6
Medical Criteria for Ancillary Benefits

INTRODUCTION

Military veterans are generally eligible for a number of benefits through the Department of Veterans Affairs (VA) aimed at easing their reentry into and improving the quality of their civilian lives. These include health-care services, compensation for service-connected disabilities, means-tested pensions for nonservice-connected disabilities, education benefits under the GI Bill, home loan guaranties, life insurance, burial benefits, and survivor benefits.

Part 9 of VA’s Compensation and Pension Adjudication Procedure Manual (M21-1MR) breaks down veterans benefits into two categories— ancillary and special. The Veterans’ Disability Benefits Commission asked the committee to focus on the appropriateness of medical criteria for five specific ancillary benefits available to veterans with disabilities: vocational rehabilitation and employment (VR&E) services, automobile assistance and adaptive equipment, housing adaptation, and clothing allowances. (See Box 6-1 for the current medical eligibility criteria to qualify for these selected benefits.)

VA’s special benefits—called special and ratings for special purpose benefits—for veterans with disabilities are therefore not discussed in this report. They include the Special Allowance under 38 U.S.C. 1312(a), Medal of Honor Pension (special benefits), and the following ratings for special purposes:

  • rating determinations for dependents educational assistance, veteran’s civil service disability preference, and discharge of liability for educational loans under 38 U.S.C. 3698;



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A 21st Century System for Evaluating Veterans for Disability Benefits 6 Medical Criteria for Ancillary Benefits INTRODUCTION Military veterans are generally eligible for a number of benefits through the Department of Veterans Affairs (VA) aimed at easing their reentry into and improving the quality of their civilian lives. These include health-care services, compensation for service-connected disabilities, means-tested pensions for nonservice-connected disabilities, education benefits under the GI Bill, home loan guaranties, life insurance, burial benefits, and survivor benefits. Part 9 of VA’s Compensation and Pension Adjudication Procedure Manual (M21-1MR) breaks down veterans benefits into two categories— ancillary and special. The Veterans’ Disability Benefits Commission asked the committee to focus on the appropriateness of medical criteria for five specific ancillary benefits available to veterans with disabilities: vocational rehabilitation and employment (VR&E) services, automobile assistance and adaptive equipment, housing adaptation, and clothing allowances. (See Box 6-1 for the current medical eligibility criteria to qualify for these selected benefits.) VA’s special benefits—called special and ratings for special purpose benefits—for veterans with disabilities are therefore not discussed in this report. They include the Special Allowance under 38 U.S.C. 1312(a), Medal of Honor Pension (special benefits), and the following ratings for special purposes: rating determinations for dependents educational assistance, veteran’s civil service disability preference, and discharge of liability for educational loans under 38 U.S.C. 3698;

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A 21st Century System for Evaluating Veterans for Disability Benefits BOX 6-1 Medical Eligibility Criteria to Qualify for Selected Benefits VR&E assistance Ten percent rated disabled with a serious employment handicap and discharged or released from military service under other than dishonorable conditions Twenty percent or more rated disabled with an employment handicap and discharged or released from military service under other than dishonorable conditions Twenty percent rated disabled if pending medical separation from active duty if their disabilities are reasonably expected to be rated at least at 20 percent following their discharge Automobile assistance Service-connected loss or permanent loss of use of one or both hands or feet Permanent impairment of vision of both eyes to a certain degree (i.e., permanent impairment of vision in both eyes with a central visual acuity of 20/20 or less in the better eye with corrective glasses, or central visual acuity of more that 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field has an angular distance no greater than 20 degrees in the better eye) Ankylosis (immobility) of one or both knees, or one or both hips Adaptive equipment allowance Anyone who qualifies for the automobile allowance also qualifies for adaptive equipment. To be eligible to receive only adaptive equipment (as opposed to the automobile allowance), the veteran or serviceperson must be entitled to disability compensation for ankylosis of one or both knees or hips based on: the establishment of service connection, or entitlement under 38 U.S.C. 1151 as the result of VA treatment or examination, compensated work therapy, or vocational training under 38 U.S.C. Chapter 31. ratings for dental treatment, medical care, service connection for psychosis under 38 U.S.C. 1702, insanity determination, insurance purposes, and Polish and Czechoslovakian Armed Forces under 38 U.S.C. 109(c); and rating to extend the delimiting dates for educational assistance. Table 6-1 describes the full complement of veterans benefits by service-connected disability rating percentages.

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A 21st Century System for Evaluating Veterans for Disability Benefits Specially adapted homes $50,000 grant for permanent and total service-connected disability due to one of the following: Loss or loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair Loss or loss of use of both upper extremities at or above the elbow Blindness in both eyes, having only light perception, plus loss or loss of use of one lower extremity Loss or loss of use of one lower extremity together with (a) residuals of organic disease or injury, or (b) the loss or loss of use of one upper extremity which so affects the functions of balance or propulsion as to preclude locomotion without the use of braces, canes, crutches, or a wheelchair $10,000 grant for permanent and total service-connected disability due to: Blindness in both eyes with 5/2000 visual acuity or less, or Anatomical loss or loss of use of both hands Supplemental financing: Veterans with available loan guaranty entitlement may also obtain a VA-guaranteed loan or a direct loan to supplement the grant to acquire a specially adapted home. The VA maximum direct loan from a private lender varies; the VA maximum is $33,000. Special Home Adaptation Grant for veterans who do not qualify for special adaptive housing, for actual cost up to a maximum of $10,000. May be applied for if the veteran is permanently and totally disabled due to blindness in both eyes with visual acuity of 5/200 or less or the loss or permanent loss of use of both hands. Clothing allowance Service-connected disability for which a veteran uses prosthetic or orthopedic appliances Service-connected skin condition that requires prescribed medication that irreparably damages the veteran’s outer garments Paid annually SOURCES: Adapted from VA (2006b), and VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9. Perhaps the most important benefit provided to veterans with service-connected disabilities is priority access to free health care for all medical care needs from the Veterans Health Administration (VHA). They are not required to enroll for the health-care benefits, but are urged to enroll for better planning of health resources (VA, 2006a). Veterans with disabilities receive health care if they (1) have a service-connected disability rated 50 percent or higher; (2) need care for a disability the military determined was incurred or aggravated in the line of duty, but which VA has not yet

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 6-1 Veterans Benefits by Service-Connected Disability Rating Percentages If a veteran has a service-connected disability rating percentage of … Additional Benefitsa 10 percent with an effective date of October 1, 1993, or after Veteran may be entitled to vocational rehabilitation services if the veteran either originally applied for vocational rehabilitation before November 1, 1990, reapplied after that date, and has an employment handicap; or did not originally apply for vocational rehabilitation before November 1, 1990, applied on or after October 1, 1993, and has a serious employment handicap. 0 to 20 percent Home loan guaranty fee exemption Vocational rehabilitation and counseling under title 38 U.S.C. Chapter 31 (must be at least 10 percent) Service-disabled veterans’ insurance (maximum of $10,000.00 coverage), must file within 2 years of date of new service connection 10-point civil service preference (10 points added to civil service test score) Clothing allowance for veterans who use or wear a prosthetic or orthopedic appliance (artificial limb, braces, wheelchairs) or use prescribed medications for skin condition which tend to wear, tear, or soil clothing 30 percent (in addition to the above) Additional disability compensation for dependent spouse, child(ren), stepchild(ren), helpless child(ren), full-time student between the ages of 18 and 23 and parent(s) 40 percent (in addition to the above) Automobile grant and/or special adaptive equipment for an automobile provided there is loss or permanent loss of use of one or both feet, loss or permanent loss of use of one or both hands, or permanent impaired vision of both eyes with central visual acuity of 20/200 or less in the better eye. Special adaptive equipment may be applied for if there is ankylosis of one or both knees or one or both hips. 50 percent (in addition to the above) Preventative health-care services Hospital care and medical services in non-VA facilities under an authorized fee-basis agreement

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A 21st Century System for Evaluating Veterans for Disability Benefits If a veteran has a service-connected disability rating percentage of … Additional Benefitsa 60 to 90 percent (in addition to the above) Increased compensation (100 percent) based on individual unemployability (applies to veterans who are unable to obtain or maintain substantial gainful employment due solely to the service-connected disability) 100 percent (in addition to the above) Special adaptive housing for veterans who have loss or permanent loss of use of both lower extremities, blindness in both eyes, having light perception only, plus loss or permanent loss of use of one lower extremity or permanent loss of use of one upper extremity or the loss or permanent loss of use of one extremity together with an organic disease that affects the function of balance and propulsion as to preclude locomotion without the aid of braces, crutches, canes, or wheelchair Special home adaptation grant (for veterans who do not quality for special adaptive housing). May be applied for if the veteran is permanently and totally disabled due to blindness in both eyes with visual acuity of 5/200 or less or the loss or permanent loss of use of both hands 100 percent permanent and total (in addition to the above) Civilian health and medical program for dependents and survivors (CHAMPVA) Survivors and dependents educational assistance under Title 38 U.S.C. Chapter 35 aService-connected veterans with current disability ratings by VA may be eligible for additional benefits as outlined. SOURCE: Adapted from VA’s Compensaton and Pension Adjudication Procedure Manual, M21-1MR, Part 9.

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A 21st Century System for Evaluating Veterans for Disability Benefits rated, during the 12-month period following discharge; or (3) need care for a service-connected disability only. Veterans with service-connected conditions rated at any percentage, from zero percent and higher, receive care for the condition(s) that are service connected, without requiring a copayment. Depending on the nature and degree of the veteran’s service-connected disabilities, free VHA health-care benefits may include eyeglasses, hearing aids, cochlear implants, pharmacy services, dental treatment, prosthetic devices (e.g., artificial limbs, orthopedic braces, shoes), durable medical equipment (e.g., wheelchairs, crutches, canes), and other medical supplies. (It should be noted that some of these health-care benefits are also indicated as ancillary benefits, as described below.) In 1999, in accord with the Veterans’ Health Care Eligibility Reform Act of 1996, VHA developed a priority group system to balance demand for health care with available resources. Service-connected disability is an important factor in assigning veterans to higher priority groups. For example, first priority (group 1) is given to veterans with service-connected disabilities rated 50 percent or more and to veterans deemed unemployable because of service-connected conditions (see Table 6-2 for eligibility criteria by group). Priority groups 2 and 3 include veterans with service-connected disabilities rated 30 or 40 percent, or 10 or 20 percent, respectively. Group 8, in contrast, includes all other nonservice-connected veterans and zero percent, noncompensable service-connected veterans who agree to make copayments. As of January 2003, VHA stopped enrolling new veterans in priority group 8. ANCILLARY BENEFITS Ancillary benefits are secondary benefits considered when evaluating claims for disability compensation, pension, or dependency and indemnity compensation (DIC) entitlement. Eligibility for ancillary benefits depends on the veteran’s type of disability entitlement, his or her degree of disability, or in the case of DIC, the circumstances of his or her death.1 This report addresses ancillary benefits in compensation cases, and not such benefits as pensions for low-income veterans, VA’s Civilian Health and Medical Program (geared toward dependents and spouses of both living and deceased veterans), loan guaranties for surviving spouses, and the entitlement program for survivors. The benefits addressed in this report are VR&E services, automobile and adaptive equipment allowances, specially adapted homes, special housing adaptation grants, and clothing allowance. In fiscal year 1 VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 3, Ch. 6, Topic 3.

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 6-2 Priority Groups for Health-Care Benefits Priority Groups Criteria 1 Veterans with service-connected disabilities rated 50 percent or more Veterans determined by VA to be unemployable due to service-connected conditions 2 Veterans with service-connected disabilities rated 30 or 40 percent 3 Veterans with service-connected disabilities rated 10 or 20 percent Veterans who are Former Prisoners of War (POW) or were awarded a Purple Heart Veterans awarded special eligibility for disabilities incurred in treatment or participation in a VA vocational rehabilitation program Veterans whose discharge was for a disability incurred or aggravated in the line of duty 4 Veterans receiving aid and attendance or housebound benefits Veterans determined by VA to be catastrophically disabled Some veterans in this group may be responsible for copayments. 5 Veterans receiving VA pension benefits or eligible for Medicaid programs Nonservice-connected veterans and noncompensable, zero percent service-connected veterans whose annual income and net worth are below the established VA means-test thresholds 6 Veterans of the Mexican border period or World War I Veterans seeking care solely for certain conditions associated with exposure to radiation or exposure to herbicides while serving in Vietnam For any illness associated with combat service in a war after the Gulf War or during a period of hostility after November 11, 1998 For any illness associated with participation in tests conducted by the Department of Defense (DoD) as part of Project 112/Project SHAD Veterans with zero percent service-connected disabilities who are receiving disability compensation benefits 7 Nonservice-connected veterans and noncompensable, zero percent service-connected veterans with income above VA’s national means-test threshold and below VA’s geographic means-test threshold or with income below both the VA national threshold and the VA geographically based threshold, but whose net worth exceeds VA’s ceiling ($80,000 in 2006) who agree to make copayments 8 All other nonservice-connected veterans and zero percent, noncompensable service-connected veterans who agree to make copayments. (Note: Effective January 17, 2003, VA no longer enrolls new veterans in priority group 8.) SOURCE: VA (2006a).

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A 21st Century System for Evaluating Veterans for Disability Benefits (FY) 2005, more than 160,000 veterans received approximately $700 million for these benefits (VA, 2006b). Vocational Rehabilitation and Employment Services VR&E services are provided under Title 38, Chapter 31, by VA’s Vocational Rehabilitation and Employment Service. VR&E Service, like the Compensation and Pension (C&P) Service, is part of the Veterans Benefits Administration (VBA). VR&E Service helps veterans with service-connected disabilities prepare for and find jobs within their physical, mental, and emotional capabilities. According to VR&E, strategic goal 1 is to “restore the capability of veterans with disabilities to the greatest extent possible and improve the quality of their lives and that of their families,” and objective 1.3 is to “provide all service-disabled veterans with the opportunity to become employable and obtain and maintain employment, while providing special support to veterans with serious employment handicaps” (Steier, 2006). VR&E services may include an evaluation of the individual’s abilities, skills, and interests; help with resumes and other work readiness assistance; help finding and keeping a job; vocational counseling and planning; on-the-job training and work-experience programs; training, such as certificate, two-year, or four-year college or technical programs (including assistance with applications and preparation for preadmission testing); supportive rehabilitation services and additional counseling; and for veterans whose disabilities are so severe they cannot currently consider employment, a program of services to assist in achieving independence in daily living.2 To be eligible for VR&E services, a veteran must have a service-connected disability of at least 20 percent with an employment handicap or at least 10 percent service-connected disability with a serious employment handicap, and be discharged or released from military service under other than dishonorable conditions.3 Servicemembers pending medical separation 2 VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Subpart i, Ch. 1, Topic 1; and VA (2006a). 3 See also VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Subpart i, Ch. 1, Topic 1.

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A 21st Century System for Evaluating Veterans for Disability Benefits from active duty may also apply if their disabilities are reasonably expected to be rated at least 20 percent following their discharge (VA, 2006a). According to VA, “The term employment handicap means an impairment of the veteran’s ability to prepare for, obtain, or retain employment consistent with the veteran’s abilities, aptitudes, and interests” (emphasis added). The veteran’s service-connected disability “must materially contribute to the impairment,” although it does not have to be the sole or even the primary cause of the handicap.4 “The term serious employment handicap means a significant impairment of a veteran’s ability to prepare for, obtain, or retain employment consistent with such veteran’s abilities, aptitudes, and interests” (emphasis added). Also, “A veteran who has been found to have an employment handicap shall also be held to have a serious employment handicap if he or she has (1) a neuropsychiatric service-connected disability rated at thirty percent or more disabling; or (2) any other service-connected disability rated at fifty percent or more disabling.” The determination of a serious employment handicap is made by a VR&E counseling psychologist.5 Veterans rated individually unemployable (IU) because of a service-connected disability may request an evaluation by VR&E and, if entitled, receive rehabilitation services and assistance in securing employment. If the veteran secures employment, the IU rating is protected from reduction for the first 12 months of continuous work. Currently, there is no requirement for people with an IU rating to participate in the VR&E program, although these services are available to any such veteran. VA pays the cost of VR&E services and pays a subsistence allowance to veterans who participate in a training program. If the training takes place in a college or university, technical school, on-the-job training, or a specialized rehabilitation program (for individuals with severe disabilities), VA pays for tuition, books, supplies, and equipment, and may pay for other special services (e.g., transportation, tutorial assistance, adaptive equipment).6 VR&E Service offers a work-study program for veterans training at the three-quarter or full-time rate; this program is available to all veterans, not only those who are service-connected disabled. A portion of the annual work-study reimbursement equal to 40 percent of the total must be paid to the veteran in advance. Veterans in a work-study program may be employed to provide VA outreach services, prepare and process VA paperwork, work at a VA medical facility, or perform other VA-approved activities (VA, 2006a). 4 38 CFR §21.51. 5 38 CFR §21.52. 6 VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Subpart i, Ch. 1, Topic 1.

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A 21st Century System for Evaluating Veterans for Disability Benefits Generally, veterans must complete a VR&E program within 12 years from their separation from military service, or 12 years from the date VA notifies them that they have a compensable service-connected disability. Veterans may be provided up to 48 months of full-time services or their part-time equivalent, depending on the length of program needed (these limitations may be extended in certain circumstances).7 VR&E Task Force In 2004, the VA VR&E Task Force issued a report about the current VR&E program, based on a two-year study. According to the report, In general, the current VR&E service delivery system is out of date, data poor, and understaffed to meet the needs of today’s veterans with service-connected disabilities. The current situation raises many questions about how to best serve the needs of these veterans. The Task Force’s answers to those questions [are] a new employment-driven service delivery system, integrated services across agencies, and recommendations with implementation timeframes (VA, 2004:60). The report contained a number of recommendations concerning the VR&E program itself. It also recommended that VA take a broader, integrated approach to helping veterans transition from military to civilian life, by coordinating its health, VR&E, and compensation programs. According to the report, veterans receive a DoD discharge physical examination or a VA medical exam to support initial C&P disability determinations. However, veterans, when separating from active duty, are not systematically evaluated and given information to make informed career and employment decisions based on their vocational abilities at the time of the initial service-connected disability decision or subsequent disability decisions. If they are rated 20 percent or higher, they are informed of possible eligibility for VR&E services, but it is left to the veteran to initiate an application for services and be evaluated by a counselor. The task force criticized the current process as a sequence of steps that each veteran must follow in order to receive services, which are unconnected and do not address the unique needs and skills of the individual with respect to his or her environment. In the view of the task force, a more appropriate approach would be one that considers rehabilitation potential based on a combination of education, vocational, and compensation needs together. The task force urged that early functional capacity assessments 7 VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Subpart i, Ch. 1, Topic 1.

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A 21st Century System for Evaluating Veterans for Disability Benefits be done routinely by vocational experts and used as a basis for making disability compensation as well as vocational rehabilitation decisions. In addition, these evaluations should be repeated at specified intervals to determine the response to intervention or to identify the need for more or different treatment. To implement its recommendations, the task force recommended the addition of 112 full-time equivalent (FTE) employment counselors in field positions (meaning 2 per field office). As a near-term priority, the task force recommended the design and implementation of pilot formal vocational assessment projects, and suggested that VBA program and technical capabilities be leveraged by colocating the pilot project office with VBA’s C&P Examination Program (CPEP) in Nashville.8 The goal of the recommended pilot projects would be to tailor off-the-shelf technology (systems, knowledge, and protocols for functional capacity evaluation) for VA to implement nationwide. CPEP could use existing electronic processes and infrastructure (e.g., the Compensation and Pension Record Interchange [CAPRI], the Automated Medical Information Exchange [AMIE], and the electronic record system called VistA) combined with electronic templates for functional capacity exams. Five Tracks to Employment Model VR&E Service currently uses what it calls the Five Tracks to Employment Model, which focuses on employment goals and on providing veterans with better information to help them make informed choices on employment options (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2006). The Five Track Process … standardizes program orientation practices; integrates veterans, counselors and employment professionals through a comprehensive triage (evaluation) phase; and places the emphasis on employment up front and early on in the rehabilitation process (U.S. Congress, House of Representatives, Veterans’ Affairs Subcommittee on Economic Opportunity, 2007:2). This model encompasses five different rehabilitation plans intended to enable the veteran to find employment in a sustainable, high-level job. 8 CPEP was established by VHA and VBA in 2001 to improve the quality and timeliness of the disability examination process, as well as veteran satisfaction with disability examinations, through examiner training videos, examination template training CDs, and satellite broadcasts. The program’s headquarters are in Nashville.

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A 21st Century System for Evaluating Veterans for Disability Benefits Qualifying disabilities must be incurred or aggravated by service and not under 38 U.S.C. 1151.11 An additional rating is not required to establish eligibility to either automobile or adaptive equipment (see section below) if a prior rating decision had already established service connection for qualifying disabilities. The rating decisions that initially established service connection for qualifying disabilities should address eligibility for automobile or adaptive equipment even though a specific claim for the benefit has not been filed.12 According to the VA FY 2007 budget request, 1,461 veterans received this benefit in FY 2005 at an average cost of $10,784, for a total cost of about $15.8 million (VA, 2006b). Adaptive Equipment Assistance Anyone who qualifies for automobile assistance also qualifies for adaptive equipment assistance. To be eligible to receive only adaptive equipment (as opposed to the automobile allowance), the veteran or serviceperson must be entitled to disability compensation for ankylosis of one or both knees or hips based on the establishment of a service connection, or entitlement under 38 U.S.C. 1151 as the result of VA treatment or examination, compensated work therapy,13 or vocational training under 38 U.S.C. Chapter 31. It must be clear in rating decisions that grant eligibility for this benefit does not include the automobile.14 The adaptive equipment benefit may be paid more than once (no limit15), and it may be paid to either the seller or the veteran. Repair, replacement, or reinstallation of adaptive equipment may also be required because of the wear and tear caused through use over time and for the safe operation of a vehicle purchased with VA assistance. The adaptive equipment assistance pays for such items as an automatic transmission, power steering, power brakes, power window lifts, hand-operated gas and brake pedals, power seats, and special equipment necessary to assist the veteran in and out of his or her vehicle.16 11 Title 38, Part II, Chapter 11, Subchapter VI, § 1151. Benefits for persons disabled by treatment or vocational rehabilitation. 12 38 CFR 3.808 and M21-1, Part IX, subpart 1, Ch. 2. 13 The Veterans Industries/Compensated Work Therapy Program provides a structured environment where clients participate in vocational rehabilitation activities at least 30 hours per week. Clients for this program must have a primary psychiatric or medical diagnosis, be medically stable, and have a goal of competitive employment. http://www1.va.gov/VI-Dayton/page.cfm?pg=2 (accessed May 4, 2007). 14 38 CFR 3.808 and M21-1, Part IX, subpart 1, Ch. 2. 15 38 CFR 3.808 and M21-1, Part IX, subpart 1, Ch. 2. 16 The application form (VA Form 21-4502) has a preapproved list of equipment matched with disabilities (e.g., loss of right foot– and left foot–operated gas pedal). Equipment not on the list must be approved by VA.

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A 21st Century System for Evaluating Veterans for Disability Benefits According to VA’s FY 2007 budget request, 8,009 veterans received grants for specially adaptive equipment at an average cost of $4,714, for a total cost of about $37.8 million (VA, 2006b). These numbers were based on 2005 figures. Specially Adapted Homes According to the VA FY 2007 budget request, 668 veterans received grants for specially adapted homes at an average cost of $42,259, for a total cost of $28.2 billion (VA, 2006b). These numbers were based on 2005 figures. Before any improvement grant can be approved and before expenditure from the estate can be authorized, real estate must be titled in the veteran’s name. Any purchase of real estate by a fiduciary requires court appointment (VBA, 2006). The grants available to qualified veterans are described below. $50,000 Grant Veterans with certain service-connected disabilities are eligible for a grant to assist in building a new specially adapted home or in purchasing an existing home remodeled or modified to meet their disability-related needs (VA, 2006a).17 VA may approve one-time grants for half the cost of building, buying, or adapting existing homes, or to pay down the mortgage on a previously owned house being adapted, up to $50,000. In some instances, the full grant amount may be applied toward the cost of remodeling. A veteran may qualify if he or she has a permanent and total service-connected condition or conditions that preclude locomotion without the aid of braces, crutches, canes, or a wheelchair due to the loss, or loss of use, of both lower extremities; or loss, or loss of use, of one lower extremity together with residuals of organic disease or injury, or one upper extremity, together with one lower extremity, which affects the functions of balance or propulsion;18 result in the loss, or loss of use, of both upper extremities at or above the elbow; or cause blindness in both eyes, having only light perception, combined with the loss or loss of use of one lower extremity. 17 See also 38 U.S.C. 2101(a), 38 CFR § 3.809, and VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Ch. 3. 18 “Preclude locomotion” as defined by 38 CFR 3.809(d) permits occasional locomotion by other means as long as the use of aids is the normal means of locomotion. Thus, a veteran can occasionally walk unassisted and still qualify as long as the use of described aids is the usual method of locomotion. See 38 CFR 3.808, and M21-1, Part IX, subpart 1, Ch. 2.

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A 21st Century System for Evaluating Veterans for Disability Benefits $10,000 Grant VA may approve grants for the actual cost, up to $10,000, for adaptations to a veteran’s home or to help a veteran acquire a home already adapted with special features for his or her disability (VA, 2006a).19 A veteran is eligible when he or she has a permanent and total service-connected condition that is due to blindness in both eyes with 5/200 visual acuity or less, or includes the anatomical loss or loss of use of both hands. This grant may be used in conjunction with the veteran’s available loan guaranty entitlement (VBA, 2006). Supplemental Financing Veterans with available loan guaranty entitlement may also obtain a VA-guaranteed loan or direct loan to supplement the grant to acquire a specially adapted home. Amounts with a guaranteed loan from a private lender vary; however, the maximum VA direct loan is $33,000 (VA, 2006a). Special Home Adaptation Grant This one-time benefit is offered for veterans who do not qualify for special adaptive housing. If the veteran has received the special home adaptation grant and subsequently becomes eligible for the specially adapted homes grant (described above), payment more than once for the same type of adaptation, improvement, or structural alteration is not allowed by law. The grant for up to a maximum of $10,000 is offered for the actual cost of adaptations to a veteran’s residence that VA determines as reasonably necessary and may be used in conjunction with the veteran’s available loan guaranty entitlement. It may be used to help a veteran acquire a residence already adapted with special features to accommodate his or her disability (VBA, 2006). A veteran who is permanently and totally disabled due to blindness in both eyes with visual acuity of 5/200 or less or the loss or permanent loss of use of both hands may apply.20 Clothing Allowance Veterans are eligible for an annual lump-sum clothing allowance if they have a service-connected disability that requires them to wear or use prosthetics or orthopedic appliances that tend to wear out or tear clothing or if their service-connected disability is due to anatomical loss or loss of use of 19 See also 38 U.S.C. 2101(a), 38 CFR §3.809, and VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Ch. 3. 20 38 CFR 3.808 and M21-1, Part IX, subpart 1, Ch. 2.

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A 21st Century System for Evaluating Veterans for Disability Benefits a hand or foot. VA will also pay a clothing allowance to a veteran if he or she uses medication prescribed by a physician for a service-connected skin condition that causes irreparable damage to the veteran’s outer garments (VA, 2006a).21 According to VA’s FY 2007 budget request, 82,074 veterans received this benefit at an average cost of $615.42, for a total cost of $49.2 million (VA, 2006b). These numbers are based on 2005 figures. TASK FORCE ON RETURNING GLOBAL WAR ON TERROR HEROES In April 2007, President Bush approved the recommendations made by his Task Force on Returning Global War on Terror Heroes, which was appointed in March 2007 (72 FR 10589, based on Title 3—Executive Order 13426 of March 6, 2007; The White House, 2007; Task Force, 2007). Chaired by the secretary of Veterans Affairs, the membership consisted of the secretaries of Defense, Labor, Health and Human Services, Housing and Urban Development, and Education, and the director of the Office of Management and Budget, the administrator of the Small Business Administration, and the director of the Office of Personnel Management (Task Force, 2007). Regarding the Task Force report, President Bush announced a 45-day deadline for the pertinent agencies to report on the implementation of the recommendations issued by the Task Force: Today, Secretary of Veterans Affairs Jim Nicholson and members of the Interagency Task Force on Returning Global War on Terror Heroes released a government-wide action plan that sets out steps to improve our care for America’s troops and veterans. The Task Force has proposed specific recommendations to immediately begin addressing the problems and gaps in services that were identified across the veterans and military healthcare systems. These recommendations include directing the Department of Defense and the Department of Veterans Affairs to develop a joint process for disability determination…. I commend the work of the Task Force, welcome its recommendations, and have directed Secretary Nicholson to work with all agencies involved in the recommendations and to report back to me within 45 days on how these measures are being implemented (The White House, 2007). The Task Force made recommendations that could be implemented within agency authority and with existing resource levels, and the focus was 21 38 U.S.C. 1162, 38 CFR § 3.810, and VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part 9, Ch. 7. Under 38 U.S.C. 1151, veterans injured while receiving medical care or training and rehabilitation services from VA are eligible as if service connected.

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A 21st Century System for Evaluating Veterans for Disability Benefits on timeliness, ease of application, and efficient delivery of services. The services and benefits currently being provided to GWOT servicemembers were cataloged, and the Task Force found that no written or electronic single repository houses a comprehensive list. The Task Force made 15 process and 10 outreach recommendations (Task Force, 2007).22 Of particular interest for this report are Recommendations P-1 (develop a joint process for disability determinations),23 P-11 (extend vocational rehabilitation evaluation determination time limit),24 and P-12 (expedite adapted housing and special home adaptation grants claim).25 The outreach recommendations were made to encourage the inclusion as widely as possible of GWOT servicemembers by making sure they are properly and efficiently notified of services and benefits for which they may qualify (Task Force, 2007). Recommendation P-11 was formulated to allow a seriously injured GWOT servicemember sustained access to independent living services and to increase his or her ability to benefit from rehabilitation services and allow more time to determine whether he or she will be able to achieve an employment goal. Those severely disabled will have sustained access to independent living services for a period exceeding 12 months until a plan to achieve a suitable vocational rehabilitation goal can be formulated (Task Force, 2007). Recommendation P-12 requires the specially adapted housing agent to contact the servicemember or veteran within 24 to 48 hours after the rating decision that awards eligibility for the grant is received, such that the grant process can be explained, the individual’s immediate interest in using the grant can be determined, and, when appropriate, a face-to-face interview can be scheduled. The Task Force recommended that VA expedite service for GWOT servicemembers and veterans in all stages of the application process by both this more timely contact and frequent communication (Task Force, 2007). 22 These include processes such as interagency disability determination, electronic health-care record sharing, health screenings, health benefits enrollment, care management, coordination of transfers, and assuring continuity of care (Task Force, 2007). 23 This process was begun on April 3, 2007, and VA was to participate in an advisory council meeting on May 3, 2007; DoD is the lead agency, working with VA to develop an in-depth plan for a VA/DoD collaboration in the Medical Evaluation Board/Physical Evaluation Board (Task Force, 2007). 24 The target date for this process was April 20, 2007, and allowed for the immediate extension of the 12-month limit on extended evaluation plans. VA is the lead agency. 25 The target date for this process was April 30, 2007, with VA as the lead agency to develop and disseminate implementation procedures to VBA’s field stations.

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A 21st Century System for Evaluating Veterans for Disability Benefits ISSUES The VA benefits package for veterans is provided to compensate them for their service to their country and to enable them to better adjust to and function in the civilian world. The myriad benefits offered—including ancillary and special as described earlier in this chapter—and the eligibility requirements for each individually and as interconnected with other benefits in the network create a complex tapestry. The transition for a veteran leaving military service and reentering civilian life can be difficult for a number of reasons, but it is further complicated when a veteran has become disabled in the course of his or her military service. Disability compensation is one part of the benefits package aimed at increasing the ability of veterans to succeed in the civilian world and, if they have impairments, to compensate them for their loss of earning capacity (defined as the average loss of earnings of those with the same degree of impairment). An example of the interconnectedness of disability compensation with additional benefits is that of veterans with disabilities who are assisted by being able to obtain such items as hearing aids, prosthetics, and wheelchairs, and are eligible for automobile and adaptive equipment, a clothing allowance, and continuing medical care and health insurance. The committee has been asked to consider, from a medical viewpoint, the difficult question of whether the ancillary benefits of vocational rehabilitation, and the automobile, adaptive equipment, housing, and clothing allowances, are appropriate for the conditions the veteran must have to receive them. Although the committee agrees that these benefits and others should be provided to veterans with service-connected disabilities, there are many issues to consider in determining the appropriate thresholds for the entitlements, including Should the focus of a benefit be the kind of impairments (e.g., current criteria for automobile benefits and housing) or the individual veteran’s specific/actual needs in a given area (e.g., vocational rehabilitation)? Is it possible to determine with some degree of accuracy whether the current levels of benefits have improved veterans’ medical or vocational outcomes? Without knowing the impact of the current benefits on those veterans receiving them, it is difficult to make judgments about the appropriateness of the current eligibility rules and benefit amounts. In addition, it is difficult to consider whether eligibility rules and benefits amounts should be changed without benchmark information on the efficacy of the current benefits. To address such issues, it is imperative to have reliable and valid research data in such areas as the realized beneficial effect of the medical

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A 21st Century System for Evaluating Veterans for Disability Benefits and vocational benefits in veterans’ quality of life, reentrance into the workforce, and the ability to maintain gainful employment. These data should demonstrate sufficient improvement to support the existence and structure of the programs offered. The same is true on the issue of the remuneration levels that have been set and how they were determined. Some of the benefits are indexed, while others are not, and some benefits have not been adjusted for many years. Although VA takes a national average approach, consideration should be given to adjusting the rate on a regional basis, taking into account differences in cost of living nationwide. The need for an automatic adjustment for inflation should also be considered, based on rising costs in recent years of owning a home, purchasing an automobile, and purchasing adaptive equipment in homes and automobiles. Reliable data are needed to inform these decisions. The VR&E benefits are an integral part of the compensation package for many service-connected veterans. However, despite demonstrated improvements in the program in recent years, the current VR&E system was been found to be “out-of date, data poor, and understaffed” by the VA VR&E Task Force (VA, 2004). The task force recommended a new employment-driven service delivery system, integrated services across agencies, and implementation time frames for these specific suggestions. A broader, integrated approach to assist veterans in their transition from military to civilian life was recommended through the coordination of VA’s health, VR&E, and compensation programs. An even more individualized approach was suggested by the task force, including continuing and systematic medical examinations of veterans for better informed career and employment decisions; early, routine functional capacity assessments by vocational experts for both disability compensation and rehabilitation decisions; and a change from a sequential series of required steps to a more individualized sequence taking into consideration the person’s education, vocational rehabilitation, and compensation needs. The committee agrees with these recommendations and has formulated other questions as well: What is the basis for the 12-year limit on eligibility for vocational rehabilitation services? What is the basis for the requirement that a veteran have a service-connected disability rated at 20 percent (if there is an “employment handicap”) or a 10 percent rating (if there is a “serious employment handicap”) in order to qualify for VR&E services? VR&E services are likely to enable

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A 21st Century System for Evaluating Veterans for Disability Benefits the veteran with disabilities to engage in substantial and fulfilling gainful employment and improve his or her quality of life. Over the long term, this appears to be a better solution than fostering dependence on the VBA system across the veteran’s life span. The committee thus questions the current 20 percent or higher disability threshold for eligibility and encourages consideration of a lower threshold for entitlement to these services. Again, one must have reliable data to make appropriate judgments. There are also difficult policy issues to be considered: Should every veteran be offered vocational rehabilitation, or should the current threshold be lowered, taking into consideration that veterans are reentering a workforce in which desired job qualifications may well have changed from their preservice period, sometimes significantly? Currently, VR&E counselors are not involved in determining whether a service-connected veteran is unemployable, but should this approach in the decision-making process change? Should age, an issue that has been raised in individual unemployability, be a factor in determining eligibility? Certainly, the cost-benefit ratio is lower (more favorable) for younger veterans who access VR&E services and improve job opportunities over the course of their working life than older veterans who are approaching typical retirement age. Also, with increasing age, individuals are likely to have more medical problems and normal decline in some faculties that may limit employability and ease of returning to a training program. VA should therefore consider age as one of several factors in providing VR&E services, particularly during time periods when resources limit the availability of these services to all veterans with disabilities. FINDINGS AND RECOMMENDATIONS The committee supports providing a comprehensive package of benefits for veterans reentering civilian life after serving their country in the military. However, data on the mitigating effects of each type of benefit on functional limitation or work disability or other forms of participation, or on improving quality of life, are lacking. A better approach to assessing the needs of individual veterans is needed, and severity of illness and quality of life should be taken into consideration throughout the processes of determining which benefits are appropriate and how the benefits should be administered. An assessment of health-care and rehabilitation needs should be performed in conjunction with the assessment of compensation needs, so that veterans will benefit from all services VA provides to help veterans with

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A 21st Century System for Evaluating Veterans for Disability Benefits disabilities succeed in civilian life. These include specialized research and rehabilitation centers for vision impairment, spinal cord injury, traumatic brain injury, polytrauma, and difficult-to-diagnose war-related illnesses. The assessment should also include the need for education, vocational rehabilitation, and other VA ancillary services and benefits, which, together, could enhance a veteran’s ability to succeed in civilian life. The most beneficial time for comprehensively evaluating a veteran’s needs for VA services to maximize his or her success in civilian life is at the time of separation from the service, although separating servicemembers might be given a grace period of six months or a year to apply to VA for benefits. With several hundred thousand servicemembers who are leaving the service and applying for VA compensation each year, the workload of evaluating this group alone would be substantial. Accordingly, the recommendation of comprehensive multidisciplinary evaluations is not meant to be retroactive. Recommendation 6-1. VA and the Department of Defense should conduct a comprehensive multidisciplinary medical, psychosocial, and vocational evaluation of each veteran applying for disability compensation at the time of service separation. The Task Force indicated that the handling of adapted housing and special home adaptation grants claims needs to be expedited by notifying the returning GWOT applicant within 48 hours of his or her rating decision (Task Force, 2007). A larger issue than the important step of expedited notification is that VA does not systematically assess the needs of veterans or evaluate its ancillary service programs. Many ancillary benefits arose piecemeal, in response to circumstances of the time they were adopted, such as clothing allowances, automobile grants, and adaptive housing. The thresholds that have been set for ancillary benefits requirements were not based on research on who benefits or who benefits most from the services in terms of rating level. Therefore, it is not possible to judge their appropriateness. It is possible that these programs could be changed to serve veterans better or that there are other unaddressed needs. Recommendation 6-2. VA should sponsor research on ancillary benefits and obtain input from veterans about their needs. Such research could include conducting intervention trials to determine the effectiveness of ancillary services in terms of increased functional capacity and enhanced health-related quality of life. The President’s Task Force recommended that the time limit in the VA VR&E program should be extended from 12 to 18 months to allow

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A 21st Century System for Evaluating Veterans for Disability Benefits additional time for returning servicemembers to better understand their rehabilitation needs: VA Vocational Rehabilitation and Employment Service (VR&E) will authorize the immediate extension, to 18 months, for an Individualized Extended Evaluation Plan (IEEP) for those OIF/OEF participants whose severity of injuries warrant additional time to make the determination of current feasibility of achieving an employment goal while continuing to provide independent living services (Task Force, 2007:2). While this time extension is applauded, the committee must point out another important aspect of rehabilitation policy that should be considered. The current 12-year limit on eligibility for vocational rehabilitation services is a policy decision with no medical basis, although there may be administrative convenience or fiscal control reasons. There are types of employment and training requirements that do not realistically adhere to a 12-year deadline. For example, emerging assistive and workplace technologies (e.g., computing) may provide training or retraining opportunities for veterans with disabilities through continuing education of various kinds. New types of work may also emerge for which veterans with disabilities could be trained. Advancements in medical knowledge and breakthroughs in medical technology also do not abide by a 12-year limit. Recommendation 6-3. The concept underlying the extant 12-year limitation for vocational rehabilitation for service-connected veterans should be reviewed and, when appropriate, revised on the basis of current employment data, functional requirements, and individual vocational rehabilitation and medical needs. The percentage of entitled veterans applying for VR&E services is relatively low. In FY 2005, about 40,000 veterans applied for VR&E services and were accepted. About 160,000 veterans began receiving benefits for service-connected disabilities that year, but the pool of those potentially eligible is much larger. Of those deemed eligible, between a quarter and a third have not completed the program in recent years. VA should explore ways to increase participation in this program. Recommendation 6-4. VA should develop and test incentive models that would promote vocational rehabilitation and return to gainful employment among veterans for whom this is a realistic goal.

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A 21st Century System for Evaluating Veterans for Disability Benefits REFERENCES GAO (Government Accountability Office). 2005. Vocational rehabilitation: More VA and DOD collaboration needed to expedite services for seriously injured servicemembers. GAO-05-167. http://www.gao.gov/new.items/d05167.pdf (accessed March 6, 2007). Steier, F. 2006. Vocational Rehabilitation & Employment Service. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, September 21. Task Force (Task Force on Returning Global War on Terror Heroes). 2007. Task force report to the President: Returning global war on terror heroes. Washington, DC: Task Force. http://www1.va.gov/task/force/docs/GWOT_TF_Report_042407.pdf (accessed April 25, 2007). The White House. 2007. Statement by the President, April 24. Washington, DC: Office of the Press Secretary. http://www.whitehouse.gov/news/releases/2007/04/20070424-12.html# (accessed April 25, 2007). U.S. Congress, House of Representatives, Veterans’ Affairs Subcommittee on Economic Opportunity. 2007. Statement of Bill Borom, Deputy Director, Vocational Rehabilitation and Employment Service, VA. 110th Cong., 1st Sess., March 7. http://veterans.house.gov/hearings/schedule110/mar07/03-07-07/BillBorom.pdf (accessed May 2, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2006. Statement of Gordon H. Mansfield, Deputy Secretary, VA. 109th Cong., 2nd Sess., December 7. http://www.va.gov/OCA/testimony/hvac/seo/061207GM.asp (accessed May 4, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2005. Statement of Judith Caden, Director, Vocational Rehabilitation and Employment Service, VA. 109th Cong., 1st Sess., April 20. http://veterans.house.gov/ hearings/schedule109/apr05/4-2005e/jcaden.pdf (accessed March 6, 2007). U.S. Congress, Senate, Committee on Veterans’ Affairs. 2005. Statement of Daniel Cooper, Under Secretary for Benefits, VA. 109th Cong., 1st Sess., October 27. http://www.va.gov/OCA/testimony/svac/05102720.asp (accessed May 4, 2007). VA (Department of Veterans Affairs). 2001. 2001 National Survey of Veterans: Final report. Washington, DC: Department of Veterans Affairs. http://www.va.gov/vetdata/docs/NSV%20Final%20Report.pdf (accessed June 22, 2007). VA. 2004. The Vocational Rehabilitation and Employment Program for the 21st century veteran: Report to the Secretary of Veterans Affairs. Washington, DC: Vocational Rehabilitation and Employment Task Force. http://www.va.gov/op3/docs/VRE Report.pdf (accessed December 8, 2006). VA. 2006a. Federal benefits for veterans and dependents, 2006 edition. Washington, DC: VA. http://www.va.gov/opa/vadocs/fedben.pdf (accessed December 8, 2006). VA. 2006b. FY 2006 congressional submission, summary, volume 4. Washington, DC: VA. http://www.va.gov/budget/summary/HTML/ html_files/chapter_1.html (accessed December 8, 2006). VA. 2007. Department of Veterans Affairs, budget of the United States government: Fiscal year 2008. http://www.gpoaccess/usbudget/fy08/pdf/budget/veterans.pdf (accessed March 6, 2007). VBA (Veterans Benefits Administration). 2006. Chapter 4: Reviewing entitlements. LIE Program Guide. http://www.warms.vba.va.gov/admin21/guide/lie/ch04.doc (accessed May 4, 2007).