VA medical care for family insurance programs organized by the VA are available for eligible family members of particular veterans entitled the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Once a veteran is enrolled in CHAMPVA, it operates similarly to Medicare in that the veteran pays an annual deductible and a co-pay for medical care they receive.
Many healthcare services and supplies considered medically and psychologically necessary are covered by the CHAMPVA program. CHAMPVA covers such things as:
- Ambulance cost
- Ambulatory surgery
- Durable medical equipment (DME)
- Family planning and maternity, hospice, inpatient services
- Mental health services
- Outpatient services
- Nursing care
The VA determines whether the treatment is medically or psychologically necessary so the program may not cover all medical procedures. These uncovered procedures may include:
- Dental work
The CHAMPVA benefit doesn’t take care of long-term care, or custodial care, that is generally provided in nursing homes, assisted living facilities, adult day care, or in a patient’s home. Custodial care concerns assistance with activities of daily living or management of an individual mentally debilitated. As a result of not covering custodial long-term care CHAMPVA can be expensive.
Those that qualify for the following criteria are eligible for CHAMPVA:
- The spouse or child of a veteran who has been rated 100 percent permanently disabled for a service-related disability
- The surviving spouse or child of a veteran who died as a result of a VA-rated service-related disability
- The surviving spouse or child of a veteran who was rated permanently and completely disable as a result of a service-related disability at the time of death
- The surviving spouse or child of a military service member who died in the line of duty not due to misconduct.
Qualifying children include those who are unmarried under the age of 18, or 23 if attending university, and those who developed mental or physical incapacities rendering them unfit of self-support before the age of 18.
Surviving spouses who remarry before the age of 55 lose their benefits unless they terminate their remarriage.
Veterans do not qualify for CHAMPVA if they’re eligible for TRICARE.
Individuals age 65 and older, eligible for Medicare are required to enroll in Medicare Part B to resume eligibility for their participation in CHAMPVA. If this is the case, Medicare becomes the predominant insurer while CHAMPVA covers the costs Medicare doesn’t cover.
Individuals looking to enroll in CHAMPVA are required to complete VA Form 10-10d, Application for CHAMPVA benefits. This form is available at any VA regional office or for download at http://www.va.gov/vaforms/medical/pdf/vha-10-10d-fill.pdf.
Deductibles and Co-Pay
CHAMPVA requires an annual deductible in which a veteran provides a co-pay for any medical treatment they receive. The annual deductible is $50 per family member. This deductible can’t surpass the amount of $100 for an entire family.
For inpatient services, ambulatory surgery facility services, partial psychiatric day programs, hospice services, or services authorized by VA medical facilities there is no required deductible.
The VA pays 75 percent of the allowable cost of medical treatment after the annual deductible has been paid. Members pay a 25 percent co-pay. The VA assigns a maximum amount for each type of medical treatment covered under CHAMPVA.
The VA enacted an annual restriction for out-of-pocket expenses for covered services paid by veterans in order to maintain financial protection and anticipation of a long-term illness or injury. This is the maximum out-of-pocket expense a veteran and their family can acquire for CHAMPVA-related services and supplies in a year. If veteran and their family reach the limit, their co-pay for covered services for the rest of the year is waived. The VA subsequently pays 100 percent of the CHAMPVA allowable amount for covered services for the remainder of the year.
How medical Providers Work with CHAMPVA
Veterans obtain a CHAMPVA insurance card after being accepted and enrolled in CHAMPVA. During a time of medical care, a veteran must present their card to the provider. With CHAMPVA, veterans can receive medical care from a provider who accepts CHAMPVA, receive care from any other provider, or receive care from a VA medical facility (in some cases).
It is important to make sure a medical provider accepts CHAMPVA assignments when the veteran visits the facility. Providers refer to CHAMPVA care as accepting assignment, referring the provider billing CHAMPVA directly for covered services, items, and supplies. The provider, after finishing the paperwork, relays the claim to the veteran who received medical care. Doctors and providers that accept assignment welcome the CHAMPVA allowable amount and can’t chare more than the amount for the services allotted to the veteran.
The VA doesn’t provide a list of facilities that accept CHAMPVA assignments. However, most Medicare and TRICARE providers accept CHAMPVA.
Medicare providers can be found at www.medicare.gov/Physician/Search/chooseprovider.asp
Veterans have the option to see medical providers even if their assignment is turned down, but the entire charge will be billed to them (more than the CHAMPVA allowable amount). Members can submit an itemized bill from the provider with a CHAMPVA claim form (“Submitting claims”) in order to receive reimbursement. The VA sends the veteran 75 percent of the allowable amount after the claim is processed. In such a case, the veteran who received treatment must pay for their share of the CHAMPVA allowable amount but also for any charges over the allowable amount.
VA Medical Facilities
Many VA medical centers (VAMCs) cooperate in the CHAMPVA In house Treatment Initiative (CITI), which includes care for inpatients, outpatients, pharmacy, durable medical equipment (DME), and mental health services. Veterans are able to receive all or parts of their medical care through the CITI program contingent on the CITI programs a VAMC has available. Over half of all VA medical facilities cooperate in the CITI program.
CHAMPVA is able to cover medication prescribed by a doctor so long as the member has no other type of medical insurance that covers pharmacy necessities—including Medicare Part D. Members that do not have extra pharmacy insurance that are enrolled in CHAMPVA have three options: they can use VA network pharmacies, non-network pharmacies, or the Meds by Mail program.
Congress used the TRICARE model as an example during the provision of CHAMPVA, but they are distinguishable from each other. The TRICARE program is managed by the Department of Defense (DOD) and CHAMPVA is organized by the VA.
VA network pharmacies
There are over 45,000 pharmacies managed by the VA through contracts made with the pharmacy network company SXC Health Solutions Inc. CHAMPVA members can use the same network of pharmacies if they don’t have an alternative health insurance plan that covers pharmacy charges. After the outpatient deductible is met and there are no claims to file, the member pays their co-pay for the medication they receive.
Individuals can find a pharmacy network provider by contacting 800-880-1377 or search for applicable network providers in their proximity at the SXC Health Solutions site https://vahac.rxportal.sxc.com/rxclaim/VAH/index.html.
Members are entitled to select any pharmacy they like. The CHAMPVA insurance card operates as the member’s evidence of coverage, although they must confirm with the pharmacy that CHAMPVA doesn’t presently provide special drug coverage card for prescriptions. If using a pharmacy unrelated to the network, a member is generally asked to pay the full amount of the prescription. In this situation, the member is able to request reimbursement from the VA by submitting a claim for (“Submitting claims”) in addition to an itemized pharmacy statement.
Meds by Mail
With Meds by Mail there is no co-payments, deductible sulations, and no claims to file. Medication is free and mailed to the member’s home.
Meds by Mail is not suitable for immediate medical conditions that require medications, and it is advisable for individuals with such circumstances use the nearest pharmacy in such a circumstance.
To use Meds by Mail, members are required to complete the Meds by Mail Order Form and Patient Profile form available at or call 800-733-8387 and select the self-service option to request the appropriate forms be mailed to their address.
Members wishing to submit a claim for reimbursement are required to complete VA Form 10-7959a, CHAMPVA Claim Form, available at . It is important to remember to attach the itemized bill for the services received by the member.
A request form is also available to be mailed to a member’s home by calling 800-733-8387.
With the completed for and its attachments, members can mail it to:
VA Health Administration Center
CHAMPVA, P.O. Box 65024,
Denver, CO 80206-9024
Claims can’t be filed more than one year after the date they were received, or in the case of inpatient care, within one year of the discharge date.
A provider is obligated to file a claim for a member is they accept CHAMPVA assignments or one of the VA’s network pharmacies.