Families often assume VA long term care is a single program with a single waiting list. It is really a set of programs across three settings, with one bright legal line running through them: at 70 percent service connected or higher, VA must provide nursing home care (38 USC 1710A), while below that line the local medical center has discretion. Knowing which side of the line the veteran sits on changes the entire conversation with the social work team.
Overview
When a veteran becomes seriously ill or reaches end-of-life care, several different VA programs can pay for nursing home, in home care, or hospice care. Most families never learn which program applies until they are already in the middle of a crisis. This article walks through what each program covers, who qualifies, and how to get the veteran enrolled.
This is educational. For a specific situation, contact the VA Geriatrics and Extended Care office at the local VA Medical Center, or a VA social worker.
What "long term care" means at VA
VA divides long term care into three settings:
- VA Community Living Centers (CLC), the VA's own nursing homes, located on or near VA medical centers.
- Contract or community nursing homes, private nursing homes that VA pays through a contract.
- In home and outpatient programs, including Home Based Primary Care, Homemaker / Home Health Aide, Adult Day Health Care, Medical Foster Home, and Veteran-Directed Care.
Plus hospice (end-of-life care), which can be provided in any of the three settings.
Source rules:
- 38 USC 1710 (Eligibility for VA health care)
- 38 USC 1710A (Nursing home care)
- 38 CFR 17.46 to 17.49 (Nursing home and hospice eligibility)
- 38 CFR 17.34 (Eligibility for VA hospital and outpatient care)
Who qualifies for VA-paid nursing home
VA nursing home care is mandatory (VA must provide it, subject to availability) for veterans in two categories:
- The veteran has a service connected condition rated 70 percent or higher.
- The veteran needs the nursing home care for treatment of a service connected condition.
These veterans receive VA-paid nursing home care at any of the three settings (CLC, contract nursing home, or in home program).
VA may (but is not required to) provide nursing home care for veterans in other categories, subject to local availability:
- Veterans with a service connected rating below 70 percent.
- Veterans without a service connected rating who meet enrollment criteria for VA care (income-based or special enrollment categories).
- The community nursing home option requires the local VAMC to have a contract with the facility.
How to get into a CLC
The application process is initiated through the VA social work team at the local VAMC.
- The veteran's primary care provider at the VA refers the veteran for a long term care assessment.
- A VA social worker reviews medical, financial, and family-support history.
- If a CLC bed is available locally and the veteran's clinical needs match the CLC's capability, the veteran is admitted.
- If a CLC bed is not available locally, the social worker explores the contract community nursing home option or the in home program options.
For service connected 70 percent and higher veterans, VA must arrange care. For lower-rated veterans, the local VAMC determines what care is available based on resources.
How VA pays the nursing home
For VA-paid nursing home care, the veteran does NOT pay out of pocket for the room, board, and nursing services. VA pays the facility directly.
When the veteran has Medicare coverage and is in a contract nursing home, Medicare may pay for the first 100 days of skilled nursing facility (SNF) care under Medicare Part A. After Medicare benefits exhaust, VA pays the remainder.
When the veteran has private long term care insurance, the insurance generally pays first. VA coordinates.
What VA hospice covers
Hospice is end-of-life palliative care. VA hospice services include:
- Pain and symptom management.
- Emotional and spiritual support for the veteran and family.
- Bereavement support for the family after the veteran's death.
VA hospice is provided in any of the three settings:
- Inpatient hospice at a CLC.
- Inpatient hospice at a contract hospital or hospice facility.
- Home hospice, with VA-coordinated nursing visits and pain management.
VA hospice is available to any enrolled veteran who is certified by a physician as having a life expectancy of 6 months or less. There is no service connection requirement for VA hospice.
Source rules:
- 38 USC 1710 (Hospice care, generally)
- 38 CFR 17.46 (Hospice eligibility)
- VA Hospice and Palliative Care Program (national policy)
How VA hospice interacts with Medicare hospice
A veteran enrolled in Medicare Part A who elects Medicare hospice benefit is covered by Medicare for hospice. VA hospice is also available. The veteran picks one (or coordinates).
In practice:
- If the veteran is at home and the family wants hospice services delivered through the VA system, the VA team coordinates with home health agencies that VA contracts with.
- If the veteran is at a CLC, hospice is integrated into the CLC care.
- If the veteran is in a Medicare-certified hospice agency, Medicare pays the agency directly. VA does not pay double.
In home care programs
For veterans who do not need nursing home placement but who need help to remain at home, VA offers:
- Home Based Primary Care (HBPC): VA medical team visits the veteran at home. Available to veterans with complex medical needs.
- Homemaker / Home Health Aide: Personal care services (bathing, dressing, meal preparation) provided in the home, contracted by VA.
- Veteran-Directed Care: The veteran (or family caregiver) receives a flexible monthly budget from VA and hires personal care attendants directly.
- Adult Day Health Care: The veteran attends a daytime program at a contracted center, then returns home.
- Medical Foster Home: The veteran lives in a private home with a caregiver who is contracted by VA. The veteran pays room and board out of pocket; VA pays the caregiving services.
Each program has its own eligibility criteria. The starting point for any of them is a VA social work consultation at the local VAMC.
Aid and Attendance pension and these programs
The VA Pension Aid and Attendance benefit (for the veteran or surviving spouse, depending on circumstances) is a CASH benefit. It is paid directly to the recipient, who then uses it to pay for in home care or assisted living.
This is different from the in-kind programs (CLC, contract nursing home, in home programs). Some families use A&A pension to pay for care that VA itself is not providing.
A&A pension and VA-paid nursing home care can coexist when the veteran is in a non-VA facility paid by A&A pension. A&A pension does NOT continue at the same level when VA is paying for the nursing home care directly.
How to apply for any of these
- Start with the local VAMC's social work team or the VA Geriatrics and Extended Care line.
- The social worker will assess the veteran's clinical needs and the family's situation.
- The social worker will recommend the right combination of in home, outpatient, and inpatient services.
- For nursing home care at a CLC, the social worker initiates the referral.
- For contract community nursing home, the social worker arranges the placement at a contracted facility.
The intake process is typically 1 to 3 weeks for in home programs, and 4 to 8 weeks for CLC placement, depending on bed availability.
Common misunderstandings
- VA hospice and Medicare hospice are not the same. Both exist. The family picks one.
- VA nursing home care is mandatory at 70 percent SC and higher. It is not mandatory at lower ratings, even when the family needs it. The local VAMC has discretion.
- VA paid in home care does not include 24-hour live-in care. For 24-hour at-home care, families typically combine VA programs (HBPC + Homemaker hours) with privately-paid caregivers, or look at the Medical Foster Home option.
- The Aging Veteran Initiative and similar specialty programs require veterans to enroll in VA care first. Walk-in long term care without VA enrollment is not available.
Sources
- 38 USC 1710 (VA medical care eligibility)
- 38 USC 1710A (Mandatory nursing home care for 70 percent SC and higher)
- 38 CFR 17.46 to 17.49 (Nursing home and hospice eligibility)
- 38 CFR 17.34 (VA hospital and outpatient care eligibility)
- VA Geriatrics and Extended Care page (va.gov/geriatrics/)
- VA Community Living Centers page (va.gov)
- VA Hospice Care page (va.gov/geriatrics)
- VA Medical Foster Home program page (va.gov)
Related articles
- Aid and attendance for veterans: the benefit that often pays for this level of care.
- The caregiver program (PCAFC): support while care is still happening at home.