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CHAMPVA Explained
The CivIlian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides healthcare coverage to some dependents of certain veterans. The healthcare benefits can be invaluable, but many find CHAMPVA confusing. Here’s what you need to know about who is eligible, how to apply, and how to find medical providers who accept it.
Who Qualifies for CHAMPVA?
Dependents and survivors of some veterans are eligible for CHAMPVA.
To qualify, the veteran must:
- Have a permanent and total VA disability rating–either a permanent 100% rating or a permanent TDIU classification, or
- Have died of a service-connected condition, or
- Have had a permanent and total VA disability rating when they died
Survivors may also be eligible if the military servicemember died in the line of duty.
In addition, the dependent or survivor must:
- Be the spouse or dependent child of a qualifying veteran, and
- Not be eligible for TRICARE
If you are eligible for Medicare, you must have Medicare coverage to qualify for CHAMPVA.
Who is Considered a Surviving Spouse?
Unlike DIC benefits, CHAMPVA eligibility does not require that the surviving spouse have been married to the veteran for any specific length of time or require that the marriage took place within a certain time period after the veteran separated from service. However, a surviving spouse who remarries before age 55 will lose eligibility for CHAMPVA benefits. (In some cases, eligibility may be restored if the new marriage ends, whether by annulment, divorce, or the death of the new spouse.)
Who is Considered a Dependent Child?
To qualify for CHAMPVA benefits as a dependent child of an eligible veteran, the child must be:
- A natural or adopted child of the veteran who is under the age of 18
- A natural or adopted child of the veteran who is between the ages of 18 and 23, unmarried, and enrolled in a qualifying educational program
- A natural or adopted child of the veteran who is 18 or older but permanently unable to support themself due to a disability that began before age 18
- A stepchild of the veteran meeting one of the criteria above, unless the stepchild’s parent is divorced from a living qualifying veteran or remarries after the veteran’s death
Primary Family Caregivers
The primary family caregiver for a disabled veteran may be eligible for CHAMPVA benefits even if the veteran doesn’t meet the requirements listed above. For example, if the veteran meets certain other requirements, a VA disability rating of 70% is sufficient (versus permanent and total for other categories).
What Does CHAMPVA Cover?
CHAMPVA coverage is similar to many private insurance plans. CHAMPVA covers both physical and mental health services (inpatient and outpatient) and prescribed medications. Lab services and necessary medical equipment are covered, along with ambulance services and hospice care. However, there is no coverage for dental, vision, non-traditional services like chiropractic care and acupuncture, or drugs or procedures that are unapproved or experimental.
How Much is My Deductible With CHAMPVA?
CHAMPVA offers low deductibles–just $50 for an individual for most types of care and $100 for the whole family. Some services have no deductible. There is also a $3,000 annual out of pocket cap.
After the deductible is satisfied, CHAMPVA pays 75% of the allowable amount until your out of pocket for the family reaches $3,000. After that, CHAMPVA pays 100% of allowable amounts for the remainder of the calendar year.
What is the Allowable Amount?
The allowable amount for a service is the maximum cost for that service under CHAMPVA’s guidelines. It is the same as the allowable rates used by Medicare and TRICARE.
If you are using a provider who accepts assignment from CHAMPVA, that provider cannot bill more than the allowable amount. Imagine, for example, that a hospital lab typically charges $500 for a test, but the allowable amount through CHAMPVA is just $300. If you’ve met your deductible but not your out-of-pocket cap, CHAMPVA will pay $225–75% of the $300.
If your provider accepts assignment, you’ll pay just $75–25% of the allowed amount. If you’re using a provider that does not accept assignment, you can still request reimbursement from CHAMPVA. But you’ll typically have to pay in full for the service and then submit your claim to CHAMPVA and wait for reimbursement. And, they’ll still pay based on the allowable amount, not the actual amount you’re billed. In this example, that would mean you paid $275 instead of the $75 you would pay to a provider who accepts assignment of CHAMPVA benefits.
Finding a Provider Who Accepts Assignment
As you can see, working with providers who accept assignment can save you money. Unfortunately, although CHAMPVA works much like a PPO, it doesn’t maintain networks. There’s no quick online look-up to see which providers accept CHAMPVA assignment. You’ll have to ask.
Most providers that accept Medicare and TRICARE also accept CHAMPVA. CHAMPVA is less common, so be prepared to explain it when asking whether a provider accepts assignment. And, be sure to use those words: “accept assignment from CHAMPVA.” That’s how you find out whether the provider will honor CHAMPVA’s reduced allowable amount.
Applying for CHAMPVA
You can apply for CHAMPVA online or by completing and submitting a paper Form 10-10d. If you have other insurance, you will need to submit another form with that information. If you are age 65 or older, you will need to provide proof of Medicare coverage or documentation that you are not eligible for Medicare.
The processing time for CHAMPVA applications varies significantly, so the sooner you submit your application, the better.
Coordinating Other Coverage With CHAMPVA
If you have Medicare or other insurance coverage, that coverage will typically be primary and CHAMPVA secondary. Often, having CHAMPVA secondary to Medicare or other insurance coverage means that the patient pays nothing at all.
Veterans Help Group fights for veterans and their families. CHAMPVA is just one of the many programs that may provide crucial benefits to disabled veterans, dependents, and surviving family members, but it may be complicated and daunting. We’re here to reduce that stress and give you the best chance possible for the right VA disability rating and other benefits. Call us today at 855-855-8992 or fill out our contact form HERE for a FREE case evaluation.
FAQ’s
Does CHAMPVA cover my child while they’re away at college?
Yes, as long as they’re between 18 and 23, unmarried, and enrolled in a qualifying school. You’ll need to submit a school certification (Form 10-10d includes a section for this), and it’s worth renewing that proof each academic year so there’s no lapse in coverage.
Can I use CHAMPVA at a VA hospital?
In limited cases. CHAMPVA is a separate benefit from VA healthcare, and most VA medical centers don’t accept CHAMPVA directly. Some VA facilities participate in the CHAMPVA InHouse Treatment Initiative (CITI), which allows CHAMPVA beneficiaries to receive certain services at that facility on a space available basis. Ask the specific VA facility whether they participate before assuming you’re covered there.
What happens to my CHAMPVA coverage when I turn 65?
You’ll need to enroll in Medicare Part A and Part B to keep CHAMPVA active, since Medicare becomes primary. There’s an exception if you’re already covered by other insurance that qualifies as primary. Missing the Medicare enrollment window is one of the most common reasons people lose CHAMPVA unexpectedly, so mark that birthday on your calendar well in advance.
What’s the difference between CHAMPVA and TRICARE?
TRICARE serves active duty and retired servicemembers and their families. CHAMPVA serves dependents and survivors of veterans who are permanently and totally disabled or who died from a service connected condition, and it only kicks in when the person isn’t eligible for TRICARE. You can’t have both at once.
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