Audit of Caregiver Support Program Appeals Processes

Report Information

Issue Date
Report Number
25-01406-224
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Report Topic
Claims and Appeals
Major Management Challenges
Benefits for Veterans
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

VHA’s Caregiver Support Program oversees the Program of Comprehensive Assistance for Family Caregivers (PCAFC), which provides monthly stipends and healthcare coverage for primary family caregivers of eligible veterans who have incurred or aggravated a serious injury or illness during active military duty. Veterans and caregivers must meet specific eligibility requirements for the program, and during the review period, if they disagreed with decisions about enrollment or benefits, they could pursue several appeal options under the Appeals Modernization Act (AMA) or submit a clinical appeal.

The VA OIG audited how the Caregiver Support Program processes and tracks PCAFC AMA decision reviews to determine whether it meets legal and policy requirements. To provide a complete picture of all available appeal options, the OIG team also reviewed the timeliness and outcomes of clinical appeals.

The OIG found that AMA decision reviews took an average of more than 400 days to complete from February 2022 through March 2025. Clinical appeals took, on average, about 36 days to complete. The audit also found that wait times for decision reviews were not publicly reported, limiting veterans’ and caregivers’ ability to make informed choices about which appeal option to pursue.

Additionally, information provided to veterans, caregivers, and staff did not clearly explain that supplemental claims must be filed within one year to preserve eligibility for the earliest possible effective date. Without this clarity, veterans and caregivers could be missing out on earlier effective dates, resulting in fewer benefits being received.

VHA concurred with the OIG’s three recommendations to improve the timeliness and transparency of AMA decision reviews.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Develop and implement timeliness goals for completing Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers to make sure that claims are assigned and acted upon in accordance with these measures.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Develop a plan to address the backlog of Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers and report progress routinely and transparently to inform veterans.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Update language in VA Form 10‑305 and VHA Notice 2025-09 to clarify that veterans or caregivers must file a Program of Comprehensive Assistance for Family Caregivers supplemental claim within one year from the date of the decision notification letter to be eligible for the same effective date as the date of their initial application for any benefits granted in accordance with the law (38 U.S.C. § 5110).