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November/December 2022 -   -  


Chuck Byers, the Chair of VVA’s Veterans Health Care Committee, recently sat down for a Zoom question-and-answer session with Dr. Colleen Richardson, director of Caregiver Support for the VA, about the caregiver provisions of the VA MISSION Act of 2018. What follows are excerpts from that conversation.

Chuck Byers: Is the 70 percent service-connected threshold for eligibility for caregiver support under the MISSION Act a regulatory rule?

Dr. Colleen Richardson: Yes. There are two things to keep in mind. First, you need personal care service for one or more ADLs [Activities for Daily Living] for six months or longer. This pertains to neurological conditions: mental health issues; traumatic brain injuries; and supervision, protection or instruction. Statutorily speaking, you need one or more.

The other one is for three or more of the ADLs each time that activity of daily living is performed.

BYERS: If, for example, I can sort of put on my shirt, but I can’t put on my pants to dress, would I qualify for caregiver benefits?

RICHARDSON: Potentially, yes. Those are looked at as upper dressing and lower dressing, so if you need assistance each time that activity of daily living is performed, you potentially could qualify for the program of comprehensive assistance.

BYERS: What happens if I go into hospice? Am I still eligible for the caregivers support program?

RICHARDSON: We have had veterans become very ill very quickly in our pre-1975 cohort. And so we try to get those applications expedited as quickly as possible before veterans need to go into hospice, and especially if the veteran can remain in their home. We’ve done some in four days or less. Not everybody can, but we try to expedite those so that they can remain in their homes and we can support that from the caregiver standpoint.

BYERS: As Vietnam War veterans age, our caregivers are a little bit older, too. That’s why it’s important that we have a primary and a secondary caregiver, but it’s also true that the private stipend is paid only to the primary, correct?

RICHARDSON: That is correct. The primary family caregiver is the only one who receives the stipend and the benefits. That includes beneficiary travel or CHAMPVA, if qualified.

BYERS: Are there other benefits for the secondary caregiver?

RICHARDSON: Yes. We provide caregiver counseling and education.

BYERS: If I get denied for caregivers, does VA explain why? In the past, we would just get a letter saying you don’t qualify. Has that changed?


We’ve heard a lot of feedback, including from VSOs, as well as caregivers and our own staff, that the letters that we’ve mailed aren’t specific about the reason why veterans or caregivers were denied access to the program or eligibility. So we’ve revised that letter. When a letter goes out, veterans and caregivers are notified of the exact reason with all the specificities, including evidence that we use to render that decision.

BYERS: Say I’ve gotten denied. I get a letter, but I can’t appeal. Do I go through a clinical appeal or do I file directly?

RICHARDSON: Great question. There are multiple options now available to veterans and caregivers who otherwise disagree with the decision at any point during the process. So we encourage — we cannot mandate — but we really encourage everyone, if they have not exhausted the VHA clinical appeals process, to make sure they do so.

Let’s say, for example, I met VISN ‘A,’ and VISN ‘A’ says “Dr. Richardson you’re denied,” and I disagree with that. I can go to my local patient advocate and appeal that decision in writing. Then go to VISN ‘B’, and VISN ‘B’ will take a look. And those decisions are all happening in 17 days or less. We have an overturn rate of about 13 percent.

Now, if VISN ‘B’ says “Nope, we agree with VISN ‘A,’ and we’re upholding that decision,” then you get a second look. You can disagree with VISN ‘B’ and ask for VISN ‘C’ to take another look, and again, those decisions are happening in 30-45 days. So we encourage folks to start there.

Beyond that, there are other options. They can file a higher-level review. Any time a veteran or caregiver receives a decision in our program today, the additional forms that they need to file an appeal through higher-level review or supplemental claims are now embedded in the letter so that they can get that information.

They can also go to the Board of Veterans Appeals, giving them [several] appeal and review options – the VHA clinical appeals process, higher-level reviews, supplemental claims. Or they can go straight to the board. But they should know that once it goes to the board, that is the final decision.

BYERS: So it probably would be best to go through the clinical appeals process first?

RICHARDSON: Yes, absolutely. That’s what we encourage folks to do.

BYERS: A lot of veterans haven’t been able to get into the program. So it’s important to know if there will there be some changes down the road.

RICHARDSON: I think it’s all a possibility. Coming into this program, and taking over about 17 months ago, the regs were already in play. So this last year has afforded me an opportunity to evaluate the regulations and the statutory criteria and their impact on veterans and caregivers.

I’m a post-9/11 veteran. I served in Iraq with the 1st Marine Division. So when I think about my cohort of veterans, we have a very different and unique need for caregiving. We’re looking at the catastrophically wounded, severe traumatic brain injuries, those with severe mental health illnesses and injuries. The pre-1975s, your population, has a very different and unique caregiving need.

We’re only now starting to understand those caregiving needs. And so when you look at activities of daily living for our pre-1975 veterans and compare them to our post-9/11 veterans, they don’t look the same at all. Same thing with supervision, protection, and destruction.

Our pre-1975 veterans are experiencing neurological conditions such as multiple sclerosis and Alzheimer’s dementia; our post-911 veterans have severe traumatic brain injuries from blast injuries. [The question is]: How do the regulations today take care of our pre-1975 veterans, yet still take care of our post-911 veterans?

And now we’re expanding yet again to a very different generation of Gulf War veterans. I guarantee you, we’re going to see even different needs coming out of that cohort of veterans too.

So yes, ADLs are up for consideration. Operational processes are also up for consideration.

BYERS: So if I apply to the program and I am denied, what is your team doing?

RICHARDSON: We have a duty to assist and make sure that your needs are being met. So what we’re implementing are several different things with Geriatrics and Extended Care, working with care management and social work to look for a true warm handoff, not just “here’s a phone number, go ahead and call.”

I don’t want to transfer people to nine different folks. I want to walk you in, let me do a warm handoff and make sure you get a caregiver. If you identify as a veteran who has caregiving needs, I want to make sure you really, really get what you need. You need good care.

BYERS: If I am not eligible for a particular caregiver, but I may be eligible for another program — will the VA explain what my options are?

RICHARDSON: Absolutely. That is the intent. That is what we’re working toward today, to make sure folks know if they are eligible for a homemaker, home help aide, or for respite care and any other benefits.

We’ve created a fact sheet, that we’re working on to figure out if we can take that sheet and also embed it in the denial. So not only will a social worker verbally inform you of that, but now you’re going to get something mailed to you that say, gives you a phone number and a web address that lets you know, here’s what’s available to you. That is the plan as we move forward.

BYERS: Dr. Richardson, thank you for sharing this with us. Is there anything that you feel that we can do to get this information out, so that we can be prepared and not just say, “Oh, we just got denied?”

RICHARDSON: I appreciate the opportunity to speak with you. I think it’s important for veterans and caregivers to give us an opportunity. If we make a mistake, realize that we’re not perfect, we are human, so give us an opportunity to correct mistakes and appeal your decision so we can take second looks. We’re going to keep pushing forward.




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