White Paper - 10-10EC

10/24/2016

VHA Office of Community Care

VA Form 10-10EC, Application for Extended Care Services

Issue: This Department of Veterans Affairs form replaces VA Form 10-10EC, Application for Extended Care Services which is a VA Form completed by Veterans to apply for VA extended care benefits. The form includes demographic, military, insurance, and financial information.

Discussion: This is an Initial Substantive and Technical Review to ensure adequate opportunity for review and comment prior to the document being put into VA’s official e-concurrence system (VAIQ).

The proposed changes to VA Form 10-10EC:

Instructions Page 1 of 2:

1. STEP 1. Before You Start….

Change to:

STEP 1. Before you start….

2. What is VA Form 10-10EC used for?

To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, either directly by VA or paid for by VA.

Change to:

What is VA Form 10-10EC used for?

To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, either directly by VA or paid for by VA. There is no copayment for the first 21 days of extended care services that VA provides to you in any 12-month period. You must report any changes that might affect the copayment amount to your local VA medical facility within 10 calendar days of the change.

3. Who should complete a VA Form 10-10EC?

Delete section:

The language under this section has confused field staff and Veterans and their representatives. VA medical facility staff must determine ‘who should complete a VA Form 10-10EC’ and this is based on the Veteran’s eligibility and/or income on file in the local VistA system. VA Form 10-10EC is only provided to a Veteran that has been determined to be non-exempt. This section should be deleted.

4. Section IV - Fixed Assets. Do not report fixed assets if the veteran is receiving only non-institutional extended care services. Fixed assets means real property. Exclude burial plots. Do not report the value of the primary residence and one vehicle if the spouse or dependent is residing in the community and maintaining the residence. If the veteran and spouse maintain separate residences include the value of the veteran's residence and vehicle minus any outstanding liens or mortgages. Include the value of all other fixed assets such as other residences (vacation home), land, farm or ranch minus any outstanding liens or mortgages. Fixed assets are only included in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.

Change to:

Section IV - Fixed Assets. Used only in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.

Report real property minus any outstanding lien or mortgage.

Exclude burial plots, veteran’s primary residence and veteran’s vehicle (if the veteran is receiving institutional (inpatient) extended care services this is the primary residence and vehicle of the spouse or dependents).

Instructions Page 2 of 2:

1. Section V - Liquid Assets. Do not report liquid assets if the veteran is receiving only non-institutional extended care services. Liquid assets include, but are not limited to, cash, interest, dividends, stocks, bonds, mutual funds, retirements accounts, stamp or coin collections, art work, and other collectibles.

Liquid assets are only included in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.

Change to:

Section V - Liquid Assets. Used only in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.

Report cash, stocks, dividends received from IRA, 401K’s and other tax deferred annuities, bonds, mutual funds, retirements accounts (e.g. IRA, 401Ks, annuities), art, rare coins, stamp collections, and other collectibles.

Exclude household and personal items such as furniture, clothing and jewelry if the veteran has a spouse or dependents residing in the community.

If the veteran has a spouse residing in the community (not institutionalized), the spousal resource protection amount may be applied to reduce the value of liquid assets.

2. Section VI - Current Gross Income of Veteran and Spouse. Do not include income from dependents.

Report gross annual income from employment including information about your wages, bonuses, tips, severance pay and other ccrued benefits.Report

Report net income from farm, ranch, property or business.

Report other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income, Compensation benefits such a VA disability, unemployment, Workers and black lung, cash gifts, court mandated payments, inheritance amounts, tort settlement payments, interest and dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.

Change to:

Section VI – Income. Current income of the Veteran and the Veteran’s spouse.

Report wages, bonuses, tips, severance pay, and accrued benefits.

Report income from a business (minus business expenses).

Report cash gifts, inheritance amounts, interest income, and the standard dividend income from non tax deferred annuities.

Report retirement income and pension income.

Report unemployment payments, worker's compensation payments, black lung payments, tort settlement payments, social security payments, and court mandated payments.

Report payments from VA or any other Federal programs, and any other income.

Exclude income of the Veteran’s dependents.

3. Section VII. Expenses. Expenses means basic subsistence expenses. Expenses are NOT included in the determination of the extended care copyayment amount if the veteran is single and has been receiving inpatient extended care services for 181 days or more.

Change to:

Section VII. Expenses. Not used in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services and does not a have a spouse or dependents residing in the community (not institutionalized).

Report basic subsistence (living) expenses.

Footer - All Pages:

1. EXISTING STOCK OF VA FORM 10-1OEC, MAY 2005, WILL NOT BE USED.

Change to:

EXISTING STOCK OF VA FORM 10-10EC, JUL 2014, WILL NOT BE USED.

These changes are necessary to assure compliance with requirements under Title 38 Code of Federal Regulations Section 17.111, Copayments for extended care services and VHA Handbook 1601A.06, Applications and Copayments for Extended Care Services.

Implications: None

Attachment

VA Form 10-10EC, Application for Extended Care Services

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