Although this Fast Letter was intended to explain the costs associated with independent living, many VA adjudicators are applying its rules to assisted living facilities as well. The old saying, "When in Rome...." is very applicable to the VA in that it is easier to go ahead and err on the side of caution by assuming that the rules apply both to independent living and to assisted living facilities than it is to argue the point later.
The Fast Letter does allow the cost of room and board as an acceptable medical expense provided that the individual (which may be a claimant or dependent) has been rated either Aid and Attendance or Housebound AND either the facility or a third party is providing "custodial care"; i.e. assistance with two or more acceptable Activities of Daily Living (ADL).
The two supporting evidence documents which can generate either an award OR a denial are the Care Expense Statement (or other similar facility/caregiver affidavit) and the doctor's affidavit (form 21-2680). Errors or lack of relevant information on either of these can be detrimental to the claim.
There are two ways that the entire facility cost (including room and board) will be allowed as unreimbursed medical expense (UME). Both of these require that the doctor confirms the need for a "protective environment" and that the doctor confirms the need for "custodial care" in the form of assistance with two or more of the following: bathing or showering, dressing, eating, getting in or out of bed or a chair, or using the toilet (including incontinence care). Medication monitoring is no longer acceptable as an UME, but is certainly worth documenting to "add icing to the cake". These two ways are:
1. The facility is providing the custodial care (assistance with two or more ADLs as defined above), OR
2. A third-party contractor is providing the custodial care and the doctor has confirmed the need to live in that facility to obtain the third party caregiver's assistance. The Fast Letter does not stipulate that the third party caregiver must be a paid caregiver or a licensed professional, as long as the individual is rated either Housebound or A & A.
In either of the above scenarios, it is suggested that the doctor state the need for:
1. A "protective environment", and
2. The need to live in that particular facility (naming the facility), and
3. The need for two or more of the acceptable ADLs, and
4. The need for a third party caregiver to provide the custodial care (I prefer naming that caregiver) if such a need exists
As in any government agency, the VA has its own rules, regulations, and idiosyncrasies. We as care professionals must simply learn to stay within those rules and regulations for our clients.