TN 120 (01-14)

SI 00830.312 VA Payment Adjustment for Unreimbursed Medical Expenses

Citations:

Regulations 20 CFR — 416.1103(a)(7)

A. Introduction for payment adjustment for VA unreimbursed medical expenses

The Department of Veterans Affairs (VA) considers unreimbursed medical expenses when determining some needs-based pension and compensation payments. For a discussion of pensions, see SI 00830.302.

For a discussion of compensation, see SI 00830.304. The VA deducts the amount of the unreimbursed medical expenses from countable income when computing the VA payment. As a result, the veteran, surviving spouse or dependent surviving parent may receive a higher monthly VA payment, an extra payment, or an increase in an extra payment. The VA considers expenses, which exceed 5 percent of the maximum annual VA pension payment rate, as unreimbursed medical expenses.

B. Policy for the income treatment of VA unreimbursed medical expenses payments

1. Effective July 1, 1994

VA payments resulting from unreimbursed medical expenses are not income.

2. Prior to July 1, 1994

a. States in the ninth circuit

Any VA increase or extra payment resulting from unreimbursed medical expenses was not income for residents of the Ninth Circuit (Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, Washington, and the Northern Mariana Islands).

This policy was effective with determinations made:

  • on or after January 23, 1986; and

  • prior to January 23, 1986, if the appeal period extended to or beyond that date.

b. Alabama, Florida, Georgia, and Indiana

For residents of the above States, any VA increase or extra payment resulting from unreimbursed medical expenses was not income.

For Alabama, Florida, and Georgia, this policy was effective with respect to VA payments received in August 1993 or later.

For Indiana, this policy was effective with respect to VA payments received in May 1991 or later.

c. Other States

Any VA increase or extra payment resulting from unreimbursed medical expenses was income.

C. Policy for Public Income Maintenance (PIM) payments

If a VA payment to an individual is entirely attributable to unreimbursed medical expenses, then it is not a PIM payment for living arrangement (SI 00835.130) and deeming purposes.

D. Resources policy for VA unreimbursed medical expense payments

Any unspent VA payments resulting from unreimbursed medical expenses are resources if retained into the calendar month following the month of receipt.

E. Procedure for VA unreimbursed medical expense payments

1.  When to consider VA unreimbursed medical expense payments

Consider the issue of unreimbursed medical expenses in all cases involving a VA payment based on need. Develop the issue only if indicated in SI 00830.312E.2. and SI 00830.312E.3. in this section.

2. When not to develop for VA unreimbursed medical expense payments

Do not routinely develop the issue of unreimbursed medical expenses for an ineligible spouse or parent (unless you believe the payment may be entirely attributable to such expenses per SI 00830.312C in this section).

NOTE: If the payment is entirely attributable to unreimbursed medical expenses, other income of an ineligible spouse or parent is subject to deeming.

3. When to develop for VA unreimbursed medical expense payments

Develop the issue of unreimbursed medical expenses (unless precluded by SI 00830.312E.2. in this section) as indicated in the chart below:

Situation

Individual is the...

Action needed

SSI initial claim filed or VA benefits begin.

beneficiary (e.g., veteran, surviving spouse, surviving parent, independent surviving child, apportioned spouse, or apportioned child).

Develop per SI 00830.312F in this section.

 

dependent spouse or dependent child.

Develop per SI 00830.312F in this section only if you believe the expenses may affect the dependent's portion per SI 00830.312F.7. in this section.

Redetermination or other income review.

beneficiary (e.g., veteran, surviving spouse, surviving parent, independent surviving child, apportioned spouse, or apportioned child).

None. (The VA/SSR interface posts the correct amount.)

 

dependent spouse or dependent child.

Develop per SI 00830.312F in this section only if you believe the expenses may affect the dependent's portion per SI 00830.312F.7. in this section.

NOTE: When a veteran is living, he or she is the beneficiary and his or her dependents can be a spouse and children. When a veteran is deceased, his or her surviving spouse is the beneficiary and the surviving spouse’s dependents are his or her children. When a veteran is deceased, and if his or her surviving parent(s) receive parents’ dependency indemnity compensation (DIC), the surviving parent(s) is the beneficiary. When a spouse or child receives benefits directly from the VA through apportionment, the spouse or child is the beneficiary. The VA does not pay any increased benefits for any dependents of the surviving parent(s) or surviving child. For a discussion of beneficiaries and dependents, see SI 00830.314.

F. Procedure for development and documentation of VA unreimbursed medical expense payments

1.  Examine documents

If documents in file show that VA considered unreimbursed medical expenses, go to SI 00830.312F.3. in this section. If not, go to SI 00830.312F.2. in this section.

2. Question the individual

Question the individual following these steps. You need not document responses:

Step

Action

1

Did the individual or any member of his or her family report any income (other than SSI) to VA?

  • If yes, or unknown, go to Step 2.

  • If no, STOP. No further action is necessary.

2

Did VA ever notify the individual (or the VA claimant) that medical expenses were considered in the VA payment?

  • If yes, go to SI 00830.312F.3. in this section.

  • If no, STOP. No further action is necessary.

  • If unknown, go to Step 3.

3

Has the individual (or the VA claimant) ever reported medical expenses to VA?

  • If yes, or unknown, go to SI 00830.312F.3. in this section.

  • If no, STOP. No further action is necessary.

3. VA unreimbursed medical expense payments possible

  1. Adjudicate the case counting the total VA payment as income following the normal rules if a payment is possible.

  2. Explain to the applicant or recipient that we will contact VA for more information and, if we find that we should have paid more money, we will pay it when we receive the information.

  3. Control the case until the information is received.

4. VA unreimbursed medical expenses payments not possible

Take no action to deny initial claims for excess income if a payment is not possible counting the total VA payment as income and the VA payment is material to eligibility. In post-eligibility situations, input the total VA payment to suspend benefits, but do not process any overpayment. Hold these cases pending receipt of the information from VA.

5. Contact VA

Use Form SSA-L1103-U3 to contact the Veterans Affairs Regional Office (VARO) through the parallel DO:

  • For VARO addresses, see SI 00830.320E.

  • In Part I of the form, complete only the identifying information for the claimant and the veteran unless you are requesting other information.

  • In Part II of the form, enter the date you are requesting the unreimbursed medical expenses. The VA will not normally provide this information unless you enter a date.

6. VA unreimbursed medical expenses involved

If VA reports payments due to unreimbursed medical expenses:

  • reopen under the rules of administrative finality (SI 04070.001), the determination made under SI 00830.312F.3. or SI 00830.312F.4. in this section; and

  • deduct the amount from the total VA payment to determine chargeable income, and adjudicate the case.

    NOTE: If payments due to unreimbursed medical expenses exceed the amount attributable to the veteran or surviving spouse, see SI 00830.312F.7. in this section.

7. VA unreimbursed medical expenses and augmentation involved

If augmentation is involved, for a discussion of augmentation, see SI 00830.314:

  • deduct the payments due to unreimbursed medical expenses first from the veteran’s or surviving spouse's portion, and

  • deduct any remaining amount from the dependent's portion.

    NOTE 1: If more than one dependent is involved, prorate the remaining amount equally among the dependents.

    NOTE 2: When a veteran is living, the veteran is the beneficiary and his or her dependents can be a spouse and children. When a veteran is deceased, his or her surviving spouse is the beneficiary and a surviving spouse’s dependents are his or her children. When a veteran is deceased, his or her independent surviving child (e.g., the surviving child is no longer in the custody of the surviving parent or the surviving parent is deceased) is the beneficiary. When a veteran is deceased, and if his or her surviving parent(s) receive parents’ DIC, the surviving parent(s) is the beneficiary. When a spouse or child receives benefits directly from the VA through apportionment, the spouse or child is the beneficiary. The VA does not pay any increased benefits for any dependents of the surviving parent(s) or surviving child. For a discussion of beneficiaries and dependents, see SI 00830.314.

8. Systems input for VA unreimbursed medical expenses

Input the chargeable VA income for an initial claim, for a start date record, and when VA benefits begin. The monthly VA/SSR interface will post the correct amount thereafter.

G. Procedure for manual notices

1. Issuing a manual notice

In the following situations, issue a manual notice to explain to the recipient what effect medical expenses have on the SSI determination:

  1. For initial claims notices, follow general instructions in NL 00802.001.

  2. For post-eligibility notices, follow general instructions in NL 00803.001.

2. Situation 1 – initial claim

a. Description

You are allowing an initial claim, but verification of VA money paid for medical expenses is outstanding.

b. Actions

Take the following actions:

  1. Suppress the systems-generated notice.

  2. Issue a manual SSA-L8025-U2 (Notice of Award).

  3. Include INCM01 as the last paragraph in NL 00804.175 under the caption “Information About Your Payments.”

3. Situation 2 - underpayment

a. Description

After the occurrence of Situation 1 – initial claim, verification is received from VA that the claimant's VA payment includes money for unreimbursed medical expenses. The claimant is due an underpayment or an underpayment and an increase in the recurring payment amount.

b. Actions

Take the following actions:

  1. Input the corrected VA income per SI 00830.312F.8. in this section.

  2. Suppress the automated notice.

  3. Issue a manual SSA-L8100-U2 (SSI Notice of Revised Determination) for an underpayment, or an SSA-L8151-U2 (SSI Notice of Change in Payment) for an underpayment and an increase in a recurring payment.

  4. Include the paragraphs under INCM02 in NL 00804.175 under the caption “Why Your Payments Changed.”

  5. Include paragraph INCM03 in NL 00804.175 under the caption “Your Payment is Based on These Facts” and the stock paragraph 1231 for income facts.

4. Situation 3 – verification from the VA

a. Description

After the occurrence of Situation 1 – initial claim, verification is received from VA that the claimant's VA payment does not include money for unreimbursed medical expenses.

b. Actions

Take the following actions:

  1. Issue a manual SSA-8166-U2 (SSI Important Information).

  2. Use the paragraphs under INCM04 as the text of the notice in NL 00804.175.

5. Situation 4 – post-entitlement case

a. Description

You have a post-entitlement case under force pay control. The amount of a monthly VA payment that includes money for unreimbursed medical expenses changes, causing an increase or decrease in the SSI benefit.

b. Actions

Take the following actions:

  1. Issue a manual SSA-L8151-U2 (Notice of Change in Payment) for an increase or a manual SSA-L8155-U2 (SSI Notice of Planned Action) for a decrease.

  2. Include the paragraphs under INCM05 in NL 00804.175 under the caption “Why Your Payments Changed.”

  3. Include paragraph INCM06 in NL 00804.175 under the caption “Your Payment is Based on These Facts” and the stock paragraph 1231 for income facts.


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http://policy.ssa.gov/poms.nsf/lnx/0500830312
SI 00830.312 - VA Payment Adjustment for Unreimbursed Medical Expenses - 01/22/2014
Batch run: 01/22/2014
Rev:01/22/2014