Presentation on theme: "62 nd Annual Service Officers Training Nashville, TN September 20, 2012."— Presentation transcript:
62 nd Annual Service Officers Training Nashville, TN September 20, 2012
Pension Management Center Milwaukee, Wisconsin Thomas Drews, Coach James Nelson, Management Analyst
Todays Agenda Milwakee Pension Management Center –Service Area –Responsibilities –Contact Information –Faxing Claims –Authorization –Phone contact –VSO Emergency contact –Claims Folders –How You Can Help? VA Form 21-22/New POA guidance Fully Developed Claims (FDC) EVRs Medical Expenses State home fees/Asst. Living Fees/Independent Living fees Burials Net Worth Liberalizing Law Overpayments Debt Management Center Fiduciary Dependency Indemnity Compensation Questions
PMC Responsibilities Pension Centers Original Claims –Live –Death –DIC –SMP –Burials Rating Issues Reopened Claims Running Awards –EVRs –Medical Expense Reports –Dependency –Nursing Home Matching Programs –IVM –COLA/CS/RR/MR –SSA Death –Provider Proof Regional Offices DRO Reviews Fiduciary Services Sending Hospital Reports to PMCs Dual Claims are now HRO issues
Where do I send claims? Department of Veterans Affairs Pension Management Center PO Box 342000 Milwaukee, WI 53234-9907
Authorization Quality of Work FY 12 Goal: 98% National FY 12 Quality: 97.5% PMC Quality: 98%
Rating Quality of Work FY12 Goal: 98% National FY12 Accuracy: 98.1% PMC Quality of work: 99.6%
Average Days a claim is pending as of 08/20/12 EP 180 Series: 87.5 days EP 120 Series: 79.7 days EP 140 Series: 106.9 days EP 190 Series: 111 days EP 150 Group: 124.5 days EP 155: 131.9 days EP 137: 107.2 days EP 160 Group: 122.9 days
PHONE CONTACT There is no direct phone contact with the Milwaukee PMC for general information calls. Call the NPCC at: –877-294-6380 There are two email addresses that are the preferred source to be used for EMERGENT CASES ONLY: One for VSOs co-located at HRO and encrypted: –VAVBAMIW/PMC/VSO For those at out based locations and anyone NOT encrypted: –firstname.lastname@example.org@va.gov –Responses to these addresses will not include personal identifiable information (PII) if you are not encrypted
VSO Primary Contact Number All status of claim inquiries, reports of death and informal claims go through the National PMC Call Center number; 1-877-294-6380
Emergency VSO Contact Number We consider the following emergencies situations: –Homeless veterans –Terminal illness –Removal from Nursing Home –Severe Financial hardship –Eviction The Milwaukee PMC has a direct line so VSOs can call to inquire about the current status. The number you can call for emergencies is; 414-902-5062 This number is answered by employees on the Advocacy Team
Is it ok to Fax and Mail the same exact claim? Yes. However, you should be aware of the following; 1. It slows down the claims process. 2. It creates duplicate documents which require screening (time) 3. If there is missing information, development is initiated (delay) 4. You may fax claims to Virtual VA. The number is 414-902-9470
When is a File Needed? The PMC has the ability to work claims without the file (more timely decision). The ultimate goal is electronic records, such as Virtual VA. For every DIC Claim Generally, we do not request files for Death Pension cases. Only if we absolutely need it. Upon request by the PMC (PTO)
How You Can Help? –Ensure the application/forms are complete. Enter 0 or N/A in all fields on forms. –Ensure the application/forms and the 21-4142 are properly signed –Service documents must be properly certified –For nursing home claims, ensure VA Form 21-0779 and VA Form 21- 8416 are signed by the claimant (if not, a mark and two witnesses) –If the claimant has a caregiver, we must have an Attendant Affidavit signed by the caregiver and claimant –Ensure VA Form 21-22 is properly completed and signed –Ensure you report the amount of interest income (interest bearing accounts $5,000.00 or greater) –Send claims directly to the PMC. Sending the claim to the RO delays the processing.
Who signs a claim? - M21-1MR.I.3.a 1.The claimant 2. A representative is authorized to prepare, present, and prosecute a claimants claim and has the authority to: a. review the claimants records b. present evidence on behalf of the claimant, and sign an informal claim, a notice of disagreement (NOD), or a substantive appeal on behalf of the claimant. c. withdraw an appeal 3. Power of Attorneys cannot sign applications for veterans, including Eligibility Verification Reports (EVRs)
Signatures - cont… 4. Please have the claimant sign documents. 5. VA recognized fiduciaries are an exception. 6. Accredited POAs w/a VA Form 21-22 on file can sign evidentiary statements and submit evidence on behalf of the claimant. 7. Accredited POAs cannot sign forms requiring claimant certification: 21-4142, 21-8416, 21- 534, 21-526, 21-686c, 21-527
VA Form 21-22 (New changes) FL 12-16 (Revision of VA Form 21-22, Appointment of Veterans Service Organization as Claimants Representative) –Effective June 20, 2012 –Created an additional signature block for VSOs –Addition of a checkbox for claimants to authorize their VSO to change their address –Deletion of Copy 4 of the form designed for VHA –Additions and deletions of VSOs listings on the back of the form
VA Form 21-22 (New changes) cont… FL 12-16 (Revision of VA Form 21-22, Appointment of Veterans Service Organization as Claimants Representative) –Form states that priors versions of VA Form 21-22 will no longer be accepted –Prior forms will be accepted until Sept 1, 2012 –After Sept 1, 2012, VA will no longer accept any prior versions of VA Form 21-22
Fully Developed Claims (FDC) What are Fully Developed Claims? A FDC is a claim where a Veteran submits certain types of evidence, for example private treatment records and notice of Federal treatment records, to VA at the time he or she first files a formal claim and certified they have no more evidence to submit. VA gathers all federal records the Veteran identifies, like those from VA Medical Centers and the Social Security Administration. This allows the VA to start processing the claim immediately. As a result, the Veteran and his/her representative do much of the development that typically takes the VA 175 days to gather. Currently, FDC claims take and average of 110 days to decide compared to 254 days through the traditional claims method.
Fully Developed Claims (FDC) cont… VA Form 21-526EZ, Fully Developed Claim (Compensation) VA Form 21-527EZ, Fully Developed Claim (Pension) An FDC must meet the following criteria: 1. Proper form 2. Fully Developed Claim Certification 3. All necessary income and net worth information reported 4. For SMP claims, VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance 5. VA SMP based on nursing home status, VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Fully Developed Claims (FDC) cont… –If claiming dependents, VA Form 21-686c, Declaration of Status of Dependents must be included –For Guard and Reserve members, any and all service treatment records and an identification of any treatment records from a Federal treatment facility such as a VA Medical Center FDC exclusions: –Claims requiring additional development (with the exception of service verification) –Claimant submits a supplemental claim for additional evidence after receipt of the FDC certification –Claimant fails to report for an examination
Eligibility Verification Reports FACTS 1. So far in 2012, we have received 39,407 2. The PMC has approximately 326 left to work 3. We expect to receive another 40,000 starting in January 2013 HOW YOU CAN HELP WITH EVRs? - Ensure the form is completed & signed by claimant/fiduciary payee –Complete dependency information (SSN, DOB, address, age, etc.) –Nursing home information (address, whether is Medicaid) –Income (specific changes with exact date of increase/decrease) –Net worth (all bank accounts to include interest income) –Claimants signature or mark with two witnesses –Please note Medical Expense Reports have to be worked with the EVR, if an EVR was issued. So please send them together. Sending separate delays the processing.
EVR Medical Expenses The $800 rule per M21-1MR.V.iii.1.G.42 –Preprinted medical amount indicates the amount the VA is projecting –If either actual year, or estimated year is greater than projected by more than $800, they must complete VA Form 21-8416. –If not we have to develop with a threat to remove the expenses. –Estimated year is considered a claim for continuing medical expenses and must either be granted, developed, or denied.
Medical Expense Directive M21-1MR.V.iii.1.G - show all deductible expenses Claims must include the following five elements: –Purpose –Amount paid –Date paid –Name of provider –For whom paid If an element is missing, we have to develop (letter or phone call). This is where most delays occur
Medical Expenses Please use the new VAF 21P-8416, dated February 2012. (Old versions are still being accepted) Use VA Form 21P-8416, not receipts. Receipts most often do not have the five elements that are required. Mileage must state the purpose, and number of miles driven. If a fee was paid, please make it clear what the fee was for. Claimant has to claim nursing home fees. We cannot rely solely on the nursing home statement. Therefore if possible, have the claimant sign any nursing home certificates/VA Form 21-0779.
How should I list UMEs? Single listing for each provider over the course of the year; e.g. –Prescriptions, $1000, CY 2009, Walgreens, Self –Prescriptions, $500, CY 2009, Rite Aid, Spouse List for the entire calendar year, or initial year. Specific dates would be required if the IY is not delineated. We prefer no receipts or prescription printouts, unless provider proof is requested.
Listing UMEs continued.. M21-1MR.V.iii.1.G.44d Medical expenses allowed on a claim should not be an arbitrary amount VSRs may project certain predictable expenses: –SMIB (Must be projected) –Private Medical Insurance –Attendant Fees if Special Monthly Pension –Nursing Home Fees –Their estimated amount on the EVR, if within $800 of preprinted amount If your claimant wants a different specific amount projected, have them specifically request it in writing. Include the time period for the projection. The request will be considered.
How are state home fees handled? If a veteran in a State home is receiving hospital care or is a patient (as opposed to a resident) in a nursing home, out-of-pocket amounts actually paid by the veteran may be allowed as medical expenses. Amount paid, versus charged is a key factor. For your reference: M21-1MR.V.iii.1.G.42
Nursing Home Fees Allow deduction for NH fees if a responsible official of the NH certifies that the disabled person is a patient (as opposed to a resident) of the NH. Allow a deduction for NH fees even though the NH may not be licensed by the State to provide skilled or intermediate care. For your reference: M21-1MR.V.iii.1.G.43
In Home Attendants If rated for Special Monthly Pension (SMP [A+A or HB])… –Allow all fees paid to an in-home attendant as long as the attendant provides medical or nursing services. –All reasonable fees paid to individual for personal care and maintenance of the immediate environment may be allowed. –The person does not have to be a licensed health care professional.
In Home Attendants cont.. If NOT rated for Special Monthly Pension (SMP [A+A or HB]) AND a licensed physician has not stated that a dependent or other relative requires an in-home attendant… –Allow expenses paid to an in-home attendant only if the attendant is a licensed healthcare professional. –All reasonable fees paid to individual for personal care and maintenance of the immediate environment may be allowed. –An attendant affidavit is needed for each caregiver. The attendant affidavit must be completed by the caregiver and signed by the claimant.
Custodial Care/Assisted Living Facilities If a beneficiary or dependent or other person for whom UMEs can be allowed is maintained in such an institution because they need to live in a protected environment, all unreimbursed fees paid to the institution for custodial care (room and board) and medical or nursing care are deductible expenses, IF… Rated for SMP, or A licensed physician certifies that the individual has a medical condition that makes such a level of care necessary.
Independent/Senior Living Facilities Just because the VA will not take independent/senior living facilities room and board does not necessarily mean VA can not take other fees from the facility. (i.e. VA will not take room and board from independent living facilities if the only service they provide is transportation to medical appointments. However, VA can take the amount they charge the claimant for transportation to medical appointments as a medical expense.) VA considers the expenses paid to the 3rd party as attendant fees, but if the facility does not provide the services, VA would not accept the rent. Examples of medical services for Independent/Senior Living Facilities Questionable Items: –Medication reminders N, –Medication management Y, Phone Dev will be undertaken –Medication administering Y, –Ambulation assistance Y, –Emergency pull-cords N, –24-hour on-site staff to respond to emergencies N, –Meal preparation N, –Homemaker services N, –Transportation to medical appointments N.
Dependency/Death pension Death pension Claims –Use the new 21-534 (dated Mar 2009). –Box 22J has a specific question that asks about the issue of a deemed valid marriage and knowledge of any impediment to the widow being married to the veteran in event she doesnt have all marriage information –When completing 21-534, do not list of record in the boxes that ask about marriages. The law specifically calls for the widow to complete this section, even if she was on the veterans award –Always answer ALL questions
VAF 21-526 (New) Make sure the disability section on the front is answered as NONE if only filing for pension. This section is to claim S/C claimed conditions and will cause a delay if completed and only pension is being claimed. The income sections ask for monthly income. If you report any amount, it will be annualized. Example…if you report the annual figure for interest…specify so VA does not multiply by 12 Make sure all sections are answered with a statement, amount, None or N/A
What delays reimbursement for UMEs? Problematic issues include: –Incomplete 8416s. –Initial year not fully accounted for. –Unsigned or incorrectly signed. –Submitting receipts or printouts. –Listing each purchase individually. –Listing SMIB when it is no longer paid. –Any change in SSA which was not previously reported to us in detail. –Not including an attendant affidavit for a newly claimed caregiver.
Burial Claim Eligibility Non service-connected burial benefits: –NSC burial benefits payable if the veteran: was in receipt of pension or compensation at the time of death was receiving military retired pay in lieu of compensation at the time of death had an original or reopened claim pending at the time of death and has been found entitled to compensation or pension from a date prior to the date of death was hospitalized by VA at the time of death died while receiving care under VA contract at a non-VA facility died while traveling, under proper authorization and at VA expense, to or from a specified place for the purpose of examination, treatment, or care, or died on or after October 9, 1996, while a patient at an approved State Veterans' home per Section 212 of Public Law (PL) 104-275.
Burial Claim Eligibility cont… Non service-connected burial benefits, cont: –The plot allowance is payable if the veteran was: discharged for a disability incurred or aggravated in the line of duty, in receipt of compensation or pension at the time of death, receiving retired pay in lieu of compensation at the time of death, a wartime Veteran and his/her body is unclaimed, properly hospitalized by VA at the time of death, or buried in a State cemetery. –The plot allowance is not payable if burial is in a national cemetery or other cemetery under the jurisdiction of the United States employer has paid or assumed the plot and/or interment expenses, or burial was without cost for plot or interment in a section of a State or State-owned cemetery used solely for burial of persons otherwise eligible for burial in a national cemetery.
Burial Claim Eligibility cont.. Non service-connected burial benefits, cont: –NSC transportation can be paid if the veterans death occurred while: en route for VA authorized examination, treatment, or care properly hospitalized at a medical center, domiciliary, or nursing home under the direct jurisdiction of VA receiving nursing home care authorized under 38 U.S.C. 1720 in a non-VA facility, or38 U.S.C. 1720 a patient at an approved State nursing home (38 U.S.C. 2303(a)(1)(B) ) and death occurred on or after October 9, 1996.38 U.S.C. 2303(a)(1)(B) –Transportation can also be paid in NSC death cases if the veteran was buried in a national cemetery and: had a SC condition at the time of death for which he/she was receiving disability compensation, or was receiving military retired pay or VA pension at the time of death in lieu of disability compensation.
Burial Claim Eligibility cont.. Service-connected burial benefits: –Only paid when we grant service-connection for the cause of death. –Not payable for DIC grants under 38 USC 1318 or 1151. –$2,000 burial benefit (no plot payment) –Transportation: Paid if veteran was buried in a National Cemetery. Can also be paid if veteran died in a VAMC, but total payable cannot exceed $2,000.
Burial Benefits changes PL 111-275, Sec 501 PL 111-275 increased certain Burial, Funeral Benefits and Plot Allowances NSC burial rate will now be $700.00 for deaths occurring on/after 10/1/2011 for veterans who die while properly hospitalized by VA. If not properly hospitalized or indigent, the rate remains $300.00. NSC plot rate will now be $700.00 for deaths occurring on/after 10/1/2011 for all eligible veterans, regardless of the location of death. Allows for annual increases in burial and plot allowances based on Consumer Price Index beginning in FY 2013, w/first increase on 10/1/2012.
Burial Benefit changes PL 111-275, SEC 604 EXCLUSION OF CERTAIN AMOUNTS FROM CONSIDERATION AS INCOME FOR PURPOSES OF VETERANS PENSION BENEFITS. 38 U.S.C. § 1503(a) is amended to authorize VA to exclude up to $5,000 of income from a state or municipality that is paid to the Veteran due to injury or disease when determining annual income for Veterans pension benefits. The amendment applies to determinations of annual income for calendar years beginning after October 1, 2011.
Changes PL 111-275 SEC 606 APPLICABILITY OF LIMITATION TO PENSION PAYABLE TO CERTAIN CHILDREN OF VETERANS OF A PERIOD OF WAR. 38 U.S.C. § 5503(d) is amended to provide VA with the authority to apply the $90 Medicaid rule to children of Veterans in receipt of pension. The amendment limits to $90 a month the amount of pension payable to the child of a Veteran who receives Medicaid-covered nursing home care. VBA ACTION: Since this section was effective on October 13, 2010, RO employees must immediately implement action to reduce childrens pension awards to $90 a month when the child is receiving Medicaid- covered nursing home care.
Net Worth Sale of Homestead/Home/Property –Conversion of assets, not countable as income –If resulting gain in NW is over $80,000 a Net Worth Determination will have to be considered (21-8049) –If benefits are terminated due to Net Worth, benefits will be stopped the first of the year following this change –If Net Worth does not result in termination, remember, interest and dividends from bank assets must be reported as income
Stub Year/Initial Year This refers to the first full 12-month period of eligibility following the effective date of benefits Example: Effective date is 25 Mar 2012 Initial year is 3/25/12 to 3/31/13 After this we consider calendar year VA will compute to claimants advantage for initial year versus calendar year income/expenses If VA asks for specific time periods the EVR and 21-8416 must reflect those specific time periods There may be overlapping periods. VA needs to know initial year and full calendar year.
Liberalizing Law & Pension cont.. Public Law 107-103 (sections 206-207), enacted on 9/17/01, changed the disability requirement for pension. This is a Liberalizing Law. The law allowed pension to be granted presumptively, without a rating, if: –The veteran is 65 or older, or –The veteran is recognized as disabled by the Social Security Administration, or –The veteran is a patient in a nursing home.
Liberalizing Law & Pension cont.. P&F Service interprets Liberalizing Law rules for pension differently, so we have adjusted the way we process these at the Milwaukee PMC. If the veteran is entitled by rating (1521) and presumptively (1513), we will consider an earlier effective date under Liberalizing Law, even if pension was granted via rating.
Liberalizing Law & Pension cont.. When liberalizing law applies: –The veteran is granted pension (presumptively or by rating), and –The veteran met one of the presumptive requirements on the date of the law change (9/17/01)* through the present date of claim, and –The veteran has never received pension, and –The veteran was never denied for excessive net worth. If liberalizing law applies, we will solicit for a claim and request income/expense information for one year prior to our current entitlement date. –For example, if we are granting benefits effective 03/20/12, we will solicit for a claim to consider benefits from 03/20/11.
What can you do to help reduce overpayments? Request a specific, small amount of UMEs. Advise beneficiaries to inform VA of increases in income immediately (including SSA), to include the date payment was first received, over their signature. Request that immediate action be taken, and indicate that due process is waived. Dont send multiple copies of the same claim.
Understanding the Overpayment Process? Once an overpayment is created and evidence shows it is valid understand the claimants options. Shortly after the debt is created they will receive a letter from the Debt Management Center (DMC) in St. Paul, MN. At this point, the PMC no longer is involved. The claimant has the following options: –Request a waiver of the debt –Request a limited withholding of the debt –Pay the debt in full
What are DMC Time Limits? Once the DMC notice of debt letter is mailed to the claimant; –30 days to request a waiver, limited withholding or pay the debt before his running benefits are withheld to collect –After 30 days, he can still request a limited withholding –If a request for waiver is received within 30 days, benefits are not withheld during the waiver decision process –180 days to request a waiver of the debt
PMC Fiduciary Procedures The PMC identifies claimants may be incompetent, prepares a proposal rating and issues due process. A 607 EP is established. A DLP (date last paid) award is completed and all retro benefits are withheld pending final incompetency rating and a fiduciary being named. Due process expires or an answer is received, a final rating of competency/incompetency is prepared. If incompetent: –297 EP is established and a 21-592 is prepared and sent to HRO FID or FID HUB Dept. –21-555 received from HRO FID or FID HUB and w/h benefits are released
DIC Eligibility What is DIC? Dependency and Indemnity Compensation (DIC) is defined as a monthly payment made to a surviving spouse, child, or parent because the cause of death was service connected on or after January 1, 1957, or before January 1, 1957, if the survivor elects to receive DIC in lieu of death compensation.
DIC Eligibility cont… 1. DIC under U.S.C. 1310(a) –Generally, to determine entitlement to DIC, VA needs evidence showing: The cause of death, and that the cause of death was related to or hastened by: –a service-connected (SC) condition, or –related to a disease or injury that existed during active military service.
DIC Eligibility cont… 2. DIC under 38 U.S.C. 1318 –DIC can be paid if a Veteran was in receipt of, or entitled to receive, compensation for a totally disabling SC disability (to include IU) for ten or more years immediately preceding death continuously for a period of not less than five years from the date of separation from service until death, or for a period of not less than one year immediately preceding death for a former prisoner of war who died after September 30, 1999.
DIC Eligibility cont… 3. DIC under U.S.C. 1151 –DIC can be awarded if the Veterans death was attributable to: hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary, participation in vocational rehabilitation training under 38 U.S.C. Chapter 31, or38 U.S.C. Chapter 31 participation in compensated work therapy (CWT).
DIC Eligibility cont… 4. In Service Death – All in-service death claims are processed initially by the Philadelphia RO and Insurance Center (ROIC). Initial processing of a claim for DIC may begin based on receipt of the following documents: –DD Form 1300, Report of Casualty, or –Interim DD Form 1300, and –VA Form 21-534a, Application for Dependency and Indemnity Compensation by a Surviving Spouse or ChildIn-Service Death Only
How do you access VAs manual?? The VA has an internet based manual available for you to review at any time – WARMS (Web Automated Reference Material System): http://www.benefits.va.gov/WARMS/Site_Map.asp
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