- CHAMPVA is an abbreviation for the Civilian Health and Medical Program of the Department of Veterans’ Affairs.
- It is a VA program that pays for almost all medical and mental health providers and supplies.
- To be eligible, applicants must have been completely and permanently disabled and honorably discharged.
- With similar benefits to Medicare, CHAMPVA will not pay for Alzheimer’s or long term custodial care.
CHAMPVA is a much-used acronym for the Civilian Health and Medical Program of the Department of Veterans’ Affairs.
CHAMPVA is a fee for service program that is administered by the Chief Business Office Purchased Care located in Denver, Colorado. Looking at it from another perspective, CHAMPVA is a medical insurance program, very similar to Medicare in coverage and costs.
More specifically, CHAMPVA is an all-inclusive benefits program whereby the Veterans’ Affairs Department (VA) reimburses qualified beneficiaries for most or all costs of applicable medical and mental health services and supplies.
In addition, individuals may be enrolled in both Medicare and CHAMPVA, in which case CHAMPVA acts as a supplementary medical insurer, paying co-payments that Medicare does not cover.
To learn about CHAMPVA programs in greater detail, please call 1-800-733-8387 or follow this link: va.gov.
To be eligible for CHAMPVA’s medical and mental health benefits, you must be the spouse or dependent child of a veteran, providing at least one of these requirements applies:
- A VA regional office must have rated the veteran as completely and permanently disabled as a consequence of a service-related disability. That means that the disability must have interfered with the vet’s ability to perform daily functions, and that it was aggravated by, or resulted from, injuries, diseases or disorders that occurred while the vet was on active duty, or while he or she was on inactive duty for training purposes.
- The Veterans’ Administration confirmed that the vet died from a service-related disability.
- Or the Veterans’ Administration confirmed that the vet was totally and permanently disabled at the time of death.
There are various other contingency regulations that are associated with CHAMPVA eligibility and benefits:
CHAMPVA and TRICARE
CHAMPVA is not to be confused with TRICARE (previously known as CHAMPUS), which is a similar health care program, administered by the Department of Defense. TRICARE benefits active duty and retired staff of the military, including their wives and survivors. Although the same individuals may be qualified for benefits under either program, those who qualify under TRICARE may not also apply for benefits under CHAMPVA.
And while the benefits are similar, the programs are managed and administered separately with significant differences in claim filing procedures and preauthorization requirements.
Time of Disability
A disability that is rated service-connected may occur months or years following the events that caused the disability. For example, the traumatic events that cause many military personnel to experience Post-Traumatic Stress Disorder (PTSD) often occurred a considerable time span before they start showing signs of PTSD. As long as the disability occurred while on active duty, the VA might well consider it service-related.
Honorable and Dishonorable
In order to receive benefits, the service member or vet’s character at discharge must be: honorable, under honorable conditions, or “general” (meaning not “under dishonorable conditions”). Nevertheless, those discharged under undesirable, bad conduct, or other types of dishonorable conduct may still qualify for benefits subsequent to a VA special determination.
Various Degrees of Disability
Not all disabilities are the same, and the amount of compensation a vet receives depends on the gravity of the service-related disability. It also depends on how disabled the vet was left as a result of the events, diseases, or disorders that caused the disability. For that, the VA conducts assessment tests that ultimately produce a 0 to 100 percent disabled rating. Compensation for medical or mental health expenses and supplies are then linked to those disability ratings.
Medicare always takes precedence in paying out for medical, mental health, and other health care services, with CHAMPVA invariably acting as secondary payer to Medicare.
If you are 65 or over and eligible for Medicare, or at any age and for any other reasons, it is incumbent upon you to apply for both Medicare parts A and B in order to maintain your eligibility in CHAMPVA. Your Social Security Administration paperwork evidencing your enrolment in both Medicare Parts A and B will make up a part of your application to CHAMPVA.
If you are 65 years old or older, there are various conditions you have to meet to qualify for CHAMPVA benefits:
Medicare Part D: You are not required to enroll in Medicare Part D in order to become or remain CHAMPVA eligible.
June 5, 2001: If you turned 65 on or after June 5, 2001, you must be enrolled in Medicare Part A and Part B to remain eligible for CHAMPVA.
Medicare Part A only: If you turned 65 or older prior to June 5, 2001, and you were otherwise qualified for CHAMPVA benefits and were also qualified to procure Medicare Part A coverage, then you may be qualified for CHAMPVA benefits without having to procure Medicare Part B coverage.
Medicare Parts A and B: If you turned 65 before June 5, 2001, and you have both Medicare Parts A and B, you must maintain enrollment in both these Parts to qualify for CHAMPVA.
At any age and whatever the reason: If, at any age, you qualify for Medicare, and for any reason you are not eligible for Medicare Part A, it is incumbent upon you to procure and maintain Medicare Part B coverage, if you don’t want to be disqualified for CHAMPVA eligibility.
Like Medicare, CHAMPVA for Life (CFL) is not the answer to a long-term care solution, whether at home or in facilities such as memory wards and nursing homes. CHAMPVA, like a Medicare Supplemental Insurance policy, does nevertheless reimburse for co-payments and deductibles.
Here is a list of long term care costs that CFL will or will not cover:
CHAMPVA and Alzheimer’s Care
CHAMPVA for Life (CFL) pays for inpatient mental health care which may be needed for patients in the advanced to severe stages of dementia due to Alzheimer’s disease. This is not a special consideration for Alzheimer’s and other types of dementia, for CHAMPVA pays for medical and mental health expenses for all eligible beneficiaries.
CHAMPVA and Activities of Daily Living (ADLs)
CHAMPVA for Life does not reimburse for any form of assistance with activities of daily living such as help needed by the cognitively impaired in feeding, ambulating, bathing, grooming and other essential daily functions. Again, like Medicare, CFL is simply not structured for this type of long term custodial assistance.
CFL and Skilled Nursing Home Care
CFL will, again like Medicare, pay for skilled nursing care up to certain limits. For example, there has to first be a hospitalization that lasted for at least three consecutive days, and the CFL-eligible patient must be admitted to a rehab or skilled nursing center within a period not longer than 30 days following the hospitalization.
Key Difference: While Medicare covers up to a 100-day stay at a rehab or a skilled nursing facility, CFL will pay for what follows at the facility, but not for the full costs. Co-payment of a daily $100 to $200 will be borne by the patient, which makes the process prohibitive and explains why CHAMPVA is not a great way to pay for long term care.
CHAMPVA and Home Health Care
Once again CHAMPVA has a similar process to that of Medicare. Following a hospitalization, it will pay for follow-up visits by skilled nurses and therapists, as long as those do not include long term assistance with the homebound person’s daily activities.
CFL and Adult Day Care – CFL does not reimburse for adult day care.
CHAMPVA and Hospice
The CHAMPVA beneficiary’s Family Primary Caregiver must first secure an authorization from CFL, in which case CFL will pay for end of life care, including palliative and hospice care. These reimbursements must be combined with Medicare’s benefits. However, the patient must meet hospice criteria of being certified terminally ill and not expected to survive six months.
State Veteran Homes
Veteran homes are owned and operated by individual states and constitute a viable living option for many vets. They have to nevertheless conform with certain admission requirements and pay at commonly state-subsidized rates. Many states also provide various extended care services that often include adult day health care, domiciliary, and nursing home care. Those would for the most part come under “Home and Community-Based Programs” and can be viewed on the “Medicare.gov” website.
Any veteran who is dishonorably discharged loses their CHAMPV eligibility status. Other criteria for eligibility for CFL include:
CHAMPVA and TRICARE
As previously mentioned, if you are a TRICARE beneficiary, that routinely disqualifies you for CHAMPVA eligibility
A veteran’s spouse has to be at least 65 to qualify for CFL. Individuals who turned 65 before June 5, 2001 need to have only Medicare Part A, whereas individuals who turned 65 on or following that date are required to have both Medicare Parts A and B.
The spouse of a veteran qualifies if the veteran meets one of the following four conditions:
- He or she died from a service-connected disability, or they had a disability rating of 100% when they died
- He or she must be totally and permanently disabled, i.e. with a disability rating of 100%
- He or she died in the line of duty
- He or she is not enrolled on the TRICARE program
A spouse will forgo his or her qualification for CFL if divorced from the entitled beneficiary. The same goes for a widow or widower who remarries. The exception to that is if his or her remarriage ends, in which case they are entitled to re-establish their eligibility for CHAMPVA for Life benefits.
The net worth or regular income of a beneficiary’s spouse, and the state they live in, do not affect their CFL eligibility. The spouses of veterans must nevertheless purchase Medicare Part B and incur those premium costs for CFL eligibility.
Fee for Service
CHAMPVA is a fee for service (indemnity plan) program. It reimburses health care providers for a vast majority of medical and mental health services, including:
- Inpatient and outpatient services
- Mental health providers and institutions
- Durable medical equipment (DME)
- Ambulance and mobile wheelchair services
- Skilled nursing care and facilities
- Prescription drugs and supplements
- And some dental benefits that require pre-authorization (CHAMPVA does not cover routine dental care, chiropractic services or routine eye exams and corrective lenses)
In the majority of cases, CHAMPVA’s payout rates for benefits are comparable to Medicare and TRICARE rates. More specifically:
- CHAMPVA has a $50 deductible per beneficiary per annum for covered outpatient medical services and supplies, and twice that for a family.
- There is no deductible for:
- Inpatient services
- Day programs for partial psychiatric care
- Services of surgery centers
- End of life palliative and hospice services
- Мedications procured through the Meds by Mail program
- All services provided within VA centers
- CHAMPVA applies a patient cost share of 25% of its allowable amount up to a maximum of $3,000 per calendar year.
- When doctors or other health care providers accept CHAMPVA, the provider agrees to accept the VA’s allowable amount as payment in full, which means that such providers cannot bill the patient for the difference between their regular fees and the VA’s allowable amount.
- When the beneficiary has other health insurers, then CHAMPVA first deducts the $50 annual deductible, and then assumes the lesser of either 75% of the allowable amount, or the remainder of the charges, in which case the beneficiary will normally have no cost share.
Amounts per Beneficiary
For a single beneficiary with no dependents, the reimbursement for service-related disabilities ranges from $123 to $2,673, with the determinant for compensation consisting of the patient’s disability rating. For beneficiaries with dependents, or those with financially-dependent parents, the reimbursement is slightly higher (for more details, go to va.gov).
The veteran’s disability rating comprises the main factor in determining the amount of compensation. The amount of compensation also goes up slightly for veterans with a spouse or dependent minor children, or with a parent or parents who are financially dependent on the veteran for some part of their living expenses.
Individual and Dependent Beneficiaries
Based on their own veteran status, a qualified CHAMPVA beneficiary may obtain medical care services through the VA health care system. If the CHAMPVA beneficiary is the spouse of another eligible CHAMPVA beneficiary, both may now be eligible for CHAMPVA benefits, and any one of the two may opt for the VA health care system or coverage under CHAMPVA for their medical or mental health care needs.
Child Eligibility and Divorce
The eligibility of a child is not affected by the divorce or remarriage of the beneficiary’s spouse except in the case of a stepchild leaving the prime beneficiary’s household, in which case the child loses CHAMPVA eligibility.
Beneficiaries Age 18 to 23
For benefits to continue, a CHAMPVA-eligible beneficiary turning 18 is required to provide evidence that he or she has full-time enrollment in a school or other educational institution.
Caregivers of Vets
Under the CHAMPVA program, the Primary Family Caregiver of a beneficiary may also qualify to receive medical care and supplies, providing he or she is not also qualified to receive medical or mental health services under another health care insurance policy. You should also know that CHAMPVA benefits do not extend to the family members of the Primary Family Caregiver, and CHAMPVA benefits are stopped for the Primary Family Caregiver when the vet is no longer in need of personal care services or someone else assumes the role of Primary Family Caregiver.
Changes in Status
You should promptly report changes in your marital or other significant status. More specifically, if you are receiving benefits under the CHAMPVA program, your eligibility may be affected by changes such as marriage, divorce from the beneficiary, or new eligibility for TRICARE or Medicare.
CHAMPVA and Obamacare
Under the Affordable Care Act, the health care coverage that individuals benefit from meets what is referred to as the “minimum essential coverage”. The ACA designates CHAMPVA as fulfilling the minimum essential coverage requirement, and if you are a CHAMPVA beneficiary, there are no additional steps you need to take to meet the ACA minimum standards.
CHAMPVA and Medicaid
Medicaid beneficiaries may have more favorable terms than under CHAMPVA. For example, some state Medicaid programs do not necessitate beneficiaries to pay co-payments, cost shares or deductibles, whereas CHAMPVA’s outpatient deductible is $50 per calendar year for an individual, and $100 for a family. In addition, CHAMPVA has a cost share of a minimum of 25 percent of the CHAMPVA allowable charge, up to a maximum of $3,000 per annum.
If you are already a CHAMPVA eligible beneficiary, then you need to submit to CHAMPVA evidence of your enrollment in Medicare Parts A and B upon turning 65. You also need to submit information about other possible health insurance policies that you may have enrolled in.
If you are not a qualified CHAMPVA beneficiary, then you must complete the CHAMPVA application form and submit with it documents as per the above paragraph. To speed up the process, be sure to add optional documents to your application, including your latest disability rating, discharge documents, marriage licenses, and other similar documents detailing your current significant status.
A full list of requirements can be viewed at: VA Form 10-10d
You can mail the application to:
National Personnel Records Center
Military Personnel Records
1 Archives Drive
St. Louis MO 63138
Or apply online through: https://www.archives.gov/veterans/military-service-records
The application process takes about six weeks, providing that the CHAMPVA application is complete (including optional documents) and the submitted documents are easily verifiable and up to date.