A and Housebound Benefits

many elderly veterans are unaware of VA benefits for which they may be 

eligible, including enhanced monthly benefits. According to one VA 

official, this lack of awareness exists because many elderly veterans were 

never informed about VA benefits after they left the service.

If elderly veterans do not learn about enhanced monthly benefits from VA 

or other reliable sources such as VSOs, there is a risk they will be 

misinformed or become victims of predatory financial practices. According 

to some VA officials, as well as representatives from an elderly advocacy 

organization, VSOs, state and local government officials, and elder law 

attorneys we spoke with, some elderly veterans learn about enhanced 

monthly benefits from financial planners and attorneys who may charge 

for services that VA and VSOs provide for free. These officials said that 

some attorneys and financial planners may convince elderly veterans, 

who ordinarily would be ineligible for a VA pension because of excess 

assets, to reduce these assets by transferring them into annuities or 

irrevocable trusts. We also observed websites where organizations 

market asset transfer services to help elderly veterans qualify for VA 

pension and enhanced monthly benefits. Representatives from an elderly 

advocacy organization noted that financial planners may be charging 

significant fees for each senior citizen they assist in transferring assets to 

qualify for a VA pension. Once established, these investments could 

severely limit veterans’ access to their assets or prevent them from 

obtaining Medicaid benefits in the future. For example, one elder law 

attorney told us that some elderly veterans may need nursing home care, 

but transferring assets to qualify for VA pension benefits may cause them 

to be ineligible for Medicaid benefits that would pay for this care.29

 29For asset transfers, a period of up to 60 months from the time someone applies for 

Medicaid benefits is generally considered. If a transfer of assets is found to have occurred 

for less than fair market value within that period of time, Medicaid benefits that pay for 

nursing facility care and certain other long-term care services may be denied for a period

of time.
Page 22 GAO-12-153 VA A&A and Housebound Benefits

VA provides outreach to both the general veteran population and to 

specific veteran population groups identified as warranting additional 

attention, such as seriously disabled (Post 9/11), homeless, and elderly 

veterans.30

VA provides personalized outreach to seriously injured Post 9/11 

veterans, which gives them several opportunities to learn about enhanced 

monthly benefits. For example, VA assigns staff to military treatment 

facilities to provide these veterans with tailored benefits information and 

to initiate the claims process. Also, these veterans are assigned a case 

manager and have access to VHA social workers who may inform them 

about enhanced monthly benefits and help them apply for these benefits. 

In addition, for the disability compensation program, VA requests 

information on disabling conditions of all applicants. Under VA’s policy 

manual, the agency is to use this information to consider eligibility for 

enhanced monthly benefits for veterans with a disability rating of 100 

percent, and, seriously injured Post-9/11 veterans may qualify for these 

benefits as part of their disability compensation.

VA’s general outreach activities tend to focus on benefits such 

as health care, disability compensation, education, and home loans.

However, certain benefits like enhanced monthly benefits are more likely 

to be highlighted during outreach activities for specific veteran population 

groups based on their potential eligibility. For example, VA officials told us 

that there is an increased emphasis on enhanced monthly benefits during 

outreach to seriously disabled Post 9/11 veterans, as well as elderly 

veterans, who comprise major segments of the eligible population for 

these benefits.

VA’s outreach to elderly veterans provides them with fewer opportunities 

to learn about enhanced monthly benefits. VA conducts outreach 

activities in locations where the elderly reside or congregate, such as 

assisted living facilities and senior centers, and at events sponsored by or 

in collaboration with organizations that serve the elderly. However, some 

elderly veterans who may qualify for enhanced monthly benefits may 

have disabilities that prevent them from attending such events or do not 

interact with the organizations that VA collaborates with. According to VA 

officials, the agency does not have outreach designed to specifically 

target elderly veterans who may be confined to their home. In contrast to 

 30Population groups that VA targets for outreach include elderly veterans, former 

prisoners of war, homeless veterans, minority veterans, recently separated and retired 

service members, women veterans, and Post 9/11 veterans. 

VA’s Outreach Approach 

May Not Be Sufficient to 

Inform Elderly Veterans 

about Enhanced Monthly 

Benefits
Page 23 GAO-12-153 VA A&A and Housebound Benefits

the compensation program, for pension applicants age 65 and older, VA 

only requests information on disabling conditions of those applicants who 

indicate they are housebound or in need of regular assistance of another 

person to consider eligibility for enhanced monthly benefits. Therefore, 

VA would not have information needed to consider eligibility for enhanced 

monthly benefits for all pension applicants.

VA has collaborated on elderly outreach with national organizations that 

serve the elderly. For example, at the national level, VA has partnered with 

the Assisted Living Federation of America to develop informational material 

on enhanced monthly benefits and has staffed benefits booths during 

conferences held by this and other organizations that serve the elderly. 

Agency officials told us that such efforts may increase in the future as VBA 

identifies more organizations to partner with for outreach initiatives. VBA 

has also participated in an advisory group of the Center for Benefits 

Outreach and Enrollment to identify best practices for elderly outreach.

VA also provides informational material on its benefits, but the content 

may not provide enough details about eligibility and application 

requirements for enhanced monthly benefits. For example, VA’s 2011 

benefits handbook informs readers that enhanced monthly benefits are 

available, although it does not elaborate on the specific limitations with 

everyday living activities or transportation that a veteran must have in 

order to be eligible for these benefits.31

In addition to printed material, VA provides online information about 

enhanced monthly benefits, but this information may be difficult to find. 

For example, the home page on VA’s website does not provide direct 

VA benefits pamphlets, a handout 

on pension benefits, as well as presentations used during outreach 

activities that we assessed also lacked such information. Additionally, 

enhanced monthly benefits are mentioned in the attachments VA includes 

with award letters sent to veterans when they are granted pension 

benefits. However, they do not discuss eligibility requirements. Also, the 

eligibility verification form that some pension recipients annually complete 

does not include information about enhanced monthly benefits, although 

some pension recipients may qualify for these benefits, but are not 

receiving them.

 31Federal Benefits for Veterans, Dependents and Survivors is a handbook VA publishes 

that provides a summary of VA and other federal benefits that are available to veterans, 

surviving spouses, and dependents.
Page 24 GAO-12-153 VA A&A and Housebound Benefits

links to access information on these benefits, which could make it difficult 

for users to locate information about them. The home page does contain 

a link for the pension program that provides information on eligibility and 

application requirements for A&A and Housebound benefits; however, 

because it is not apparent that this link would provide such information, 

users may not be inclined to follow it. Also, VA and the Department of 

Defense recently developed the eBenefits web portal to provide veterans 

with customized information on, and how to apply for, VA benefits and 

assistance, but it does not include a direct link to information on 

enhanced monthly benefits. A few of our focus group participants 

commented that they had difficulty finding information about enhanced 

monthly benefits on VA’s website. Website guidelines recommend that 

navigation procedures to access online information be simple and that 

links be properly labeled to help users obtain desired results.32

Finally, VA provides information on enhanced monthly benefits through its 

nine call centers, including a call center that exclusively responds to 

inquiries related to the VA pension. These centers handle inquiries from 

the 800 number that VA directs veterans to call for information about 

benefits. In response to a VA Office of Inspector General study that found 

that veterans had difficulty getting through to call agents and obtaining 

correct information, VBA implemented a new call routing system in March 

2011 to improve callers’ access to call agents, and is working to develop 

national performance standards for call agents to improve the quality of 

services provided.33

Most outreach activities for VA’s benefits are conducted at the VBA 

regional office level, and VBA provides broad guidance on conducting 

outreach to its regional offices. In its procedures manual, VA requires 

each VBA regional office to designate an elderly outreach coordinator and 

provides suggestions on collaborating with agencies or organizations that 

serve the elderly. However, besides these suggestions, this manual does 

not define the specific duties of the coordinator or identify other types of 

 32U.S. Department of Health and Human Services and U.S. General Services 

Administration, “Research-Based Web Design and Visibility Guidelines.”

33VA Office of Inspector General Office of Audits and Evaluations, “Veterans Benefits 

Administration Audit of National Call Centers and the Inquiry Routing and Information 

System” (May 13, 2010).

VA Guidance to VBA 

Regional Offices on 

Elderly Outreach Is Broad, 

and the Extent to Which 

Regional Offices Conduct 

These Activities Varies
Page 25 GAO-12-153 VA A&A and Housebound Benefits

elderly outreach activities that should be conducted. We contacted 10 of 

VBA’s 57 regional offices and of these 10 offices, only 4 collaborated with 

local agencies that serve the elderly, despite suggestions in the manual to 

do so. Also, the extent to which VBA regional offices coordinated and 

collaborated on outreach with local VHA facilities varied among the 10 

regional offices we contacted. For example, while staff in all of these 

offices said that they coordinate with VHA, only six indicated that they 

provide training to social workers and other VHA employees to enable 

them to provide information on available VBA benefits to potential 

recipients. Staff in all of the regional offices we contacted told us they 

collaborate with VSOs on outreach, but the extent and nature of this 

collaboration differed. The collaboration included such things as training 

VSO staff on available benefits and working with VSO staff to conduct 

outreach in remote areas or to provide application assistance to veterans 

who are physically unable to visit the regional office. Some offices may 

have worked with VSOs in one or a combination of these ways.

Similarly, the extent to which regional offices identified locations to 

conduct elderly outreach also varied among the 10 regional offices we 

contacted. Staff in 5 offices told us they proactively identify locations to 

disseminate information on VA benefits as well as identify potential 

recipients. During these elderly outreach activities, regional office staff 

may have one-on-one conversations with attendees and provide 

information on enhanced monthly benefits to those who indicate they 

need assistance to perform everyday living activities. However, staff in 

the other five offices said that they did not conduct elderly outreach 

activities at all, or only did so in response to invitations from other 

organizations.

Agencywide, the amount of time VBA regional offices spent conducting 

elderly outreach activities varied considerably. VA’s fiscal year 2010 data 

show that the total number of hours regional offices reported spending on 

elderly outreach ranged from 0 to over 100. For example, 2 regional 

offices reported spending over 100 hours, 12 reported less than 10 hours, 

and 9 offices either reported they did not conduct any elderly outreach or 

did not report this information. There may be several reasons for this wide 

variance. Although staff in most regional offices we contacted said that 

limited staff, funding, and other resources minimize their capacity to 

conduct outreach, some offices had staff with full-time responsibilities for 

outreach, including elderly outreach. In contrast, other offices conducted 

outreach as part of ancillary duties or on a voluntary basis. VA is currently 

prioritizing outreach to the homeless as well as Post 9/11 veterans and 

staff in some offices we contacted told us they focus their outreach on 
Page 26 GAO-12-153 VA A&A and Housebound Benefits

those veteran groups rather than the elderly. Also, VA has acknowledged 

that the number of elderly veterans is increasing but has yet to establish 

detailed plans or performance goals for its elderly outreach efforts. For 

example, VA’s strategic plan for fiscal years 2011 to 2015 includes 

outreach initiatives for different veteran population groups but none that 

specifically target elderly veterans. In addition, for elderly outreach, VA is 

currently using the total number of hours devoted annually to these types 

of activities as a performance indicator, but this does not provide the 

information needed to assess the outcomes and effectiveness of the 

agency’s efforts. VBA officials told us the agency is in the process of 

identifying appropriate performance goals and measures for all of its 

outreach efforts.

VA’s broad guidance posed some challenges for regional offices in 

conducting elderly outreach, and VA has begun to take steps to address 

this issue. For example, staff in one office said they conducted minimal 

elderly outreach, in part, due to a lack of guidance from VA’s central 

office, while staff in another office told us that more specific guidelines on 

conducting elderly outreach are needed. Recently, VA has taken some 

steps to enhance guidance to regional offices. For example, in May 2010, 

VA’s central office reinstituted bimonthly conference calls with regional 

elderly outreach coordinators to facilitate information sharing among 

participants. Also, VA’s central office requires regional offices to submit 

weekly reports on their outreach activities through a web-based reporting 

tool. The reports include information on the type of outreach activity 

conducted, the number of hours devoted to each targeted veteran 

population group, and the number of attendees at an outreach event. 

According to VBA officials, the reporting tool is currently being enhanced 

to enable VA’s central office to conduct a more in-depth analysis of the 

information reported, which may in turn allow for more tailored guidance 

to each regional office.

Many of the staff at regional offices and the veterans we spoke with 

provided suggestions on how VA might increase awareness about 

enhanced monthly benefits. Staff at several VBA regional offices 

suggested VA increase awareness by using local or national media to 

disseminate information targeted to elderly veterans. Suggestions by 

veterans included mailing information on eligibility and application 

requirements to potential recipients. Some of the veterans we spoke with 

also said that VHA was their first source of information about enhanced 

monthly benefits and that VHA employees should play a primary role in 

providing this information.
 

Page 27 GAO-12-153 VA A&A and Housebound Benefits 

Enhanced monthly benefits can play a critical role in helping aging and 

disabled veterans obtain the services they need to perform everyday 

living activities and, in many cases, allow them to stay in their homes or 

other noninstitutional settings. Demand for these benefits will likely grow 

as life expectancy increases and more younger service members return 

home with injuries from global conflicts. Although enhanced monthly 

benefits have existed for decades, many within certain populations, such 

as elderly veterans, are unaware of them and are, therefore, forgoing 

valuable benefits. While VA conducts a number of outreach efforts and 

provides information to educate veterans and their families about 

available benefits, there are opportunities for VA to improve its efforts to 

ensure that potential recipients, particularly the elderly and those who are 

not connected to VA’s health care system, are aware of all benefits for 

which they may be eligible. Without specific performance goals and 

metrics to improve outreach to elderly veterans, more detailed guidance 

to better instruct regional offices on how to conduct elderly outreach, and 

improved information on application and eligibility requirements for 

enhanced monthly benefits that is easy to access, many elderly veterans 

and their family members may fail to receive assistance that could 

improve their quality of life. It will be important for VA to address these 

issues to ensure that veterans are aware of all available benefits for 

which they may qualify. Taking steps to better inform elderly veterans 

about enhanced monthly benefits will not only ensure that they receive 

benefits that could help them obtain needed services to perform daily 

living activities, but also ensure that younger veterans are aware of the 

benefits as they age and possibly develop a need to access these 

benefits. 

To enable VA to improve its efforts to educate veterans and their family 

members about enhanced monthly benefits, we recommend that the 

Secretary of VA direct the Undersecretary for Benefits to take steps to 

conduct more focused outreach to potential recipients, which could entail 

the following: 

 Improving communication of and accessibility to information about 

enhanced monthly benefits. Such efforts could include (1) providing 

more information in the VA benefits handbook and other informational 

material on VA benefits, (2) increasing the visibility of links on VA’s 

website to information about these benefits, and (3) using local or 

national broadcast and print media to disseminate information about 

these benefits. 

Conclusions 

Recommendation for 

Executive Action 
Page 28 GAO-12-153 VA A&A and Housebound Benefits

• Continuing efforts to establish specific performance goals and metrics 

for increasing outreach to elderly veterans.

• Providing more detailed guidance to regional offices on how elderly 

outreach should be conducted and on the specific duties of outreach 

coordinators.

We provided a draft of this report to VA for review and comment. In its 

written comments (see app. III), VA concurred with our recommendation 

and provided information on a number of actions the agency planned to

take or explore to address it. 

For example, VA stated that it would include more detailed language 

about enhanced monthly benefits in its 2012 Federal Benefits for 

Veterans, Dependents and Survivors handbook as well as post 

information about these benefits on VA’s website, the joint 

VA/Department of Defense eBenefits portal, and VA social media 

directories such as Facebook and Twitter. 

VA also stated that it would explore the feasibility of targeted direct 

mailings to veteran and survivor pension recipients to inform them of the 

eligibility requirements for enhanced benefits and the application process. 

As part of its efforts to establish specific performance goals and metrics, 

VA stated that it plans to analyze available data related to its current 

outreach efforts to clarify expectations and address measures and 

standards of outreach to elderly veterans and survivors. Additionally, VA 

stated that VBA would provide guidance to regional offices on how to 

conduct elderly outreach through such means as regular conference calls 

and national awareness training for outreach coordinators. 

Agency Comments 

and Our Evaluation
Page 29 GAO-12-153 VA A&A and Housebound Benefits

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to relevant congressional 

committees, the Department of Veterans Affairs, and other interested 

parties. In addition, the report will be available at no charge on the GAO 

website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7215 or bertonid@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix IV.

Sincerely yours,

Daniel Bertoni

Director, Education, Workforce

 and Income Security Issues
Appendix I: Objectives, Scope, and 

Methodology

Page 30 GAO-12-153 VA A&A and Housebound Benefits

The objectives of our review were to determine (1) characteristics of 

enhanced monthly benefit recipients, (2) how enhanced monthly benefits 

help veterans obtain needed services, and the associated difficulties they 

face in obtaining these services, and (3) the Department of Veterans 

Affairs’ (VA) efforts in educating veterans and their family members about 

the availability of the benefits.

For our first objective, we obtained and analyzed case-level demographic 

data about individuals who received enhanced monthly benefits at the 

end of each fiscal year from 2000 to 2010, or whose benefits had been 

terminated. The data included recipients’ age, disabling conditions, period 

of service, state of residence, type of benefit received, and where 

applicable, the reason for termination of benefits. We also obtained 

information on the total enhanced monthly benefit payment. These data 

were retrieved from VA’s Benefits Delivery Network and Veterans 

Services Network. Data obtained included any veterans and qualified

surviving spouses or parents who received Aid & Attendance (A&A) or 

Housebound benefits as an enhancement to monthly compensation or 

pension benefits during this time period. 1 Since these data are not 

publicly available, VA compiled data extracts for our use. We reviewed 

relevant federal laws and regulations. We also reviewed VA policies and 

other documents, and interviewed officials in the VA’s Veterans Benefits 

Administration (VBA) Compensation and Pension Services to identify 

requirements for receiving enhanced monthly benefits, and how benefit 

amounts are determined.2

 1

A&A recipients who are hospitalized at the government’s expense may receive a reduced 

rate during their hospitalization. Our analysis treated all A&A recipients as a single group, 

regardless of whether they received the reduced rate for hospitalization.

In our analysis of information about periods of 

service, we excluded veterans who fought in World War I or during the 

Mexican Border Period because they comprised a very small number of 

cases at the end of fiscal year 2000 (a total of 123, or less than 0.11 

percent of all veteran recipients) and none by the end of fiscal year 2010. 

Also, we removed duplicate entries in the diagnostic code fields in VA’s 

data. Our assessment of the reliability of VA’s data is discussed 

separately in this appendix.

2

VBA’s Compensation and Pension Services is the organizational component that directs 

policy for enhanced monthly benefits. 

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-12-153 VA A&A and Housebound Benefits

For our second objective, we reviewed studies and reports by GAO and 

others to obtain information on the services that recipients of enhanced 

monthly benefits may need to perform everyday living activities, the 

different sources of this help, and difficulties veterans may face in obtaining 

these services.3 We also interviewed two national and two local 

organizations that provide services and support to the elderly, individuals 

with disabilities, and their caregivers.4 In addition, we analyzed information 

on the cost of acquiring these services to show how costs can vary across 

all 50 states and the District of Columbia. We also examined provisions of 

the Caregivers and Veterans Omnibus Health Services Act of 20105

For our third objective, we reviewed relevant federal laws and regulations 

to identify VA’s outreach responsibilities. To evaluate outreach to 

potential recipients by VA’s central office, we interviewed officials from 

central office who were familiar with its efforts. We also identified VA’s 

past and present outreach activities, as well as its outreach plans.

to 

determine how it would help caregivers. A more detailed discussion of our 

analysis of cost data is provided separately in this appendix.

6

 3

The GAO reports we reviewed included VA Long-Term Care: Service Gaps and Facility 

Restrictions Limit Veterans’ Access to Noninstitutional Care, 

In 

addition, we reviewed the outreach guidance that VBA central office 

provides to VBA regional offices. To evaluate VBA regional office 

outreach efforts targeted to potential recipients, we contacted officials 

from 10 regional offices. These regional offices were judgmentally 

GAO-03-487 (Washington, 

D.C.: May 9, 2003); and VA Health Care: Long-Term Care Strategic Planning and 

Budgeting Need Improvement, GAO-09-145 (Washington, D.C.: Jan. 23, 2009). We also 

reviewed reports on the impact of everyday living activity restrictions, access to services in 

the rural areas, and challenges of family caregiving. 

4

The national organizations we interviewed were the National Family Caregivers 

Association and the National Association of Area Agencies on Aging, both located in the 

Washington, D.C., area. The local organizations we interviewed were VillageCare, in New 

York City, and Region IV Area Agency on Aging, in St. Joseph, Michigan.

5

Pub. L. No. 111-163, 124 Stat. 1130.

6

We reviewed VBA’s fiscal year 2010-2011 Outreach Activities Plan, VA’s fiscal year 

2011-2014 Strategic Plan, VA’s 2010 Performance and Accountability Report, and 2008 

and 2010 VA reports on outreach activities.
Appendix I: Objectives, Scope, and 

Methodology

Page 32 GAO-12-153 VA A&A and Housebound Benefits

selected to represent the different characteristics of VA’s regional offices.7

In addition, we examined fiscal year 2010 data on regional office elderly 

outreach activities. We assessed VA’s print and online informational 

materials for clarity and the extent to which they provide complete 

information on eligibility and application requirements for enhanced 

monthly benefits. We also analyzed VA’s website and eBenefits portal for 

ease of accessing information about eligibility and application 

requirements.8 In addition, we reviewed studies about Internet usage 

among elderly and disabled populations. To enhance our evaluation of 

VA’s outreach efforts, we interviewed representatives of veterans service 

organizations (VSO) to obtain their views on VA’s outreach efforts. We 

also interviewed representatives of organizations that represent and 

interact with elderly populations and individuals with disabilities, some of 

whom have collaborated with VA on outreach.9

• outlining of strategic goals for the campaign and determination of a 

desired response;

In addition, we used key 

outreach best practices identified in GAO and other reports as criteria to 

assess VA’s outreach efforts. The criteria included

• identification and researching of the target audience to understand 

some of its key characteristics, such as size of population;

• establishment of strategic partnerships with other entities that are 

stakeholders in the issue to get help with planning and implementing 

the outreach campaign;

 7

Criteria we used to select the judgmental sample of regional offices included the extent to 

which elderly outreach was conducted, the concentration of actual and potential recipients 

of enhanced monthly benefits in the service area, whether service areas are 

predominantly urban/suburban or rural, the size of the regional office, and the VBA region 

in which the office is located. The 10 regional offices included: Boise, ID; Detroit, MI; 

Fargo, ND; Houston, TX; Lincoln, NE; Louisville, KY; Philadelphia, PA; Roanoke, VA; St. 

Petersburg, FL; and San Diego, CA.

8

VA’s website can be accessed at www.va.gov. VA’s eBenefits portal can be accessed at 

https://www.ebenefits.va.gov/ebenefits-portal/ebenefits.portal.

9

VSOs we interviewed include American Legion, Blinded Veterans Association, Disabled 

American Veterans, Paralyzed Veterans of America, and Veterans of Foreign Wars. Other 

organizations we interviewed include the Assisted Living Federation of America, National 

Association of Area Agencies on Aging, and National Council on Aging’s Center for 

Benefit Outreach and Enrollment. 
Appendix I: Objectives, Scope, and 

Methodology

Page 33 GAO-12-153 VA A&A and Housebound Benefits

• targeting of the outreach message with audience specific, culturally 

sensitive content and use of media and languages that are the most 

appropriate for the audience;

• reinforcement of the message with repetition and different media, 

especially when targeting people who may be challenging to serve; 

and

• development and implementation of performance measures for 

evaluating the effectiveness of the outreach campaign.

As part of our audit work for objectives two and three, we conducted a 

series of focus groups and one-on-one interviews with veterans who 

receive enhanced monthly benefits or a family member they chose to 

represent their views. A detailed discussion of the methodology used to 

plan, conduct, and analyze the results of these focus groups, and one-onone interviews, is provided separately in this appendix.

We conducted this performance audit from December 2009 through 

December 2011 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

To assess the reliability of these data, we (1) reviewed documentation for 

data extracts, (2) conducted electronic testing for obvious errors in 

accuracy and completeness, and (3) worked closely with agency officials to 

identify any data problems. When we found discrepancies (such as missing 

or invalid values), we brought them to VBA’s attention and worked with 

agency program and data specialists to correct the discrepancies before 

conducting our analyses. In some cases, we opted to limit our analysis to 

avoid using unreliable information. For example, because of persistent 

problems with data on terminated cases, we narrowed our scope to include 

only cases that were active as of the end of each fiscal year. In addition, 

because the data for fiscal years 2007 to 2010 lacked information on the 

disabling conditions for a large number of veterans from earlier periods of 

service, we limited our analysis of this information to veterans from the Gulf 

War period. Based on our assessment and steps taken to limit our use of 

problematic information, we determined the data were sufficiently reliable 

for the purposes of our report.

Reliability Assessment of 

VA Data on Enhanced 

Monthly Benefit Recipients
Appendix I: Objectives, Scope, and 

Methodology

Page 34 GAO-12-153 VA A&A and Housebound Benefits

We obtained summary-level data on the cost of noninstitutional care in all 

50 states and the District of Columbia from the MetLife Mature Market 

Institute’s 2010 Market Survey of Long-Term Care Costs and Genworth 

Financial’s 2010 Cost of Care Survey. Both studies report costs for each 

type of service provider at the state level and for some localities within 

each state. We limited our analysis to the three types of noninstitutional 

care reported in these studies: home care aides (or homemaker 

services), home health aides, and assisted living facilities. For home care 

aides and home health aides, we reported hourly rates.10 For assisted 

living facilities, we reported monthly rates.11

To assess the reliability of the data reported in these studies, we 

reviewed methodological documentation for both studies. We also 

interviewed knowledgeable individuals from each organization who were 

involved in the design and execution of the survey and analysis of the 

survey data. As a result of our work, we determined that the data were 

sufficiently reliable for our purposes.

To demonstrate how costs of obtaining services vary across the county, 

we reported the median cost for the three types of service providers in all 

50 states and the District of Columbia. While the Cost of Care Survey 

reported median costs for each type of service, we calculated the median 

costs using record-level data from the Market Survey of Long-Term Care 

Costs. We report the midpoint between the two median costs from each 

study. There was a small and methodologically immaterial difference in 

data we reported about the median hourly cost of home care aides in Los 

Angeles; the MetLife data represented Los Angeles and the Genworth 

data represented Los Angeles County.

 10The Cost of Care Survey reported annual rates for home care aides and home aides, 

based on 44 hours of care per week. We calculated an hourly rate from that to align the 

unit of time with comparable rates reported in the Market Survey of Long-Term Care 

Costs. 

11The Cost of Care Survey reported annual rates for assisted living facilities. We 

calculated a monthly rate from that to align the unit of time with comparable rates reported 

in the Market Survey of Long-Term Care Costs.

Analysis of Information on 

the Cost of Obtaining 

Services
Appendix I: Objectives, Scope, and 

Methodology

Page 35 GAO-12-153 VA A&A and Housebound Benefits

To help assess the role played by enhanced monthly benefits in helping 

veterans obtain needed services and the impact of VA outreach activities, 

we obtained views from veteran recipients or their designated family 

representatives through a series of six focus groups we conducted in 

September 2010. We conducted two focus groups in each of three 

locations—San Antonio, Texas; Saint Petersburg, Florida; and Norfolk, 

Virginia. These locations were selected because each provided a large 

pool of veterans who likely were receiving enhanced monthly benefits as 

part of their compensation or pension payments from which to draw focus 

group volunteers. To obtain information from focus group participants, we 

established a standard protocol to facilitate the discussions. We pretested 

the protocol to identify any needed changes before conducting the focus 

groups and one-on-one interviews.

We randomly selected enhanced monthly benefit recipients to participate 

in our focus groups using VA fiscal year 2009 data on recipients who lived 

in or around our three focus group locations. We obtained information 

from 33 veterans or their designated family representatives. To increase 

the number of responses from veterans or their representatives, we 

conducted phone interviews with veterans who could not attend a focus 

group. During these interviews, we covered the same topics discussed 

during our focus groups. In addition to the focus groups and one-on-one 

interviews, one veteran chose to provide written responses.

The characteristics of focus group participants varied widely. The age of 

participants ranged from 39 to 96 years of age, with an average age of 73 

years. Also, the veterans we contacted served in various war periods, 

including World War II, the Korean Conflict, Vietnam War, and the Gulf 

War. In addition, participants reported a variety of disabling conditions. 

Some focus group participants received enhanced monthly benefits as 

part of their pension and others as part of their compensation benefit 

payment. Table 2 summarizes characteristics of veterans we contacted.

Focus Groups and One-onOne Interviews with 

Recipients of Enhanced 

Monthly Benefits
Appendix I: Objectives, Scope, and 

Methodology

Page 36 GAO-12-153 VA A&A and Housebound Benefits

Table 2: Characteristics of Participants in Focus Groups and One-on-One 

Interviews

Characteristic Number of veterans

State of residence • Texas: 10

• Florida: 13

• Virginia: 10

Period of service • World War II: 10

• Korean Conflict: 5

• Vietnam War: 15

• Gulf War: 2

• Peace time era: 1

VBA benefit program 

enrollment

• Enhanced pension: 24

• Enhanced compensation: 9

Disabling conditions • Neurological conditions and convulsive disorders: 5

• Skeletal conditions: 5

• Cardiovascular conditions: 11

• Mental disorders and eating disorders: 6

• Genitourinary system: 2

• Digestive system: 4

• Respiratory system: 3

• Ear Conditions: 1

Source: GAO analysis of VBA data.

Each focus group covered several major topics, including VA outreach 

activities, processes for filing a claim for enhanced monthly benefits, 

services obtained as a benefit recipient, and recommendations for 

improving VA outreach practices, as well as veteran experiences in 

obtaining these benefits. A GAO facilitator led each discussion to keep 

participants focused on the specified issues within discussion time 

frames. With the consent of all focus group participants, we recorded 

each discussion and had each recording professionally transcribed.12

 12Information that could identify any participant was left out of the transcripts to protect 

participants’ privacy. 

The 

focus group discussion protocol was also used to guide one-on-one 

interviews. We summarized the information collected and identified 

common themes. While we identified a number of common themes 

across the six focus groups, our results cannot be generalized to the 

universe of veterans receiving enhanced monthly benefits.
Appendix II: Qualifying Periods of War for VA’s 

Pension Program

Page 37 GAO-12-153 VA A&A and Housebound Benefits

Note: Under 38 U.S.C. § 1501(4), the term “period of war” in reference to 

pension entitlement means all of the war periods listed in this appendix 

except the Indian wars and the Spanish-American War. Veterans of these 

two wars are still entitled to VA pension benefits under 38 U.S.C. §§ 1511 

and 1512, respectively.

Indian wars. January 1, 1817, through December 31, 1898. Service must 

have been rendered with the United States military forces against Indian 

tribes or nations. 

Spanish-American War. April 21, 1898, through July 4, 1902. If veterans 

served with the United States military forces engaged in hostilities in the 

Moro Province, the ending date is July 15, 1903. The Philippine 

Insurrection and the Boxer Rebellion are included. 

Mexican border period. May 9, 1916, through April 5, 1917, in the case 

of veterans who served in Mexico, on the borders thereof, or in the waters 

adjacent thereto.

World War I. April 6, 1917, through November 11, 1918. If veterans served 

with the United States military forces in Russia, the ending date is April 1, 

1920. Service after November 11, 1918, and before July 2, 1921, is 

considered World War I service if the veterans served in the active military, 

naval, or air service after April 5, 1917, and before November 12, 1918. 

World War II. December 7, 1941, through December 31, 1946. If the 

veterans were in service on December 31, 1946, continuous service 

before July 26, 1947, is considered World War II service. 

Korean Conflict. June 27, 1950, through January 31, 1955. 

Vietnam Era. The period beginning on February 28, 1961, and ending on 

May 7, 1975, in the case of veterans who served in the Republic of 

Vietnam during that period. The period beginning on August 5, 1964, and 

ending on May 7, 1975, in all other cases. 

Persian Gulf War. August 2, 1990, through date to be prescribed by 

Presidential proclamation or law.

Future dates. The period beginning on the date of any future declaration 

of war by Congress and ending on a date prescribed by Presidential 

proclamation or concurrent resolution of Congress.

Appendix II: Qualifying Periods of War for 

VA’s Pension Program
Appendix III: Comments from the Department 

of Veterans Affairs

Page 38 GAO-12-153 VA A&A and Housebound Benefits

Appendix III: Comments from the 

Department of Veterans Affairs
Appendix III: Comments from the Department 

of Veterans Affairs

Page 39 GAO-12-153 VA A&A and Housebound Benefits
Appendix III: Comments from the Department 

of Veterans Affairs

Page 40 GAO-12-153 VA A&A and Housebound Benefits
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 41 GAO-12-153 VA A&A and Housebound Benefits

Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov.

In addition to the contact named above, individuals making key 

contributions to this report were Shelia Drake, Assistant Director; James 

Bennett; Melinda Cordero; Mary Crenshaw; Alex Galuten; Isabella 

Johnson; Nelson Olhero; Kate Van Gelder; Walter Vance; and Mark Ward.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 42 GAO-12-153 VA A&A and Housebound Benefits

VA’s Fiduciary Program: VA Plans to Improve Program Compliance and 

Policies, but Sustained Management Attention is Needed. GAO-10-635T. 

Washington, D.C.: April 22, 2010.

VA’s Fiduciary Program: Improved Compliance and Policies Could Better 

Safeguard Veterans’ Benefits. GAO-10-241. Washington, D.C.: February 

26, 2010.

VA Health Care: Long-Term Care Strategic Planning and Budgeting Need 

Improvement. GAO-09-145. Washington, D.C.: January 23, 2009.

Veterans’ Benefits: Improved Management Would Enhance VA’s Pension 

Program. GAO-08-112. Washington, D.C.: February 14, 2008.

VA Long-Term Care: Service Gaps and Facility Restrictions Limit 

Veterans’ Access to Noninstitutional Care. GAO-03-487. Washington, 

D.C.: May 9, 2003.

Related GAO Products

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