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What are Pension Aid and Attendance and Housebound Ratings?

A "rating," in relation to Pension, from VA recognizes either the claimant's regular need of aid and attendance from a caregiver or the condition of being housebound.

This medical rating, determined by a doctor's examination, made on VA Form 21-2680, then allows certain medical and care expenses (like assisted living or home care) and ancillary non-medical expenses to be subtracted or deducted from income. A medical need for assistance or supervision due to disability is, in many cases, crucial to getting the Pension or Survivors Pension benefit or not getting it.

Except for very poor veteran households, most veteran households could not get the Pension benefit without this special rating provision for the deduction of personal care and medical-related expenses, simply because their income is too high.

The high cost of medical and medical-related expenses associated with long term care such as home care, assisted living or nursing home care are usually the main deductible expenses VA counts when calculating the benefit. A single veteran, for example, who is paying $3,000/month for care at assisted living and has income of $2,800/month would qualify for the full Pension benefit with the aid and attendance allowance of $1,911 a month IF that veteran was "medically rated" for the need of aid and attendance of another person.

There is a rule that applies to assisted living where lodging and meals in assisted living can also become deductible medical expenses, not only with a rating for aid and attendance, but also with the need for custodial care. The definition of custodial care is very similar to the rules for a rating for aid and attendance. The difference is that without the aid and attendance rating, the Maximum Allowable Pension Rate (MAPR) is much smaller. So under the example in the previous paragraph, where the rating for aid and attendance allowed a maximum monthly benefit of $1,911 a month, the lack of need for custodial care would only generate a maximum benefit of $1,127 a month.

Unfortunately, not all eligible claimants – especially aging claimants – are receiving Pension or Survivor Pension. Most do not know about the benefit or this special medical deduction to reduce income. Often one of these unknowing claimants will call VA or go to a local veteran's service officer for assistance and they will be asked what their income is. In many cases, the service representatives are not aware of or do not discuss the special rules allowing for reduction of income due to medical costs. If potential claimants have an income greater than the MAPR for their rating category, they often will be told that they do not qualify.

We run across people all the time who have been told that they don't qualify when they actually do because of bad information from veterans service representatives. Because of this lack of training with VA employees and service officers who assist with Pension, most of the claimants receiving benefits are receiving it based on low income only.

Without aid and attendance or housebound ratings, there are typically no large medical deductions present. In addition, without the ratings, the MAPR is much lower, resulting in a much smaller benefit or resulting in no benefit at all.

For applications that include a rating for aid and attendance, the MAPR is much larger and in addition the gross household income can be substantially more than the MAPR and still result in a benefit. This is because having an aid and attendance rating is usually a result of needing long term care in the home, in assisted living or in a nursing home. These care costs are usually quite large and result in substantial medical deductions from income.

The aid and attendance or housebound ratings also are necessary in order to deduct certain medical expenses. Without the medical deductions from an aid and attendance rating, it is unlikely for the IVAP to large enough to generate any pension income. Thus, the difference between MAPR and IVAP might be only a few hundred dollars a month. Or the IVAP may not be enough to reduce the income below the MAPR and thus there is no benefit at all.

For example suppose that a single veteran claimant has a medical rating for aid and attendance and has household income of $4,000 a month which is substantially more than the MAPR of $1,911 a month for this particular claims category. In order to generate any pension benefit at all, the income adjusted for medical expenses must be less than $1,911. There is no way that this applicant could qualify based on income alone and without a rating and the subsequent medical deductions, in this particular case, he could not reduce his income without those costs.

However, the applicant also has $3,500 a month in deductible medical costs due to being in an assisted living facility and receiving assistance with showering and dressing. This assistance triggers a rating for aid and attendance which in turn allows for the MAPR of $1,911 a month. Without this rating, the MAPR is much smaller. Converting everything to an annual basis and calculating for the benefit, results in a monthly benefit of roughly $1,354 a month.

What is notable here is with large medical deductions – usually associated with a rating for aid and attendance – household income can be substantially higher than the MAPR and still result in a benefit. This is not true for those applicants who are applying based on income only.

Criteria for Determining a Need for "Aid and Attendance"

VA's criteria for evaluating the claimant's need for "Aid and Attendance" or being "Housebound" are outlined in 38 CFR Part 3. Below is an excerpt of the criteria for aid and attendance.

38 CFR § 3.352 Criteria for determining need for aid and attendance and "permanently bedridden."

Basic criteria for regular aid and attendance and permanently bedridden. The following will be accorded consideration in determining the need for regular aid and attendance:

  • inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable;
  • frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.);
  • inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness;
  • inability to attend to the wants of nature;
  • or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment.
  • "Bedridden" will be a proper basis for the determination (need for aid and attendance). For the purpose of this paragraph "bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.

It is not required that all of the disabling conditions shown above be found to exist before a rating may be issued. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary the evidence establish that the veteran or surviving spouse is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran or surviving spouse is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance.

VA's Interpretation of 38 CFR 3.352

We have taken rules from 38 CFR §3.352 and applied them to a practical interpretation of what the Rating Officer in the Regional Office is looking for in order to make determination for a rating. Here is our list based on our experience with the Regional Offices.

  1. Assistance with bathing or showering
  2. Assistance with toileting and incontinence
  3. Assistance with feeding (having a need to be fed by someone else)
  4. Assistance with dressing or undressing
  5. Assistance with transferring in or out of a bed or chair, ambulating, and/or walking
  6. Assistance with keeping oneself ordinarily clean and presentable, including hygiene issues
  7. Assistance with frequent need of adjustment of special prosthetic or orthopedic devices which cannot be done without the aid of another person
  8. Having an incapacity (physical or mental) requiring care or assistance on a regular basis to protect the patient from hazards or dangers incident to his or her daily environment
  9. Is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less in both eyes
  10. Is a patient in a nursing home because of mental or physical incapacity
  11. Meets the criteria of being totally bedridden as defined in the regulation

As mentioned in the regulation, there does not need to be a certain number of these incapacities in order to determine a rating for aid and attendance. The rating service representative simply must determine from the evidence whether the claimant is so helpless as to require the regular aid and attendance of another person based on one or more of these conditions.

From our experience with the rating activity, the individual applying should exhibit the need for and be receiving at least two or more of the services from #1 through #7 above. If #8 through #11 are more relevant, only one of these need apply.

The Housebound Rating

This will be the only instance on this website where we discuss the relevance of having a "housebound rating." Essentially, being housebound means the claimant is substantially confined to his or her residence. The living arrangement can be a personal residence, assisted living, a nursing home or any other similar institution. This does not mean applicants need to be imprisoned in their living arrangement. They can be allowed to leave the residence for purposes of doctors' visits or other necessary services, if accompanied.

As a general rule, we hardly ever see a rating for housebound. This is because people who are housebound are just as likely to need the aid and attendance of another person and there would be no need for the housebound rating as the MAPR for housebound is a lesser amount. This does not mean that a housebound rating is of no use. If a claimant is applying for Pension based on a very low income and indeed has few medical deductions to offset income, and the claimant could qualify for a housebound rating, then the MAPR for this rating is a larger amount than the basic MAPR and would result in a larger partial benefit.

Examples of the Importance of a "Rating" when Deducting Expenses

A medical or disability rating for "Aid and Attendance" or "Housebound" is not only important in producing a larger possible Pension income – due to the MAPR with a larger rating allowance – but also in receiving credit for unreimbursed medical expenses (UMEs). A list of allowable medical expenses is provided further on.

For example, a veteran in independent living who is there primarily for retirement and social interaction and not because of the need for assistance could not apply his or her room and board costs towards reduction of his or her income. VA would not allow these expenses without a rating. On the other hand, with a rating for "Aid and Attendance", the cost of food and lodging is deductible from income, so long as the care involves 2 or more activities of daily living and the other specific criteria for medical deductions in independent living are met.

Here is another example for someone receiving care at home. Without the additional disability ratings, the only recurring medical costs the claimant is allowed to count as unreimbursed medical expenses (UMEs) are those paid to licensed health professionals providing care in the home. With a rating for "Aid and Attendance," the veteran's payments to unlicensed caregiver attendants such as children, friends, church members or neighbors would be considered UMEs by VA. it should be noted that payments to a spouse for care are not recognized even though they reduce income, because the payments also represent income so it's just a matter of shifting money from one pocket to another within the same household. Unfortunately, the deduction doesn't work for paying a spouse.

If the disabled veteran has been rated "Housebound" or in the need of "Aid and Attendance," VA will allow deduction of all fees paid to a non-licensed in-home attendant as long as the attendant provides what VA calls "custodial services" for the disabled person. In this case this means assistance with 2 or more Activities of Daily Living (ADLs). As an example, helping the care recipient shower and dress would be considered counted as two ADLs and allow for the medical deduction.

Triggering the rating with ADLs now allows deduction of all services offered. This expanded deduction for care may include payments for services such as cooking, laundry, transporting, medical medications, answering the phone, paying bills, housecleaning and so on so long as two ADLs are part of the care.

Certain medical expense deductions require distinguishing persons who are and who are not eligible to be rated for aid and attendance or housebound. For Pension, veterans and surviving spouses may be rated for aid and attendance or housebound. Spouses of living veterans or children or any other relative who is a member or constructive member of the household may not be rated for aid and attendance or housebound. This same rule applies to dependents of surviving spouses as well. There are some special rules for these non-rated people that allow for medical deductions in lieu of the rating for aid and attendance.

Please refer to the table of contents in the top right column of this page for more topics on Pension with Aid and Attendance.