Benefits

Question:

Hello Sir, I recently had a surgery for an artificial disc replacement and was hospitalized for a few weeks after. There is not currently a rating for a prosthetic implant in the spine, but areas such as the shoulder, elbow, wrist, and ankle allow for a 100% rating for one year following implantation, after the initial month following a hospital discharge. Replacement of the hip and knee allow for a 100% rating for four months following implantation. (Prosthetic Implants and Resurfacing, diagnostic codes 5051-5056). I have submitted for my temporary 100% for what my surgeon estimates is a 3-6 month recovery, but how can I get the VA to consider my spine’s new titanium addition as with other areas of the body?

Jim's Reply:

You tell VA just what you told me and you ask for extraschedular consideration. The VA is prepared to step outside the box and give some thought to why you're saying what you're telling them. That things change in health care happens all the time and VA adapts the ratings schedule to fit settings just like you speak to.
 

If you can have your doctor agree with you in notes to your chart and record, that will have a lot of impact. If the provider tells the same story you do this should be a chip shot.
 

Be prepared to appeal. This is the VA you're dealing with and just because you make a logical argument doesn't mean you'll prevail the first time around. However, your logic is sound and if you are denied, I'd predict the appeal will go your way.
 

Good luck sir.

Question:

Hi Jim, I am rated on multiple conditions, 65 yrs old and want to file for a secondary condition to CLD stage II (gout and hallux rigidity and sessimoiditis). If I do so, will I lose the protection of the over 55 rule of re-examination and then possible get reduced from current 80%. I am seeking to get enough extra to qualify for 90% if new condition is approved, but I don’t want to actually risk a retaliatory reduction so to speak. Thanks for your assistance.

Jim's Reply:

I don't see any risk to your plan. If you're reasonably sure the symptoms are documented in your record, go for it. However, it may be easier for you to apply for the TDIU benefit, assuming you aren't working. The TDIU benefit can cut through a lot and elevate your rating to 100% pretty quickly. Give this some thought. Good luck sir.

Question:

Hi Jim. I have Medicare Parts A&B, the VA, and Blue Cross Medicare supplement. Without that Medicare supplement, who pays the 20% deductible that Medicare doesn’t cover when I use the Medicare ?

Jim's Reply:

You pay it out of pocket. It's more complex than that of course but that's it in a nutshell. 
 

Health care providers may set a charge for a given product at $100.00. If the provider accepts Medicare, Medicare may offer a payment in full of $40.00 for that product. Medicare will pay all but 20% of that and that's your out of pocket copay.
 

Some services covered by Medicare are provided w/o any copay. You have to ask around at your providers place of business to sort out the preventive care services that come to you at no cost but if you take the time to do that, they're there.
 

I have A & B as well as my VA care. I never take a supplement because it's my opinion that they aren't worth the (very expensive) premiums charged. I get my medicines through VA and I have primary care both at VA and in my home town. I pay a small copay to my civilian primary care provider and I use VA Community Care for specialty providers.
 

This works for me because I've put a lot of thought into how to not go bankrupt trying to stay alive. Every setting will differ depending on the location of health services, a convenience factor and your ability to pay the ever increasing toll for health insurance.
 

I'm a cheapskate so I do the bear minimum and keep my fingers crossed. Good luck sir.

Question:

When I was a pre-teenager I broke both of my wrist, two years apart. When I joined the Navy at 19 years old I noted the wrist fractures on my entrance physical. I am now having severe wrist pain and intend to file a disability claim for aggravation. I do not have any documented issues in my military medical records. So my question is: Can pre -existing conditions like these be service connected? I was a Navy (CB) Construction Battalion Builder in Vietnam in 1970. I am currently seeing a civilian Rheumatologist and am waiting on test results for arthritis. My disabilities include PTSD, Diabetes II and some others. Currently at 80%. Thank You.

Jim's Reply:

 'Can preexisting conditions like these be service connected?'
 

Yes, absolutely. This is too often a steep uphill climb but with the appropriate evidence and logical presentation, you may have an opportunity to prove service connection.
 

You'll need an Independent Medical Opinion (IMO) written by a professional who speaks the language of the VA rater. While your rheumatologist may (or may not) agree that military service caused, aggravated  or contributed to your current disabling wrist conditions, how the opinion is phrased can make or break the claim for you. If you think your doctor is going to do a good job, go for it. Otherwise talk with an IMO doctor to have your records reviewed by a pro who does this every day.
 

Good luck!

Question:

Can I lose my VA benefits if I refuse drug testing? I am treated for mental health issues among other health issues. No prior history of usage, 20 years of service, and 16 years of VA documented medical treatment and drug testing... never one positive test.

Jim's Reply:

No. Benefits aren't associated with health care. Drug screens aren't meant to be to set you up for punishment, they're to detect a health care problem just like a kidney test or a liver test. VA is treating substance use and abuse as a health care issue, and that's very appropriate.

You can learn more here at the VAWatchdog site. 

Question:

I am rated at 90% with a PTSD rating at 70%. I have OSA, central apnea and complex apnea. I started experiencing sleep apnea after being discharged from the service. A forensic psychologist who is also on the board of sleep medicine reviewed my records and connected my sleep apnea to my severe PTSD symptoms. He can write me a six page Nexus letter with citations and scientific studies showing how sleep apnea and PTSD relate to one another. He also completed a DBQ stating the same. The VA wants to schedule me for a QTC exam with one of their doctors. I was told to take my sleep studies, TV Q, and Nexus letter in when I go to ensure examiner sees the information. Can you give me any insight that I might not be aware of. Your input would be greatly appreciate it as I will be at the exam this coming week. Thank you in advance.

Jim's Reply:

I think that you're about as well prepared as anyone I've worked with. The best advice I can give you is to do the best you can to present your case to the examiner while recognizing that the examiner may not accept any documents from you and may insist on sticking to a scripted Q & A dialogue. 
 

VA examiners aren't required to accept any documents from you. Documentation supporting your claim is routinely sent in by you or your rep as a part of your file for review by the rater, not the examiner. VA C & P exams are tightly controlled and the examiner is only allowed to focus on exactly what the rater has requested.
 

Some examiners are more rigid than others and if your examiner isn't open to reviewing your documents, no worries...accept it and don't worry about it.
 

In the final analysis anything the examiner reports is only a part of the process. Good luck.

Question:

Hi Jim. I have been 100% P&T for 14 years. I am 66 years old and I have Medicare and a supplement plan. Recently, I received a statement from my Medicare supplement plan showing that the VA billed my supplement plan for my treatment. The statement also shows that Medicare was billed and both Medicare and the supplement provider paid for this service. Up until this year, all of my VA care was covered by my 100% P&T disability. I don't understand why this VA is billing Medicare and my supplement provider. Thanks for any insights you can give me.

Jim's Reply:

This is nothing more or less than the usual sloppy bookkeeping done by VA. If you're 100% nobody should be billed. However, no matter what you do, VA is going to bill anyone on your list of insurers and hope they get a bite. 

Billing Medicare doesn't reap a payment, it just offsets the VA budget in a creative way. If your supplement carrier doesn't raise a fuss, VA will just take the money and never look back.

This usually happens when the provider you're seeing doesn't tick the correct boxes in the screen they're looking at so billing occurs because you have an insurer listed there.

There's little you can do. You can spend your time trying to find the responsible people inside your VAMC...lots of luck with that. You could tell your insurer but the last I heard of anyone doing that, nothing at all happened. Most insurers see it as the cost of doing business with VA and if it doesn't run into hundreds of thousands of dollars, nobody pays it any attention. Trying to correct mistakes at VA is like arguing with a stop sign...it usually goes nowhere.

My thought is, why do you pay for a Medicare supplement? I've never used one and can't see where there are any benefits to that...other than throwing money at another insurer. Those plans are expensive as heck and after the deductible and copay, I can't see a benefit? I have A & B as well as VA care and it's never been a problem.

Good luck sir.

Question:

I have a 2 100% ratings in which the VA awarded me SMC S. Then I also have: 50%, 60%, 20%, 20%, 20%, 10%, 10%. I was awarded Aid & Attendance(SMC L). When I questioned what the Aid and Attendance covered they lumped everything under my homebound (SMC S). My understanding is that there are steps after the SMC L rating that the VA decided to lump under one instead of awarding at least SMC M. Can you break down how the SMC ratings work and is it based off the time in which the ratings are awarded or does that even matter?

Jim's Reply:

Like so many of the rules and regulations that are required in the VA disability rating process, SMC benefits are hard to calculate.

This is the best explanation I know of https://militarydisabilitymadeeasy.com/special-monthly-compensation.html  Good luck sir.

Question:

Hi. I’m currently being paid compensation at 100% due to TDIU. For the past 14 years I have also been rated total and permanent. I was just diagnosed with Non Hodgkin Lymphoma. I served 12 months in Vietnam - boots on the ground. If I file for disability based on exposure to Agent Orange and am granted an additional temporary 100% schedular, do I go back to my original rating before I filed for Agent Orange exposure if I go into remission? Thanks.

Jim's Reply:

You'll have two 100% ratings. VA will do the math and you'll come up with a 'housebound' SMC-s rating. Read about SMC ratings here.
 

As you receive your first treatments over time all this will remain the same. Once you complete the first round of chemo you'll be given a sort of grace period and then you'll have a C & P exam (a 'future exam') to determine whether or not you're truly in remission and what sort of leftover disabling conditions you have from treatments...like scarring around the infusion port you're likely to receive.
 

At that C & P exam your future rating will be determined largely by the conditions that you suffer from treatment. You should be prepared to detail just how hard all this has been for you both physically and mentally. Don't hesitate to seek help from a mental health provider within the VA as you progress. Not only will that provide you with some peace of mind, it will support any mental health claim you may need to make in the future.
 

If you are in remission, your rating will most likely eventually fall back to TDIU w/o the SMC. Good luck sir.

Question:

My wife qualifies for CHAMPVA. If I pass and she is unable to qualify for DIC, will she still receive the CHAMPVA? Thank you.

Jim's Reply:

No. CHAMPVA is part and parcel of your benefit array and comes with your (living) 100% P & T rating or DIC. If you are rated 100% P & T for ten uninterrupted years, you can die of anything and she'll be DIC eligible. If you're rated 100% P & T for less than 10 uninterrupted years you must pass from a rated service connected condition or there are no VA benefits for her.