Veteran-Directed Home and Community Based Services Program (VD-HCBS)

Page Reviewed / Updated - Apr. 2018

Definition

The Veterans Directed Home and Community Based Services (VD-HCBS) program is designed to allow veterans who are potential candidates for nursing home placement to receive that level of care in their homes, their caregivers' homes or in non-supportive, independent living communities (not assisted living residences). The program provides veterans with a budget and allows them to choose their own care providers in place of receiving care services from the VA health care system. In some cases, family members of the veteran can be paid for the care they provide.

Discussion

Veterans Directed Home and Community Based Services allows veterans to prioritize their own care needs, select their own care providers, and act as an employer instead of receiving nursing home care from the VA directly. This program started in 2009 and is being rolled out through local VA Medical Centers (VAMCs). It is a stated objective to make the VD-HCBS Program available nationwide, however no timeline has been given toward reaching that goal.

Surveys of program participants have found 95%+ of participating veterans found this program was meeting their needs, improving their overall satisfaction and improved their access to care. Having said that, these programs are not appropriate for everyone. A substantial amount of effort is required of the veteran and their family in the determination of care requirements, selection of providers and ongoing management of the care services. However, for many families the independence to choose care providers, the potential to pay family members for their assistance, and the ability for the veteran to continue living at home make participation in this program well worth the effort.

How the Program Works

1) The veteran, working with family members, and usually an advisor from the state, develops a “Care Plan” outlining the services, supports, supplies and estimated budget for the veteran to live at home or in the community instead of a nursing home. The name “Care Plan” or “Participant Spending Plan”, changes from state to state but the concept is the same. 

2) The veterans submit their Care Plan for approval to the administering agency. The Plan is reviewed and any required modifications, are agreed upon through a collaborative back-and-forth process. In conclusion, a spending budget is established for the veteran.

3) The veteran hires and schedules all care providers, services providers, and necessary supplies.  It is very common for a veteran to hire family members, including their spouses, neighbors and / or friends to provide them with personal care.  Hired care providers are expected to pay taxes for the wages received.

4) The administering agency provides a Financial Management Service (FMS) that pays for care and issues checks to the service providers and / or reimbursement for goods purchased with pre-approval. Payments made to care and service providers are authorized by both the veteran and the FMS.

VD-HCBS vs. Medicaid Cash and Counseling

An important distinction between the VD-HCBS program and Medicaid’s Cash and Counseling program is that in the VD-HCBS program, participants have a budget and the ability to authorize payments to their care providers but do not personally receive cash from the program as is the case with most Cash and Counseling programs. These two programs are mutually exclusive. Therefore, a veteran cannot participate in both VD-HCBS and in a Medicaid’s Cash and Counseling program concurrently. Medicaid Cash and Counseling programs are also referred to as Consumer Directed Medicaid Waivers.

Qualifications

Veterans Directed HCBS program is open to all US Veterans enrolled in the VA health care system that require a nursing home level of care. These programs are at various stages of development in different states and often participation requirements change as a program matures. What follows are the typical requirements.  It is recommended that the applicant check with their local Area Agency on Aging to determine final eligibility.

Age - the VD-HBCS Program is open to veterans of any age.

Disabilities / Health Requirements - Veterans are eligible provided they require “nursing home level care”. However, there are multiple factors and exceptions associated with this requirement. Typically, individuals requiring assistance with 3 or more activities of daily living are eligible. These restrictions are less rigid for those veterans over 75 years of age, or who are clinically depressed, or receiving hospice care or live alone. A diagnosis of Alzheimer’s alone does not make an individual eligible, but the care requirements of most individuals with moderate to advanced Alzheimer’s will make them eligible. 

Marital Status - a veteran’s marital or family status does not make them ineligible for participation in this program. However, individuals that live alone may experience less rigid requirements.

Residential Location - veterans must live at home, in the home of a loved one, or in an independent living residence (which do not offer care support). They cannot reside in a nursing home or assisted living community. 

Financial - the program does not have specific income and asset limits. However, participants must be enrolled in VA Health Care and assigned to a Priority Group and some Priority Group benefits are impacted by one’s income and assets.  Aid and Attendance payments are not considered a factor when determining the amount of a veteran's care budget in the VD-HCBS Program.

Veteran Service and Discharge - veterans are required to have had 24 months of continuous active duty military service and a discharge status other than Bad Conduct or Dishonorable to be eligible for VA Health Care. There are exceptions to the 24-month rule for:

• Reservists or National Guard members that were called to Active Duty and completed their terms.
• Those requiring treatment for a service-connected condition or disability
• Those discharged or released from active duty for a hardship or an “early out”

Geographic - As of April 2018, there are 77 programs in the 42 states listed below (including Washington DC and Puerto Rico). While not all geographic areas within these states have coverage, veterans are permitted to travel from the home area to participate. Also, many other states are in the process of approving pilot-programs.   If one's state is not listed below, the candidate should check with their local Area Agency on Aging to see if a program is in development in their geographic area.

Benefits

VD-HCBS programs will pay for a very wide range of services and goods. Any product or service that is required for the participant’s care, health maintenance, or improves the participant’s ability to live independently, will usually be covered by the program. Participants receive a monthly budget to use for their personal care and relevant supplies in place of receiving the same from the VA Health Care system. To be clear, the veteran authorizes the agency to pay service providers on his or her behalf but does not personally receive the cash payments.

Paying Family Members as Caregivers

The option to pay any family member to provide caregiving assistance is probably the single most attractive benefit of veterans directed care.  To be clear, the adult children, siblings, grandchildren and even the veteran's spouse can be hired and paid as caregivers.  Of course, caregivers must be physically and mentally capable of providing the care for which they will be compensated.  Caregivers are paid an hourly rate set nationally by the Veterans Health Administration and adjusted for local geographic factors.  The hourly rate is referred to as the "reimbursement rate" and caregivers can expect compensation in the range of 50-75% of the average hourly rate for home care for their region.  In very general terms, this may be between $8 - $22 / hour.

Covered Product and Services

The following is a list of products and services that are typically paid for under this program:

• Adult day care
• Caregiver education, training and support
• Chore and maintenance services such as yard trash, debris and snow removal
• Electronic monitoring products and services such as room and bed monitors, voice-activated phones and emergency response systems
• Home modifications such as bathroom grab bars, railings, wheelchair ramps, walk-in tubs and vehicle modifications
• Health maintenance costs such as health counseling, massage therapy, weight reduction programs and health club memberships
• Homemaker services such as laundry, house, kitchen and bath cleaning
• Personal care services which includes assistance with bathing, toileting, personal grooming and dressing
• Other services or products needed in the home to keep the veteran living independently
• Respite care in-home, out-of-home and overnight
• Nutritional services such as home delivered meals and supplements provided they have been prescribed by a physician or dietitian
• Home safety services
• Shopping, errand and escort assistance
• Socialization support services such as having a caregiver accompany the veteran to education or exercise classes and on social engagements
• Transportation required for socialization support or medical support activities

Ineligible Expenses

While the range of goods and services the VD-HCBS program will pay for is extensive, certain costs are not covered. These include:

• Any service duplicating a service which the veteran receives from the VA
• Room and board, including rent or mortgage payments
• Personal items and services not related to one’s disability or independence
• Experimental treatments not approved by the VA
• Personal care in assisted living communities.  However personal care provided by outside caregivers in independent living communities should be considered eligible.

Budgets & Limits

The monthly budget allocated for a veteran’s care depends on their individual requirements and is determined during the development of their Care Plan. The maximum amount allowed varies from state to state. Typically, the cost of this care cannot exceed the cost for the same care were it provided by the VA in a skilled nursing facility. In real dollar terms, budget maximums rarely exceed $4,500 / month.

Time to Receive Benefits

Participants should expect several months for the preparation and approval of a Care Plan prior to actually receiving care services. The process can be accelerated if a participant begins the hiring process for care providers after submitting their Care Plan while waiting for its approval. However no payments can be made until the Care Plan has been approved.

Costs

Veterans do not incur any costs to participate in the program.

How to Apply

The VD-HCBS program is a joint effort of the VA and the local Area Agencies on Aging.  Review the list of participating VA Medical Centers and then contact your local Area Agency on Aging.