Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
CHAMPVA is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.
Compared to most health insurance policies, CHAMPVA is exceptionally affordable per calendar year:
There is a $50 deductible per dependent, up to $100 MAX per family!
MAX out of pocket amount per family is $3,000!
Eligibility
CHAMPVA provides coverage to the spouse or widow(er) and to the children (aged 0-17, 18-23 enrolled in school, 18+ Helpless child) of a Veteran who:
Is rated Permanently and Totally disabled due to service-connected condition(s);
Was rated Permanently and Totally disabled due to service-connected condition(s) at the time of death;
Died due to a service-connected condition; or
Died on Active Duty and the dependents are NOT otherwise eligible for Department of Defense TRICARE benefits.
IMPORTANT NOTES:
To be eligible for CHAMPVA, the beneficiary CANNOT be eligible for TRICARE.
For Gray Area Retirees see the Frequently Asked Questions section.
Children who marry will lose eligibility.
In the event of divorce, entitlement for the former spouse is ended effective the date of the divorce!
If entitlement is established due to death of Veteran/Servicemember, then remarriage will end entitlement UNLESS:
Remarriage takes place on or after your 55th birthday; or
If you remarry before age 55, and your remarriage ENDS (you will need to reapply to reestablish this benefit).
Additional Eligibility
A Veteran's primary caregiver under Program of Comprehensive Assistance for Family Caregivers (PCAFC) can be eligible for CHAMPVA, assuming the caregiver does NOT have any other health insurance coverage.
IMPORTANT NOTE:
To be eligible for CHAMPVA, the beneficiary CANNOT be eligible for TRICARE.
Applying
You have several ways to submit an application and supporting documents:
Online;
Fax; and
Snail mail.
Copies of Documents to include:
Related to Medicare status (if applicable):
If the dependent qualifies for Medicare for ANY reason, they’ll need to submit a copy of their Medicare card.
If the dependent is 65 years old or older and does not qualify for Medicare, they’ll need to send documentation from the Social Security Administration that confirms they don’t qualify for Medicare benefits under anyone’s Social Security Number.
If you are including dependent children ages 18-23:
If you’re a spouse or surviving spouse:
Certificate of civil union;
Common-law marriage affidavit; or
Marriage certificate.
If you’re a surviving spouse who remarried before age 55 and your remarriage has ended:
Annulment decree;
Divorce decree; or
Death certificate.
IMPORTANT NOTE:
To expedite processing (for any dependent) include COPIES of:
Dependents’ birth certificate;
Benefits Letter - showing the Veteran is Permanently and Totally disabled (or the death rating if you’re a survivor); and
Veteran’s DD214.
1. Online
Click HERE to apply online.
2. Fax/3. Snail Mail
Complete the following forms:
And include copies of any of the previously mentioned supporting/expediting documents.
Fax
303-331-7809
VHA Office of Community Care CHAMPVA Eligibility PO Box 137 Spring City, PA 19475
Finding a Provider
CHAMPVA does not have a network of providers. As such it is recommended you visit the Medicare website or TRICARE website to find a doctor.
Generally, providers who accept Medicare, Medicaid, or TRICARE also accept CHAMPVA - but they may not be familiar with the program and incorrectly assume that it is a group health insurance plan rather than a government health care program.
If the receptionist tells you they don't accept CHAMPVA, ask the billing department - sometimes they are the only ones that really know! And don’t forget to ask if they take Medicare, Medicaid, or TRICARE. Since if they do - that means they should also accept CHAMPVA.
Providers that Accept “Assignment” for VA Family Member Programs
When you locate a medical provider, confirm that they will participate in the VA family member health care program you belong to. Providers most often refer to participation as "accepting assignment." Providers that accept assignment will bill the VA directly for covered services, items and supplies. Doctors or other providers who accept assignment must accept the VHA Office of Community Care (VHA OCC) allowable amount as payment-in-full and cannot collect additional amounts from you beyond your cost share and deductible (balance billing).
IMPORTANT NOTE:
All hospitals that participate in Medicare, and hospital-based health care professionals who are employed by, or contracted to, such hospitals are required by law to accept the VHA OCC allowable amount for inpatient hospital services.
Providers that do NOT Accept “Assignment” for VA Family Member Programs
If your provider does not accept assignment, you can still see that provider, but be aware that you will likely have to pay the entire charge at the time of service. Additionally, you may be charged more than the VHA OCC allowable amount.
Providers that do not accept assignment are not permitted to file for reimbursement. If you choose to use them, you will have to submit for reimbursement yourself.
To obtain reimbursement in cases where a VA family member health care program is your only insurance, you will have to submit the itemized bill from the provider along with the appropriate VA form. When the claim is processed, the VA will send you the VHA OCC share of the allowable amount.
What this means to you is that when the medical provider does NOT accept assignment, your cost will include not only your share of our determined allowable amount, but also any charges over the VA's allowable amount.
Benefits
In general, CHAMPVA covers most health care services and supplies that are medically and psychologically necessary. Upon confirmation of eligibility, you will receive a CHAMPVA Program Guide that specifically addresses covered and non-covered services and supplies.
Dental care is NOT covered UNLESS you also enroll in VA Dental Insurance Program (VADIP).
For a complete listing of non-covered services and supplies consult the CHAMPVA Policy Manual.
Pharmacy Benefits
Click HERE for information on pharmacy benefits.
Filing a Claim
Generally, the providers should handle billing to CHAMPVA automatically.
However if you need to; click HERE to file a claim online.
Frequently Asked Questions
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In most cases, CHAMPVA's allowable amount (what VA pays) for specific services and supplies—is equivalent to Medicare/TRICARE rates. CHAMPVA has an outpatient deductible ($50 per beneficiary per calendar year or a maximum of $100 per family per calendar year) and a patient cost share of 25% of our allowable amount up to the catastrophic cap ($3,000 per calendar year). Beneficiaries should NOT send checks to VHA OCC for their annual deductible; as claims are processed, charges are automatically credited to individual and family deductible requirements for each calendar year.
If your provider accepts assignment, which means the provider accepts CHAMPVA, the provider agrees to accept the VA's allowable amount as payment in full. A provider cannot bill you for the difference between the VA's allowable amount and their normally billed amount.
If the patient has other health insurance, then CHAMPVA pays the lesser of either 75% of the allowable amount after the $50 calendar year deductible is satisfied, or the remainder of the charges and the beneficiary will normally have no cost share.
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4-6 months.
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Pay out of pocket for now and to file for reimbursement once you are finally approved.
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Only if they are eligible via their spouse or being a caregiver as noted previously.
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Only at participating VA facilities (most VA facilities do NOT participate).
Under the CHAMPVA In-house Treatment Initiative (CITI), CHAMPVA beneficiaries may receive cost-free health care services at participating VA facilities.
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Follow the following link.
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None. CHAMPVA beneficiaries don’t pay out-of-pocket expenses when receiving services under the CITI program.
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No. According to 38 CFR § 17.271 - Eligibility they are NOT eligible (outside of being an appropriate caregiver)
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NO UNLESS the other insurance is:
Medicaid;
State Victims of Crime Compensation Programs;
Indian Health Services; or
Supplemental CHAMPVA policies.
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YES UNLESS the other insurance is:
Medicaid;
State Victims of Crime Compensation Programs;
Indian Health Services; or
Supplemental CHAMPVA policies.
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Your health care provider should bill the other insurance first. The provider should then submit the Explanation of Benefits (EOB) from the other insurance along with the claim for reimbursement to CHAMPVA.
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You won’t be able to add them till they have a Social Security Number. Once you get it, be sure to Claim them as a dependent and THEN apply to have them added to CHAMPVA.
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Don’t worry! The hospital and billing staff are well aware it is a process to get newborns added to insurance. With most not requiring you to pay immediately.
In short, once the child has been added, go ahead and let the appropriate billing offices know their details and you will be fine.
For procedures/treatment which may have required you to pay out of pocket - you will need to file a claim with CHAMPVA to seek reimbursement.
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Double check to see if DEERS has you listed as eligible or not.
Click HERE to see if you are listed as eligible for TRICARE coverage.
If you think your eligibility is listed incorrectly call DMDC/DEERS support at 1-800-538-9552 and explain why you think it is wrong (i.e., you are a Gray Area Retiree under 60 years of age).
The keyword in their system is “Direct”, it needs to be removed.
With DEERS now updated, submit a question to AskVA to have your denial looked into again. Be sure to include your denial case number/application ID.
Click HERE to use AskVA.
The VA should then review the denial and grant CHAMPVA!
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Please see the answer to the previous question.
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Yes! If you live or travel overseas (excluding countries that are restricted or prohibited by the U.S. Department of Treasury), CHAMPVA will provide the SAME benefits. If the billing and medical documentation are written in a foreign language, translation will be arranged at no cost to you; but if you want to speed up the process you may translate things to English. Payments are made in U.S. dollars.
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While they may get removed as a dependent child, it does NOT remove them from CHAMPVA coverage.