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Frail Disability Benefits Recipients

Issuing Authority: Director General, Policy and Research
Effective Date: April 1, 2019
Document ID: 2282

Care has been taken to ensure these policies accurately reflect the acts and regulations. Should any inconsistencies be found, the acts and regulations will prevail.

Purpose

This policy provides guidance on determining eligibility for the Veterans Independence Program (VIP) for certain disability pensioners, disability award or pain and suffering compensation recipients.

Definitions

  1. For the purpose of administering this policy, the following definitions apply:

    Frail is defined as the occurrence of a critical mass of physiological conditions that place an individual at risk for falls, injuries, illnesses or the need for supervision or hospitalization. Frailty also results in a severe and prolonged impairment of function with little or no likelihood of improvement. The designation of “frail” is based on the premise that for individuals suffering from multiple health conditions, one of which is a disability benefits entitled condition; this complex interplay of disabilities impairs their ability to remain self-sufficient at their principal residence.

    Inordinate amount of time means significantly more time than it would take an individual of the same age to complete the activity in the absence of the impairment.

    Prolonged impairment means the impairment(s) has lasted, or is expected to last, for a continuous period of at least 12 months (i.e. an ongoing health issue that has a significant impact on the lives of a person and/or their family, or other caregivers). Life expectancy is not a consideration when determining if an individual is suffering from a prolonged impairment, and a Veteran who has been diagnosed to be in the last stages of life (i.e. palliative) may be deemed “frail”.

Policy

General

  1. For the purpose of administering this policy, the term “Veteran” is interpreted to include all individuals eligible for the VIP. If applicable, it also includes a duly authorized representative of the Veteran.
  2. This policy applies only to the following:
    1. Veteran pensioners whose total disability assessments under the Pension Act and the Veterans Well-being Act are less than 48% (see policy entitled Eligibility for Health Care Programs - Veteran Pensioner)
    2. Civilian pensioners whose total disability assessments under the Pension Act and the Veterans Well-being Act are less than 48% (see policy entitled Eligibility for Health Care Programs – Civilian Pensioners);
    3. Special duty service pensioners (see policy entitled Eligibility for Health Care Programs – Special Duty Service Pensioner);
    4. Military service pensioners (see policy entitled Eligibility for Health Care Programs – Military Service Pensioner);
    5. Former members or reserve force members entitled to a disability award or pain and suffering compensation (see policy entitled Eligibility for Health Care Programs - Entitled to a Disability Award (Regular and Reserve Force Services); and
    6. Former members or reserve force members entitled to a disability award in respect of special duty service (see policy entitled Eligibility for Health Care Programs – Entitled to a Disability Award or Pain and Suffering Compensation for Special Duty Service).
  3. Access to the VIP for Veteran Pensioners and Civilian Pensioners whose extent of disability is equal to or greater than 48% is based on need; there is no requirement that the need be in respect of a pensioned condition.
  4. Royal Canadian Mounted Police (RCMP) Pensioners are not eligible for VIP nor can their RCMP service be added to their service in World War II or Korea to qualify them as Medium Disabled or Seriously Disabled Veteran Pensioners. See policy entitled Eligibility for Health Care Programs – Royal Canadian Mounted Police for information regarding benefit eligibility for RCMP pensioners.

Veterans Independence Program Entitlement

  1. Entitlement for the VIP is based on an assessment that indicates either:
    1. the Veteran’s ability to remain self-sufficient in their principal residence is impaired by their disability benefits enititled condition; or
    2. the Veteran needs the required services because he/she is “frail”.
  2. Where possible, every effort should be made to establish that the need for the service is linked to the disability benefits enittled condition, as it is more beneficial for the Veteran. For example, a Veteran who is admitted to VIP intermediate care because they are “frail” will be responsible for paying an Accommodation and Meals Contribution; however, if the admission is in respect of a diasability benefits entitled condition, the Veteran will not be required to pay the Accommodation and Meals Contribution.

Treatment Benefits Eligibility

  1. Veteran pensioners, civilian pensioners, special duty service pensioners and former members entitled to a disability award or pain and suffering compensation for special duty service who are receiving VIP services because they are “frail” are eligible to receive treatment benefits for disability benefits entitled conditions (i.e. eligible for B-line health coverage).
  2. Military service pensioners and former members or reserve force members entitled to a disability award or pain and suffering compensation that is not for special duty service are eligible to receive treatment benefits only for their disability benefit entitled condition(s), even if they are in receipt of VIP services because they are “frail” (i.e. not eligible for B-line coverage).

Frail Criteria

  1. In establishing whether a disability benefits recipient satisfies the criteria to be considered “frail”, there must be evidence that the individual suffers from one of the prolonged impairments described in paragraph 11, or two or more of the prolonged impairments described in paragraph 12.
  2. One of the following conditions is present all or most (85%) of the time:
    1. visual acuity in both eyes with corrective lenses is 20/200 (6/60) or less, or the greatest field of vision is less than 20 degrees (i.e. legally blind);
    2. amputation or paraplegic in accordance with Table 3 of Chapter 5 of the Table of Disabilities;
    3. unable to speak so as to be understood in a quiet setting, or takes an inordinate amount of time to do so, even with the aid of medication, therapy or a device (excludes stuttering);
    4. unable to hear (without lip-reading) a spoken conversation in a quiet setting, even with the aid of medication, therapy or a device;
    5. unable to personally manage bowel or bladder functions - requiring assistance with the use of incontinent supplies, ostomy care or catheter care;
    6. unable to walk 50 metres on level ground, or takes an inordinate amount of time to do so, even with the aid of medication, therapy or a device;
    7. unable to perceive, think or remember, even with the aid of medication, therapy or a device. As an example cannot initiate or manage personal care without constant supervision;
    8. unable to feed himself or herself, or takes an inordinate amount of time to do so, even with the aid of medication, therapy or a device;
    9. is totally dependent on another to dress or wash the entire body; or
    10. requires life-sustaining therapy to support a vital function (e.g. oxygen therapy; clapping therapy to help in breathing; kidney dialysis to filter blood) at least 3 times per week for an average of at least 14 hours per week. NOTE: Life-sustaining therapy does not include implanted devices such as a pacemaker or special programs of diet, exercise, hygiene, or medication.
  3. Two or more of the following conditions are present:
    1. Vision impairment – e.g. enrolled for services with the Canadian National Institute for the Blind but not legally blind (e.g. macular degeneration, severe cataracts);
    2. Musculoskeletal/neurological disorders resulting in difficulty walking or severe functional disability in the upper limbs. For example:
      1. decreased strength in the knees (e.g. gunshot with significant nerve damage)
      2. balance and gait abnormalities (e.g. Parkinson’s, stroke)
      3. lower extremity disability (e.g. severe arthritis)
      4. infrequent walking or exercise due to physical limitations (e.g. severe arthritis, stroke, amputation at ankle)
      5. loss or severe restriction of the functional use of arm/hand (e.g. amputation at wrist or above, severe intention tremors).
    3. Either (i), (ii) or both:
      1. Cardiac – diagnosed as Class 4 of the New York Heart Association Functional Classification System: unable to perform any physical activity without discomfort. Symptoms of inadequate cardiac output, pulmonary congestion, systemic congestion, or angina syndrome may be present at rest. If any physical activity is undertaken, discomfort is increased. (E.g. Ischemic Heart Disease, Cardiomyopathy, Valvular Heart Disease.)
      2. Respiratory – results of Pulmonary Functions Testing indicate severe limitations. (E.g. COPD including emphysema, lung cancer, Pneumonectomy.)
    4. Congnitive Impairment – significant cognitive or behavioural problems, psychosis or severe neurosis requiring ongoing supervision or assistance (e.g. dementia, depression). NOTE: Individuals entitled to a disability benefit for PTSD would not be expected to meet these criteria except in extreme cases where the individual cannot be left alone.
    5. Multiple drug use that significantly impairs cognitive or behavioural ability requiring ongoing supervision or assistance (e.g. demonstrated evidence of cognitive or behaviour impairment objectively measured as a result of using benzodiazepines, narcotics, anti-depressants, major tranquillizers, anti-seizure or anti-Parkinsonian drugs).

Decision-making

  1. If the decision maker is able to create a body of evidence that enables them to make a frail determination using documentation that already exists (e.g. medical, nursing and/or other assessments/records completed by a provincial entity, DND, or some other source) it is unnecessary to also complete a VAC assessment. However, if no other assessments have been completed, an in-person assessment is necessary, to confirm the existence of the condition(s) set out in paragraphs 11 or 12 of this policy.
  2. Once all information has been collected and reviewed, the delegated decision maker will draw from all the circumstances every reasonable inference in favour of the Veteran. Where a fact must be proven, the evidence provided by the Veteran should be accepted as proof in the absence of contradictory evidence. Where there is uncertainty regarding a Veteran’s eligibility, the case should be resolved in favour of the Veteran.

References

Veterans Health Care Regulations

Eligibility for Health Care Programs – Eligible Client Groups

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