Part IX, Subpart ii, Chapter 2, Section CSpecial Monthly Pension (SMP) Ratings

Revised March 17, 2025

IX.ii.2.C.1.a#Criteria for A&A Eligibility

Per 38 CFR 3.352(a), to be eligible for the aid and attendance (A&A) allowance, a Veteran or surviving spouse must be so helpless that they require the aid of another person to

• perform the personal functions required in everyday living, also called activities of daily living, or
• protect themselves from hazards or dangers incident to daily life because of a mental or physical disability.

Per 38 CFR 3.351(c)(1), a claimant who has bilateral vision of 5/200 or less, or contraction of the central visual field to five degrees or less, is eligible for A&A without the requirement of additional findings. Note: The need for A&A does not have to be permanent to be granted for Pension, see VAOPGCPREC 21-1994.

IX.ii.2.C.1.b#Medical Evidence Used for A&A Ratings

Determination of a claimant's need for A&A by rating is based on medical evidence. The following are some examples of medical evidence used for A&A ratings:

• VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, completed by a licensed health care professional, including the claimant's private medical provider
• Department of Veterans Affairs (VA) medical center (VAMC) examinations, and
• statements by licensed health care professionals meeting the requirements of 38 CFR 3.326(b) and 38 CFR 3.159(a)(1).

Notes :

• The above medical evidence is also used for housebound ratings.
• VAMC examinations of survivors are not generally conducted except at the discretion of the Pension Management Center Manager.
• The following are examples of licensed health care professionals:
  • medical doctor
  • doctor of osteopathy
  • physician's assistant, or
  • advanced practice registered nurse (APRN). APRNs include:
    • certified nurse-midwives (CNM)
    • clinical nurse specialists, and
    • certified nurse practitioners.

Important :

• APRNs are prepared by accreditation and certification to provide initial and ongoing comprehensive assessment, diagnosis and treatment when it is within the scope of their respective practice, role, and patient population. For example, the scope of practice for a CNM patient population would encompass a full range of primary health care services for women.
• Claims processors must consider the type of APRN or other health care provider in the context of the full evidentiary record to determine the probative value of the examination report and/or opinion consistent with the requirements set forth in 38 CFR 3.326 and 38 CFR 3.159(a)(1).

References : For more information on

• A&A criteria, see 38 CFR 3.351(c) and 38 CFR 3.352(a)
• housebound criteria, see 38 CFR 3.351(d)
• examiner qualifications and signature requirements, see M21-1, Part IV, Subpart i, 3.A.1.b
• determining the probative value of evidence, see M21-1, Part V, Subpart ii, 1.A.2.e
• full practice authority for APRN in VA, see 38 CFR 17.415, and
• acceptable medical evidence and definition of adequate medical evidence for pension rating purposes, see M21-1, Part IX, Subpart i, 2.2.f.

IX.ii.2.C.1.c#No Requirement for a Single 100-Percent Evaluation for A&A for Veterans Pension

There is no statutory or regulatory requirement for a Veteran pensioner to have a single disability rated 100-percent disabling to be determined in need of regular A&A. Therefore, if a Veteran pensioner meets the criteria for A&A under 38 CFR 3.352(a), the rating activity may grant special monthly pension (SMP) at the A&A rate even though the Veteran is not rated 100-percent disabled under the rating schedule. Code all claimed and noted disabilities, and show the evaluation of each disability, as appropriate.Exception : Rating evaluations for individual disabilities are not required when A&A can be granted

• under the criteria listed above or under 38 CFR 3.351(c)(1), and
• a rating determination of permanent and total (P&T) disability is not needed to establish eligibility for Veterans Pension as described in M21-1, Part IX, Subpart ii, 2.A.1.a.

Reference: For more information on the statutory and regulatory requirements for SMP eligibility for Veterans Pension, see

• 38 U.S.C. 1521(d) and (e), and
• 38 CFR 3.352(a) and (b).

IX.ii.2.C.1.d#Action to Take When There Is No 100-Percent Evaluation or Need for A&A Shown

Use the table below to determine the action to take when the disability evaluation is less than 100 percent or there is no need for A&A.

IX.ii.2.C.1.e#When to Infer a Claim for A&A or Housebound

The table below shows when to infer a claim for A&A and housebound eligibility.

_ _

Important : Do not infer the issue of SMP eligibility merely to deny, if the evidence does not show the claimant would qualify.

Reference: For more information on housebound eligibility, see

• 38 CFR 3.351(d), and

• M21-1, Part IX, Subpart ii, 2.C.2.a.

IX.ii.2.C.1.f#Presuming the Need for A&A Based on Nursing Home Care

A Veteran or surviving spouse entitled to pension is presumed to be in need of A&A if they are a patient in a nursing home on account of a mental or physical disability.Note: For pension purposes, a medical foster home that VA has recognized and approved under 38 CFR 17.73 is equivalent to a nursing home. References: For more information on

• presumptive A&A based on nursing home care, see M21-1, Part IX, Subpart ii, 1.B.1 and 2, and
• the necessary action following nursing home discharge, see
  • M21-1, Part IX, Subpart ii, 1.B.3, and
  • M21-1, Part X, Subpart ii, 4.A.5.

IX.ii.2.C.1.g#When No Rating Decision Is Required to Grant A&A

A rating decision is not required in any claim where A&A is presumed unless other claimed issues need to be rated. If A&A has been granted based on nursing home or medical foster home status without a rating decision, and a claim is being considered on other issues, do not consider A&A in the rating decision.

IX.ii.2.C.1.h#Future Employment and A&A

Pension beneficiaries are required to inform the VA if there is a change in any condition affecting their right to continued payments. If a beneficiary who is receiving A&A by rating obtains employment, the rating activity should review the claim to determine whether the beneficiary still meets the statutory and regulatory requirements for A&A. If the requirements are no longer met, follow the procedures in M21-1, Part X, Subpart ii, 4.A.5. Note: Participation in a program of Compensated Work Therapy (CWT) alone does not affect VA pension, however, if a Veteran obtains employment following a CWT program, this suggests that they may no longer qualify for A&A. References: For more information on

• A&A eligibility requirements, see
  • 38 CFR 3.351, and
  • 38 CFR 3.352, and
• reductions in pension, see 38 CFR 3.105(f).

2Ratings for Housebound Allowance

This topic contains information on ratings for housebound benefits, including

• criteria for qualifying for housebound
• when a rating decision is required for a housebound claim
• when to submit a housebound claim for an advisory opinion
• permanency requirement for the 100-percent disability, and
• requirement for the independently ratable 60-percent disability.

Revised February 19, 2019

IX.ii.2.C.2.a#Criteria for Qualifying for Housebound

Veterans who are eligible to receive pension qualify for pension at the housebound rate if they have a single, permanent disability that is assigned a 100 percent schedular evaluation and

• other disabilities independently ratable at 60 percent or more per 38 CFR 3.351(d)(1), or
• are permanently housebound by reason of their disabilities per 38 CFR 3.351(d)(2).

Note: Because the single 100-percent disability must be a schedular evaluation, a total evaluation based on unemployability under 38 CFR 4.17 will not suffice. A surviving spouse eligible to receive pension or Dependency and Indemnity Compensation qualifies for increased benefits based on being housebound if they are permanently housebound by reason of their disabilities per 38 CFR 3.351(e) and (f). Reference: For more information on permanently housebound, see

• 38 CFR 3.351(d), and
• M21-1, Part IX, Subpart ii, 1.A.2.c.

IX.ii.2.C.2.b#When a Rating Decision Is Required for a Housebound Claim

A rating decision is required to dispose of all housebound claims and must include all applicable laws and regulations.Reference: For more information on the requirement to include all applicable laws and regulations, see M21-1, Part VI, Subpart i, 1.B.1.b.

IX.ii.2.C.2.c#When to Submit a Housebound Claim for an Advisory Opinion

Submit a claim for housebound eligibility to Pension and Fiduciary (P&F) Service for an advisory opinion if the disability

• evaluation is less than 100 percent, but
• is so severe as to render the claimant housebound.

Note: A current examination must be of record before the claim may be submitted for an advisory opinion.Reference : For more information on requesting an advisory opinion from P&F Service, see M21-1, Part X, Subpart v, 1.A.

IX.ii.2.C.2.d#Permanency Requirement for the 100- Percent Disability

In pension claims, both the single 100-percent disability and the disability that causes the Veteran to be housebound (if different disabilities) must be permanent. A P&T evaluation protected under 38 CFR 3.951 or 38 CFR 3.953 is sufficient if it is based on a single 100-percent disability. Housebound based on a factual determination under 38 CFR 3.351(d)(2) requires the housebound state to be permanent.

IX.ii.2.C.2.e#Requirement for the Independently Ratable 60-Percent Disability

There is no requirement that the independently ratable 60-percent disability be permanent. If an independent 60-percent disability that is not permanent is an essential part of a housebound determination, control the claim for possible reduction following a future examination.