VA Pensions – Aid and Attendance and Housebound Ratings

Jun 10, 2024

I discussed the basics of the U.S. Department of Veterans Affairs (“VA”) pension benefits program (collectively “VA Pension Benefits”) in a prior article.[1] In that article, I alluded to additional benefits available to those that meet the requirements for Aid and Attendance or Housebound. If you have not read that article yet, I strongly encourage you to do so before tackling this article since an individual must meet requirements to be eligible for the basic VA Pension Benefits (with a few modifications, as discussed below) before possibly qualifying for the additional Aid and Attendance or Housebound benefits. Those eligibility requirements are discussed in my prior article.

In the VA context, “Aid and Attendance” and “Housebound” are medical ratings and correspond to numerous VA programs, including pensions, disability compensation, and dependency and indemnity compensation. All references to “Aid and Attendance” and “Housebound” in this article are specifically addressing those ratings in the context of VA Pension Benefits. Obtaining an Aid and Attendance rating entitles Veterans and their surviving spouses to additional financial benefits to assist them with the activities of daily living and to maintain a good quality of life. As discussed below, these activities include items such as bathing, grooming, dressing, and toileting. Obtaining a Housebound rating likewise provides additional financial benefits to permanently disabled Veterans and surviving spouses so that they can receive the care they need while they are confined to their homes. Importantly, an individual cannot receive additional benefits by qualifying for Aid and Attendance rating and Housebound rating together, even if they met the requirements for both.

Additional Benefits

Similar to my prior article on the basic VA Pension Benefits, we will begin with a discussion of the additional pension benefits provided for individuals that have an Aid and Attendance or Housebound rating. As a refresher, the maximum annual pension rate (“MAPR”) is the maximum VA Pension Benefits an individual can receive in a given year. The MAPR varies based on whether the individual is a veteran, surviving spouse, or dependent child, and is increased based on how many dependents the individual has. These base amounts adjust each year for inflation. Additionally, the MAPR is reduced dollar for dollar for every dollar of income for VA purposes (“IVAP”) that the individual has.[2] As such, a significant portion of planning for VA Pension Benefits revolves around reducing an individual’s IVAP. A discussion of those planning strategies is beyond the scope of this article.

Obtaining a rating for either Aid and Attendance or Housebound increases the MAPR for a given individual. Thus, they increase the maximum amount of cash benefits that a beneficiary of a VA Pension Benefit can receive. The following charts summarize the various MAPRs for those eligible for basic VA Pension Benefits, with a Housebound rating, and with an Aid and Attendance rating.

Basic VA Pension MAPRs
Veteran with no dependents	$16,551
Veteran with at least one dependent	$21,674 (increased by $2,831 for each additional dependent)
Surviving Spouse with no dependents	$11,102
Surviving Spouse with at least one dependent	$14,529 (increased by $2,831 for each additional dependent)
A qualified surviving child	$2,831

Housebound MAPRs
Veteran with no dependents	$19,598
Veteran with at least one dependent	$24,562 (increased by $2,831 for each additional dependent)
Surviving Spouse with no dependents	$13,568
Surviving Spouse with at least one dependent	$16,989 (increased by $2,831 for each additional dependent)

Aid and Attendance MAPRs
Veteran with no dependents	$27,609
Veteran with at least one dependent	$32,729 (increased by $2,831 for each additional dependent)
Surviving Spouse with no dependents	$17,743
Surviving Spouse with at least one dependent	$21,166 (increased by $2,831 for each additional dependent)

Importantly, there is no qualified surviving child box on the Aid and Attendance or Housebound charts since they are not eligible for either additional benefit. Additionally, where two veterans are married to each other, a whole different set of MAPRs apply. As you can tell, obtaining an Aid and Attendance rating can increase the MAPR by as much $11,058 and a Housebound rating can increase the MAPR by up to $3,047. The increase in MAPR is larger for the Aid and Attendance, so an individual who meets the requirements for both would always elect to receive the Aid and Attendance benefit over Housebound.

While increasing the MAPR is the main advantage of obtaining an Aid and Attendance or Housebound rating for VA Pension Benefits purposes, it also allows additional medical and medical-related expenses to be deducted in the IVAP calculation.[3] These additional deductible expenses are related to the additional level of care necessary for the individual, and importantly, can include care provided in the individual’s home. Essentially, as long as two activities of daily living (“ADLs”, as discussed in further detail below) are part of the care provided by the in-home attendant, the payments may also cover Incidental Activities of Daily Living (“IADLs”) such as cooking, laundry, and housecleaning.

For example, if an individual who meets the rating requirements for Aid and Attendance hires a local church member (who is not licensed to furnish health services) to assist them with showering, toileting, cooking, eating, laundry, and bill payments, they can deduct the entire amount paid instead of deducting only the portion attributable to ADLs.[4] If the individual did not have a rating for Aid and Attendance, no portion of these expenses would be deductible unless they were provided by an individual licensed to furnish health services, such as a doctor, physical therapist, or nurse or if a physician, physician assistant, certified nurse practitioner, or clinical nurse specialist states in writing that, due to a physical, mental, developmental, or cognitive disorder, the individual requires the health care or custodial care that the in-home attendant provides.[5]

A similar situation exists for individuals living in assisted living facilities.[6] Even if the facility is providing services that cover at least two ADLs, if the individual does not have a rating for Aid and Attendance or Housebound as well as a need for custodial care (with similar requirements as those to obtain a rating of Aid and Attendance), then the VA essentially sees it as just another retirement living arrangement, and therefore the costs may not be deducted when computing the individual’s IVAP.[7] But once the individual has a rating for Aid and Attendance and establishes a need for custodial care, the costs of meals, lodging, and assistance provided in the facility may all be deducted in the IVAP calculation.[8]

Additional Eligibility Requirements

Since the Aid and Attendance and Housebound benefits are in addition to the basic VA Pension Benefits, the individual has to meet the requirements to qualify for basic VA Pension Benefits. Please see my prior article for an in-depth discussion of those requirements. Since the MAPR is increased, then the income test, while functioning the same (other than the allowance of the additional deductible expenses referenced above), has an increased upper limit.

Additionally, the individual must have obtained a medical rating stating that they either need the regular medical assistance of another person or are housebound. The criteria for determining whether an individual meets the requirements for regular aid and attendance are as follows:[9]

He or she 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; or
He or she is a patient in a nursing home because of mental or physical incapacity; or
He or she establishes a factual need for assistance based on the following ADLs:[10]
- bathing or showering;
- toileting and incontinence;
- feeding (having a need to be fed by someone else);
- dressing or undressing;
- transferring in or out of a bed or chair;
- ambulating (walking);
- keeping oneself ordinarily clean and presentable, including hygiene issues;
- frequent need of adjustment of special prosthetic or orthopedic devices which cannot be done without the aid of another person; and
- 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.

With regard to the ADLs, the regulations do not require that an individual need assistance with a specific number of ADLs. Instead, the particular personal functions which the individual is unable to perform should be considered in connection with his or her condition as a whole.[11] However, in practice, this typically requires that the individual needs assistance with at least two of the aforementioned ADLs. Additionally, the individual does not need to establish that they are so helpless as to need constant aid and attendance, only that it is needed regularly.[12] Determinations that the individual 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.[13] They must be based on the actual requirement of personal assistance from others.[14]

The following are some of the most common IADLs, which again, are not deductible under the IVAP rules unless at least two ADLs are being provided as well.[15]

Preparing and serving meals;
Providing room and board;
Doing housework and laundry;
Supervising or providing reminders for medication;
Providing transportation;
Help with answering the telephone;
Help with keeping track of money and paying bills; and
Secured living arrangements and emergency pull cords.

To obtain a rating that the individual is Housebound, they must be permanently housebound by reason of disability or disabilities.[16] This requirement is met when the veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime.[17] Practically speaking, the Housebound rating is pretty rare. This is largely due to a combination of the fact that an individual who would meet the requirements for a Housebound rating is very likely to meet the requirements for an Aid and Attendance rating and that the MAPR associated with Aid and Attendance is higher than that for a Housebound rating.

How does the individual prove that they meet the Aid and Attendance or Housebound rating requirements? As a preliminary matter, a doctor has to examine the individual and certify on VA Form 21-2680 of their condition.[18] If the individual is in a nursing home they will also need to submit VA Form 21-0779, which is filled out by an official at the nursing home certifying that the individual resides at the facility and is receiving treatment because of a mental or physical disability.[19] These forms will be evaluated and the VA may require additional information or examinations.

Conclusion

The requirements for VA Pension Benefits are extremely intricate, especially when considering the additional requirements to obtain a rating for Aid and Attendance or Housebound. However, given the increase to the MAPR as well as the allowance for additional deductions in the IVAP calculation, obtaining one of these ratings (typically Aid and Attendance) is often critical in allowing an individual to receive any VA Pension Benefits. Unfortunately, many individuals that might be eligible for VA Pension Benefits are completely unaware that they might be eligible. Even among those that know about them or are receiving them, most do not know about the benefits of obtaining an Aid and Attendance or Housebound rating. Often these individuals call the VA or go to a local veteran’s service officer for assistance. They are typically asked what their income is. In many cases, the service representatives are not aware of, or do not discuss, the special rules allowing for the expanded medical deductions associated with obtaining these ratings. If the individuals have an income greater than the MAPR for their rating category, they are often told that they do not qualify and the conversation is ended prematurely. I encourage all veterans and their surviving spouses and children to reach out for assistance in evaluating whether they are eligible for VA Pension Benefits, especially if they believe they might be eligible for an Aid or Attendance or Housebound rating. Importantly, there are certain planning strategies that may be implemented to increase the benefit available to the individual for which an elder law attorney is likely the only reliable resource.

[1] Devin Mills, “VA Pension Benefits Summary” (April 9, 2024), https://esapllc.com/va-pension-benefits-summary-2024/.

[2] 38 C.F.R. § 3.23(b).

[3] 38 CFR § 3.278.

[4] 38 CFR § 3.278(d)(2).

[5] Id.

[6] 38 CFR § 3.278(d)(3).

[7] 38 CFR § 3.278(b)(4) and § 3.278(e).

[8] 38 CFR § 3.278(d)(3).

[9] 38 CFR § 3.351(b).

[10] 38 CFR § 3.352(a).

[11] Id.

[12] Id.