Paying Family Caregivers through the Veterans Family Caregiver Program

Program of Comprehensive Assistance for Family Caregivers

The Program of Comprehensive Assistance for Family Caregivers (PCAFC) is for eligible Veterans who have incurred or aggravated a serious injury or serious illness in the line of duty on or before May 7, 1975 or on or after September 11, 2001. This program provides

• Online and hardcopy resources and phone counseling for veterans and their caregivers,
• Online and hardcopy education programs for veterans and their caregivers,
• Free support services from veterans health care including wheelchairs, ramps and other adaptive equipment,
• A financial stipend paid to the caregiver - including a spouse,
• Health insurance - if applicable - for caregivers and
• Beneficiary travel reimbursement - if applicable - for caregivers of eligible Veterans.

Starting on October 1, 2022, eligible Veterans who incurred a disabling illness or serious injury in the line of duty between May 7, 1975, and September 11, 2001 will also be able to enroll. This change will include all estimated 18 million living veterans in 2020. The number of participants in the PCAFC is expected to grow from 21,113 in 2020, to 43,328 in 2021, and to 51,645 in 2022. The number of CSP staff has increased to over 1,740 staff as of May 2021, which is over 90% of the Department's goal of 1,900 CSP staff system wide.

Veterans may be eligible for this clinical program if they sustained or aggravated a serious injury - INCLUDING SERIOUS ILLNESS - (disabling effects of the illness or injury need not manifest during service) in the line of duty on or before May 7, 1975 or on or after September 11, 2001; and meet both of the following criteria to be eligible for PCAFC. Among other applicable eligibility criteria, the Veteran must:

1. Have a single or combined service-connected disability rating by the Department of Veterans Affairs (VA) of 70% or more. This requirement is included in the definition of "serious injury;" and
2. Be in need of personal care services (requiring in-person personal care services) for a minimum of six continuous months based on either of the following:
- an inability to perform an activity of daily living (ADL) or
- a need for supervision, protection, or instruction.

We believe the estimates above for the number of participants in the future is way too low. Based on the liberal requirements from above for eligibility, the number of participants will probably be more in the hundreds of thousands in the future. By requiring only a 70% disability rating along with only one activity of daily living or cognitive impairment and allowing all veterans of any age to participate; as well as including serious illness as a way to get in, there will be many many more veterans applying than VA anticipates. Take for example these 3 of many presumptive conditions for agent orange such as parkinsonism, heart disease and diabetes. Most Agent Orange exposed veterans are in their middle 70s through early 80s in age. And there are millions of them. Many of them will have developed and many will have complications from diabetes, parkinsonism and heart disease which will likely allow them to meet the criteria of the caregiving program. And this is just one example.

Case Study Tying Together Special Benefits and the Caregiver Program

Description of This Case

This case study will illustrate how applying for the new caregiver program can also generate additional benefits for a veteran who qualifies for this benefit. This is a real case and we have the permission of the veteran to use his experience in helping other veterans apply for benefits. For ease-of-use we will call this veteran "Jim" even though that is not his real name.

Before application for the caregiver program, Jim was 100% service-connected disabled and in need of aid and attendance. He was receiving a monthly income under SMC Schedule L with a spouse, which in 2022 is $4,331.91. After a long process, Jim and his wife as caregiver were accepted into the caregiver program and after a year and a half of additional applications for other benefits as well as additional time for training the caregiver, his previous benefits were extended as a result of this process to include the following:

• Without his input or application he was given a rating increase to SMC Schedule R.1 which increased his VA compensation benefit to $8,499.39 a month, effectively doubling his income.
• His wife, who lives with him and takes care of him, is also being paid the highest monthly stipend as his caregiver at $2,660 a month. (See stipend explanation below)
• The prosthetics department and physical therapy department at his local regional medical center gave him a power wheelchair worth about $10,000 and installed ramps in his home to the outside for wheelchair access, all at no cost to Jim.
• The prosthetics department also preauthorized a HISA grant of $6,800 that he can apply for anytime in the future but that he currently does not need.
• Due to encouragement from his care program supervisor at his medical center, he was prompted to file an application for an SAH grant as well as for the automobile adaptation allowance.
• He was conditionally approved for an SAH grant which likely will be somewhere in the amount of $30,000-$40,000 to renovate his home for easier mobility
• He was approved to purchase a new mobility modified minivan that cost approximately $72,000, but after subsidies from VA healthcare and from the Veterans Benefits Administration, Jim's total out-of-pocket cost for the vehicle was around $17,000.

In order to understand and help other veterans with potentially similar benefits, we will provide further on the details of how Jim applied for all of the ancillary income and benefits listed above. This was probably a very special case where Jim had the right disabilities to qualify for all of the benefits that are available due to his disabilities. The only benefit which has not been applied for is the clothing allowance, but even though he would qualify due to the use of orthotics, Jim has decided not to apply for that. Not all applicants will be accepted and probably not that many applicants will get all of the benefits that Jim is receiving. On the other hand, there may be many veterans out there who definitely will qualify for some of the benefits that Jim is receiving.

Details of This Case

In 2020 the caregiver program was extended to veterans who were in service prior to 1975. Jim decided to apply in the summer of 2020. Since the program is administered through the Veterans Health Administration, any beneficiary of this benefit must be in the healthcare system. Jim was in VA healthcare and have been using specialists in the system for 20 years, however, he had not seen his primary care provider at the local VA healthcare location for many years. In order to be approved for the caregiver program, he needed an assessment and a prescription from his primary care provider. Because of COVID and the wait time for getting an appointment with his provider, it took a number of months before he could meet with his newly appointed primary care provider. And because of COVID the meeting was done virtually. His care provider did submit a prescription for the program and Jim was preapproved. This was in November 2020.

Next came a long process of assessment encounters for the need for a caregiver which was initiated by employees of the local VA Regional Medical Center. These individuals who work with the caregiver program are typically nurses and occupational therapists. Despite COVID some of the assessments were done through a home visit evaluation. But because of COVID most of the interviews were done online. If the virus had not been a factor, all of the assessments would have been done face-to-face in the home. In January 2021, Jim was officially accepted into the program with his wife as caregiver. In order to be paid her higher monthly stipend of a little over $2,600, she had to go through some rigorous online training. In addition, she had to set herself up as a VA vendor in order to be paid. Even though the instructions to become a vendor are furnished to the caregiver, be aware that it is an unnecessarily difficult and time-consuming process to do it correctly the first time.

After being accepted, Jim was encouraged to meet with a specialist in the physical therapy department at his local regional medical center for assessment of additional disability support. This resulted in the installation of wheelchair ramps, an expensive power wheelchair and further support if needed all at no cost to Jim. He was also encouraged to apply for the automobile adaptation allowance from Veterans Benefits Administration and the automobile mobility adaptation subsidy from Veterans Health Administration. We describe this process further on. Even though his contact with the prosthetics department assured him a HISA grant for $6,800 was forthcoming with a simple application, he was also encouraged to apply for an SAH grant that would pay more money than the HISA for home modifications up to a limit of $101,754.

The automobile allowance from VBA of $22,355.72 and the mobility equipment subsidy from VHA were both approved in a VBA rating decision issued August 19, 2021. Jim was directed to purchase an approved minivan model with the appropriate mobility adaptations on the private market. He found a 2020 low mileage Toyota Sienna which was the one of the manufacture and model on the approval list and which had the newly installed approved adaptations. The cost was a little over $72,000 which included the adaptation cost. The vehicle was adapted with a side door wheelchair ramp, removal of the center row of seats and a locking device on the bed of the vehicle for the wheelchair similar to a fifth wheel engagement for an RV hitch. The passenger seat had been renovated with a so-called 6 way transfer modification which motorized the seat to move backward and forward, up-and-down and swivel in order for Jim to slide from his new wheelchair to the passenger seat and then reposition himself as a passenger.

As of January 2022, the SAH grant has been given a conditional approval pending bids from 3 contractors which then will be considered for final approval. The bidding is currently in process to completely gut and rebuild and convert his bathroom with a roll in shower, wider doorway, floating vanity, wall and ceiling tile and so forth for wheelchair access. In addition, a hard surface floor will be installed throughout the home for wheelchair maneuverability. Additional mobility modifications are also included. He currently has a bid for $38,700 for the remodel and is awaiting more bids for the final submission.

Caregiver Program Application Requiring Approval from VHA Care Program Specialists
Jim initiated a joint application for the Program of Comprehensive Assistance for Family Caregivers using VA Form 10-10CG for him and his wife in the summer of 2020. After months of home visit assessments as well as online assessments, final determination and caregiver training for his wife, the program was started officially in March 2021. His wife was given instructions to set up as a VA vendor and this took several months to set up and for her back payments to come through. She is being paid at the higher level of caregiver's stipend using the government wage scale of GS-4, step 1, for a full-time government employee in her geographic area. However, because this is an extension of VA benefits, her income is not taxable.

Here are the rules for becoming a caregiver and qualifying for the monthly caregiver's stipend. A qualifying caregiver must be:

• at least 18 years of age
• the eligible veteran's spouse, son, daughter, parent, stepfamily member, or extended family member; or
• someone who lives with the eligible Veteran full-time or will do so if designated as a family caregiver.
• initially assessed by VA as being able to complete caregiver education and training.
• able to to carry out the speci?c personal care services, meet core competencies, and provide additional care requirements if needed.

The qualifying veteran must be eligible for or receiving disability compensation and in addition:

The veteran has a single or combined service-connected disability rating by the Department of Veterans Affairs (VA) of 70% or more. and be in need of personal care services (requiring in-person personal care services) for a minimum of six continuous months based on either of the following:

• an inability to perform an activity of daily living (ADL) or
• a need for supervision, protection, or instruction.

The "inability to perform an ADL" means the Veteran or service member requires personal care services each time he or she completes one or more of the ADLs listed below.

• Dressing or undressing oneself
• Bathing
• Grooming oneself in order to keep oneself clean and presentable
• Adjusting any special prosthetic or orthopedic appliance, that by reason of the particular disability cannot be done without assistance (this does not include the adjustment of appliances that nondisabled persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.)
• Toileting or attending to toileting
• Feeding oneself due to loss of coordination of upper extremities, extreme weakness, inability to swallow, or the need for a non-oral means of nutrition
• Mobility (walking, going up stairs, transferring from bed to chair, etc.)
• Requiring assistance with an ADL only some of the time does not meet the definition of an "inability to perform an ADL."

A "need for supervision, protection, or instruction" means the Veteran or service member has a functional impairment that directly impacts the ability to maintain his or her personal safety on a daily basis.

An eligible Primary Family Caregiver, may qualify to receive a monthly stipend paid at one of two levels. These stipends are not treated as taxable income. The level of stipend depends on whether the veteran meets any one or all all seven eligibility requirements listed on the previous page, and whether or not the veteran is "unable to self-sustain in the community."

Level One: If VA determines that a Veteran is NOT "unable to self-sustain in the community" the designated Primary Family Caregiver will receive the lower-level stipend payment.

Level Two: If VA determines the Veteran is "unable to self-sustain in the community" the designated Primary Family Caregiver will receive the higher-level stipend payment. "Unable to self-sustain in the community" means that an eligible Veteran either:

Requires personal care services each time he or she completes three or more of the seven activities of daily living (ADL) listed in the de?nition of an inability to perform an activity of daily living in this section, and is fully dependent on a caregiver to complete such ADLs; or has a need for supervision, protection, or instruction on a continuous basis.

For an eligible Veteran who is determined NOT to be "unable to self-sustain" in the community, the Primary Family Caregiver's stipend amount will be 62.5% of the monthly stipend rate. For example, the GS rate at Grade 4, Step 1, in Dallas, Texas, for 2020 is $33,638 annually. Thus, the monthly stipend amount for a primary family caregiver of an eligible veteran in Dallas, Texas, at this rate (62.5%) of $33,638 will be approximately $1,751.98.

For an eligible Veteran who is determined to be unable to self-sustain in the community, the Primary Family Caregiver's stipend amount will be 100% of the monthly stipend rate. For example the GS rate at Grade 4, Step 1, in Dallas, Texas, for 2020 is $33,638 annually. The 2020 monthly stipend amount for a Primary Family Caregiver of an eligible Veteran in Dallas, Texas, at this rate (100%) of $33,638 will be approximately $2,803.17.

SAH Grant Application Which Requires a Rating Decision from VBA

Jim filed VA form 26-4555 in May 2021 to start the process for renovating his home to accommodate his disabilities. At the same time, he also submitted an application for the automobile adaptation allowance. Both of these benefits require a disability compensation rating decision from the Veterans Benefits Administration. In other words, these benefits are not available unless the veteran is receiving disability compensation. In July 2021, VA ordered a C & P exam through one of their regular contract examiners in Jim's area. This is because Jim's original disability rating decision was over five years old and that rating decision did not consider he might be eligible for the special benefits for which he applied over five years later.

We need to note here that some initial rating decisions will automatically include approval for special benefits if the rating computer in the regional office spits out these results. Here is an important consideration for anyone NOT receiving approval for special benefits with an initial application for compensation. Just because an original rating decision does not include approval for these benefits, it does not mean that the veteran is barred from applying for special benefits after he or she is on claim. Jim's case is a good example of this. This anomaly in the system might be why so few veterans are receiving special benefits from VA.

Here is the rating decision that Jim received concerning both of his claims for special benefits:

August 19, 2021
(veterans address)

We made a decision on your VA benefits.

Dear (veterans name):

This letter will guide you through the information you should know and steps you may take now that VA has made a decision about your benefits.

We are returning VA Form 21-4502, Application For Automobile or Other Conveyance And Adaptive Equipment. We have determined the eligibility, and completed Section II for you. You may now purchase a vehicle, and adaptive equipment from the seller, and complete section ll. Please see page three and four of the complete form for extensive details.

Your Benefit Information:

• Entitlement to specially adapted housing is established.
• Entitlement to special monthly compensation based on loss of use of both feet is granted from June 3, 2021.
• Entitlement to an allowance for an automobile or other conveyance and adaptive equipment is established.

This new rating decision also resulted in a reassessment of Jim's monthly compensation benefit income. It appears the input from the VA examiner and the subsequent decision from the rating computer in the regional office, increased Jim's Special Monthly Compensation benefit from Schedule L at $4,331.91 to SMC Schedule R.1 which increased his VA compensation benefit to $8,499.39 a month, effectively doubling his income. Jim did not ask for this rate increase. It was handed to him a automatically as a result of the P&C exam required for the special benefits.

Automobile Adaptation Allowance Application Requiring a Rating Decision from VBA
Jim applied for the automobile adaptation allowance in May 2021 using VA form 21-4502. For qualifying veterans, the Veterans Benefits Administration (VBA) will pay the automobile allowance towards the vehicle cost of a suitable new or used vehicle that has been adapted for disability or mobility access or will be adapted for this use. Adaptations can include installation of a wheelchair ramp, wheelchair locking device, six way transfer seat for either the driver or the passenger who is disabled, special operating controls for the disabled driver and any other features that are necessary to operate the vehicle. In Jim's case, VBA paid $22,355.72 to the dealer towards the cost of Jim's new vehicle.

Automobile Mobility Adaptation Requiring Approval from a VHA Adaptation Specialist
Jim's application for the automobile adaptation allowance and approval through a new rating decision addressed above, also triggered a response from Veterans Health Care through the local regional medical center prosthetics department. The healthcare side of the Department of Veterans Affairs will pay the cost of modifying a vehicle for mobility access. If the vehicle is already modified, the subsidy will be prorated based on how old the modification is and in some cases if the modification is too old, nothing will be paid. However, for qualifying veterans, healthcare will pay the full cost of a brand new modification. Sometimes this can be as much as $20,000-$40,000. In Jim's case, veterans health care paid a little over $32,000 for the cost of newly renovating Jim's new vehicle for accessibility. His total out-of-pocket cost including sales tax for the low mileage 2022 minivan, after both subsidies from VBA and from VHA, came to around $17,000. This as compared to the total cost of the vehicle of a little over $72,000 with the new mobility modifications.