CHAMPVA Insurance Explained
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CHAMPVA—the Civilian Health and Medical Program of the Department of Veterans Affairs—is a comprehensive health benefits program that covers eligible spouses, surviving spouses, and dependent children of certain disabled or deceased veterans. If you qualify, VA shares the cost of medically necessary health care services and supplies, paying up to 75 percent of the allowable amount after a modest deductible. Most dental, vision, and chiropractic care are not covered.
Key facts about CHAMPVA:
- Who qualifies: Dependents of veterans rated permanently and totally (P&T) disabled due to a service-connected condition, or dependents of veterans who died of a service-connected condition.
- What it costs: A $50 annual outpatient deductible per person ($100 max per family), then a 25 percent cost share—capped at $3,000 per family per calendar year per 38 CFR § 17.274.
- What it covers: Most medically necessary services, including inpatient care, mental health services, prescriptions, and skilled nursing care.
- What it does not cover: Routine dental, chiropractic care, routine vision, hearing exams, and most experimental procedures.
What Is CHAMPVA?
CHAMPVA is a health benefits program in which VA shares the cost of certain health care services and supplies with eligible beneficiaries. It is administered by the Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC) in Denver, Colorado, which processes all eligibility determinations and medical claims.
CHAMPVA is distinct from TRICARE, which is the Department of Defense‘s health care program for active-duty service members, retirees, and their families. A person who qualifies for TRICARE is not eligible to have CHAMPVA at the same time.
Who Is Eligible for CHAMPVA?
To qualify for CHAMPVA, a beneficiary must not be eligible for TRICARE and must meet at least one of the following conditions under 38 USC § 1781:
- The veteran sponsor is rated permanently and totally disabled due to a service-connected condition; or
- The veteran was rated permanently and totally disabled at the time of death (even if they did not die from that condition); or
- The veteran died of a service-connected condition; or
- The veteran died on active duty and the dependents are not otherwise eligible for TRICARE.
How Does Remarriage Affect CHAMPVA Eligibility?
Surviving spouses who remarry before age 55 lose CHAMPVA eligibility as of midnight on the date of their remarriage. However, if the remarriage ends by death, divorce, or annulment, eligibility may be restored. The effective date of restored benefits is the first day of the month after the remarriage ends, or December 1, 1999, whichever is later.
Surviving spouses who remarry on or after their 55th birthday retain their CHAMPVA benefits.
Do Non-Minor Dependents Qualify for CHAMPVA?
Dependent children covered under CHAMPVA who turn 18 must provide proof of full-time enrollment in a high school, college, or another educational institution to continue receiving benefits. VA recommends submitting a college acceptance letter to avoid a gap in coverage between high school graduation and the start of a college term.
Do Stepchildren Qualify for CHAMPVA?
Stepchildren generally qualify for CHAMPVA. However, if a stepchild leaves the veteran’s household due to divorce or remarriage, they are no longer eligible.
What If the Veteran’s Dependent Is 65 or Older?
As of October 1, 2001, CHAMPVA benefits were extended to dependents age 65 and older. Beneficiaries in this group generally must be enrolled in both Medicare Part A and Part B to remain eligible for CHAMPVA. Medicare Advantage (Part C) plans also satisfy this requirement.
What Does CHAMPVA Cover?
CHAMPVA covers services and supplies that are medically necessary and provided by an authorized provider. Covered services include:
- Inpatient and outpatient care
- Mental health services (therapy, psychiatric care, substance use treatment)
- Ambulatory surgery
- Prescription medications (including through the free Meds by Mail program)
- Skilled nursing care
- Durable medical equipment
- Family planning and maternity care
- Lab and radiology services
- Ambulance services
- Organ and bone marrow transplants (preauthorization required)
- Hospice care (no cost share)
How Much Does CHAMPVA Pay?
CHAMPVA’s allowable amount—the rate it uses to calculate payments—is equivalent to Medicare and TRICARE rates. Here is how cost sharing works under 38 CFR § 17.274:
| Cost Type | Amount |
| Annual outpatient deductible (per person) | $50 |
| Annual outpatient deductible (per family, maximum) | $100 |
| Cost share (your portion) | 25% of allowable amount |
| Catastrophic cap (per family, per calendar year) | $3,000 |
Once a family reaches the $3,000 catastrophic cap, CHAMPVA pays 100 percent of covered services for the remainder of the calendar year. There is no deductible for inpatient care.
There is no cost share for care received at a participating VA facility through the CHAMPVA In-house Treatment Initiative (CITI).
What Does CHAMPVA Not Cover?
The following services are generally not covered under CHAMPVA:
- Routine dental care (including dentures and orthodontia)
- Chiropractic services
- Routine vision exams and eyeglasses
- Routine hearing exams
- Laser eye surgery
- Acupuncture
- Non-FDA-approved drugs
- Experimental or investigational procedures
- Health club memberships
This list is not exhaustive. Consult the CHAMPVA Guidebook or contact VA directly for a complete list of non-covered services.
Does CHAMPVA Have a Provider Network?
CHAMPVA does not maintain a formal provider network. When selecting a provider, ask whether they “accept assignment” from CHAMPVA. If a provider accepts assignment, they agree to accept CHAMPVA’s allowable amount as payment in full and will bill CHAMPVA directly. A provider who accepts assignment cannot bill a beneficiary for the difference between their standard rate and the CHAMPVA allowable amount.
Most Medicare and TRICARE providers accept CHAMPVA patients. VA’s website provides a tool to help locate providers.
How Do You Apply for CHAMPVA?
To apply, submit the following to VA:
- VA Form 10-10d—Application for CHAMPVA Benefits
- VA Form 10-7959c—Other Health Insurance Certification
- Documentation of Medicare status (required if you are eligible for Medicare for any reason, or if you are 65 or older)
For newborns, the child must first have a Social Security number and be established as a dependent of the veteran at a VA regional office before the application can be processed.
After applying, VA will review the application for completeness and eligibility. Applications can be filed online. Processing times can vary very significantly; reports range from 1-2 weeks to 6-8 months.
Frequently Asked Questions About CHAMPVA
Does CHAMPVA cover dental care?
In most cases, no. Routine dental care—including cleanings, dentures, and braces—is not covered through CHAMPVA. However, certain dental treatments may be covered if they are directly related to a covered non-dental medical condition. Examples include:
- Gingival hyperplasia
- Loss of jaw substance
- Mercury hypersensitivity
- Temporomandibular joint (TMJ) dysfunction
Veterans and their families may also be eligible to purchase supplemental dental coverage through the VA Dental Insurance Program (VADIP).
Can a surviving spouse keep CHAMPVA if they remarry?
It depends on their age. Surviving spouses who remarry before age 55 lose eligibility on the date of remarriage. Those who remarry on or after age 55 keep their benefits. If a marriage that ended eligibility is later dissolved, eligibility may be restored.
Does CHAMPVA cover prescriptions?
Yes. CHAMPVA covers most medically necessary prescription drugs. Beneficiaries can also use VA’s Meds by Mail program to receive maintenance medications at no cost, with no premiums, deductibles, or copayments, if they do not have other prescription drug coverage.
What happens if I have Medicare and CHAMPVA?
If you are eligible for Medicare, you must have both Part A and Part B (or a Medicare Advantage plan) to keep CHAMPVA. Medicare pays first; CHAMPVA may cover remaining costs. CHAMPVA does not cover Medicare Part B premiums.
What if I have other health insurance besides CHAMPVA?
CHAMPVA is generally a secondary payer. Your other insurance pays first, and CHAMPVA may cover some or all of the remaining costs. A beneficiary with other insurance typically pays no out-of-pocket cost share.
Can a primary family caregiver qualify for CHAMPVA?
Yes. Primary family caregivers enrolled in VA’s Program of Comprehensive Assistance for Family Caregivers (PCAFC) may be eligible for CHAMPVA if they have no other health insurance coverage.
Does CHAMPVA cover 100 percent P&T veterans themselves?
No. CHAMPVA covers eligible dependents and survivors of qualifying veterans, not the veterans themselves. Veterans may receive health care directly through VA or other programs.
