CHAMPVA Insurance Explained

What is CHAMPVA?

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health benefits program in which VA shares the cost of certain health care services and supplies with eligible beneficiaries.

CHAMPVA is currently managed by the Veterans Health Administration Office of Community Care (VHA OCC) located in Denver, Colorado.  The VHA OCC thereby processes all claims submitted for the reimbursement of medical services and supplies rendered by authorized providers in the community.

Eligibility for CHAMPVA

To be eligible, the beneficiary (i.e., person receiving the benefits) cannot be eligible for TRICARE.  Importantly, TRICARE is the Department of Defense (DoD) health care program for uniformed service members, retirees, and their families.  It provides comprehensive coverage to all beneficiaries, including health plans, special programs, prescriptions, and dental plans.

CHAMPVA is a completely separate program with a totally different beneficiary population than TRICARE.  While the benefits are similar, the programs are administered separately with differences in claim filing procedures and preauthorization requirements.  This program provides coverage to the spouse or widow and to the children of veterans who:

• Are rated permanently and totally disabled due to a service-connected condition; or
• Were rated permanently and totally disabled due to a service-connected condition at the time of death; or
• Died of a service-connected condition; or
• Died on active duty and the dependents are not otherwise eligible for DoD’s TRICARE benefits.

As of October 1, 2001, these benefits were extended to individuals ages 65 and older.  According to VA, this age group must meet the following conditions in order to be eligible:

• If the beneficiary was 65 or older prior to June 5, 2001, and was otherwise eligible for CHAMPVA, and was entitled to Medicare Part A coverage, then the beneficiary will be eligible for CHAMPVA without also requiring Medicare Part B coverage.
• If the beneficiary turned 65 before June 5, 2001, and has Medicare Parts A and B, the beneficiary must keep both Medicare Parts A and B to be eligible.
• If the beneficiary turned age 65 or older on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible.

Additional factors may affect whether you qualify for CHAMPVA, including the following:

New or Expectant Parent

New or expectant parents must take the two steps indicated below prior to applying for CHAMPVA for their newborn:

• Get a Social Security number for the baby by applying at the nearest Social Security Administration (SSA) office; and
• Set up the baby’s status as a dependent of the veteran by contacting the nearest VA regional office.

Newborns are not eligible for CHAMPVA until the above-mentioned steps have been completed.

Remarried Surviving Spouses

Surviving spouses of qualifying CHAMPVA veterans who remarry before age 55 no longer qualify as of midnight on the date of their remarriage.  However, if they remarry on or after their 55^th birthday, they can retain their benefits.  Moreover, if the remarriage (prior to the age of 55) ends by death, divorce, or annulment, the surviving spouse may qualify again for CHAMPVA.

The effective date for Civilian Health and Medical Program of the Department of Veterans Affairs would become the first day of the month after the remarriage ends or December 1, 1999, whichever date is later.  Surviving spouses will be required to provide copies of marriage certificates, as well as death, divorce, or annulment documents.

School-Aged Dependents (Ages 18 to 23)

If you are covered under Civilian Health and Medical Program of the Department of Veterans Affairs and turn 18 years old, your benefits will be discontinued unless you send VA proof that you are enrolled full time in college or another educational institution.

Veterans’ Stepchildren

Generally speaking, stepchildren qualify for CHAMPVA insurance.  However, if a veteran’s stepchildren were covered under CHAMPVA and subsequently left the veteran’s household as a result of divorce or remarriage, they would no longer qualify.

Types of Benefits Received Under CHAMPVA

Again, CHAMPVA offers many benefits and covers services and supplies when determined to be medically necessary and received from authorized providers (i.e., providers who perform services within the scope of their license or certification).  CHAMPVA covers the following services:

• Ambulance service
• Ambulatory surgery
• Durable medical equipment
• Family planning and maternity
• Hospice
• Inpatient services
• Lab and radiology services
• Mental health services
• Outpatient services
• Pharmacy (prescription medicines)
• Skilled nursing care
• Transplants

How Much Does CHAMPVA Pay?

Generally speaking, CHAMPVA’s allowable amount (i.e., the amount paid for specific services and supplies) is equivalent to Medicare/TRICARE rates.  CHAMPVA has an outpatient deductible ($50/beneficiary/calendar year or a maximum of $100/family/calendar year) and a patient cost share of 25 percent of the allowable amount, up to the cap of $3,000 per calendar year.

What Services are Not Covered Under CHAMPVA?

The following services are not covered under CHAMPVA:

• Acupuncture
• Chiropractic services
• Most dental care, including dentures or partial dentures (see section “CHAMPVA and Dental Care” below)
• Non-FDA-approved drugs
• Routine hearing exams
• Routine eye exams and glasses
• Laser eye surgery
• Experimental and investigational procedures
• Health club memberships

Please note this list is non-exhaustive and there may be additional services for which CHAMPVA does not provide coverage.

CHAMPVA and Dental Care

As indicated above, most dental care, including dentures or partial dentures, routine care, and orthodontia care (i.e., braces), is not covered through CHAMPVA.  Instead, coverage is limited to dental treatments as part of the appropriate treatment of some other (non-dental) covered medical condition.  The following dental-related conditions may also be covered:

• Gingival hyperplasia
• Loss of jaw substance
• Mercury hypersensitivity
• Temporomandibular joint disease (TMJ)

Do Veterans Have to Use CHAMPVA Provider Networks?

Importantly, Civilian Health and Medical Program of the Department of Veterans Affairs does not have a network of medical providers.  However, it is recommended that the Primary Family Caregiver ask the provider if they accept CHAMPVA.  If so, then the provider will bill CHAMPVA directly.  To locate a provider, veterans can visit VA’s website.

How to Apply for CHAMPVA

Beneficiaries can apply for Civilian Health and Medical Program of the Department of Veterans Affairs insurance by completing two forms: (1) the Application for CHAMPVA Benefits (VA Form 10-10d); and (2) the Other Health Insurance Certification (VA Form 10-7959c).  Documents related to Medicare status are also required if you qualify for Medicare (for any reason) or you are 65 years old and do not qualify for Medicare.  After submitting the application for CHAMPVA, VA will review it for completion and eligibility.  It generally takes anywhere from 2 to 8 months for the application to be processed; however, the timeframe may vary.