VA Medical Care for Family

VA Medical Care for Family

VA Medical Care for Family

 

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 health care 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
  • Pharmacy
  • Nursing care
  • Transplants

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 long-term custodial 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 for 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 primary 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 https://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 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 the 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).

CHAMPVA Assignments

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. After finishing the paperwork, the provider relays the claim to the veteran who received medical care. Doctors and providers that accept assignment welcome the CHAMPVA allowable amount and can’t charge 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/physiciancompare/

Other Providers

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.

Covering Medication

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.

Non-Network Pharmacies

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 are no co-payments, no deductibles, 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 suggested that individuals 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.

Submitting Claims

Members wishing to submit a claim for reimbursement are required to complete VA Form 10-7959a, CHAMPVA Claim Form. 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 form 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.

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9 Comments
  • CATHERINE MEREDITH
    Posted at 17:01h, 11 December Reply

    I am a VSO for the State of Oklahoma and I am assisting a Veteran and his family with applying for CHAMPVA. They have received, in the mail, a pharmacy card but not the initial insurance card or booklet for CHAMPVA. We have tried calling the 800# and have not been able to get through. What can I do to help this family get the CHAMPVA card and booklet explaining what they are eligible for. This is an elderly couple that will not use the computer. Thank you so much for any assistance you can give.

  • William A. Remick
    Posted at 18:43h, 06 December Reply

    I’ve found that getting any information about CHAMPVA services are met with answers from the book only if they even know that. Every time my wife tries to get care using her champva insurance it is met with a blank stare .. the same seems to be true when I call direct to secure her “ALLOWED” benefits which I have been told by them that she is entitled to. I am trying to get information “WITH VERIFICATION” what the government no pay list contains. So far when champva is listed I get either “TRICARE or MEDICARE” and I am told that CHAMPVA has it’s own list. This makes me suspicious about those making these claims. It appears that there is NO real list only something MADE UP for the occasion. NOW I want to see the FEDERAL LAW authorizing this before I call the FBI! This looks like CORRUPTION and needs to be rooted out!!

  • Restituto Diaz Barraquias
    Posted at 12:30h, 26 May Reply

    I am only homeless veterans family
    hiw to avail and to get this benefits healthcare, Medicare card under champva or tricare insurances I am now suffering of high blood pressure and not clear to see or temporary blind. I am now 53 years old jobless, and hopeless son and I am now financially hard up my parent both applied of service connected and no service connected all denied all deaths. Again how to get and avail healthcare,Medicare insurance I am only homeless veterans family members.
    ?

    please advice

  • edna emery
    Posted at 21:18h, 23 January Reply

    I need a replacement card I lost mine

    • Matt Terry
      Posted at 19:17h, 23 April Reply

      Edna,

      Contact the Veterans Affairs office nearest you for the answers you seek.

      -Matt

  • Gerald D. Bond, Jr.
    Posted at 16:38h, 26 October Reply

    I spent 20 years in the Air Force, retired 1992. I had applied to be seen at my local VA and was told I did not qualify for medical care. I do have TRICARE Prime at this time. I have a refural and have seen an ENT Dr. I am told that I need hearing aids but TRICA does not cover them. What are my options beside paying for them outright, which I can not afford.

    • VA.org Editor
      Posted at 15:50h, 08 November Reply

      TRICARE doesn’t cover hearing aids and hearing aid services for retirees and their family. Retirees and veterans may be able to get hearing aids from other government programs, including: Retiree-At-Cost Hearing Aid Program (RACHAP). This is at certain military hospitals and clinics. The RACHAP lets you get hearing aids at a significant cost savings. RACHAP doesn’t cover retiree family members. Department of Veterans Affairs (VA). Veterans may be eligible. You must first register at any VA medical center. If you’re eligible, you’ll get your hearing aids at no charge.

      See here for more information: https://www.prosthetics.va.gov/psas/Hearing_Aids.asp

    • Laura
      Posted at 17:52h, 03 July Reply

      I am surprised that you would not qualify for medical care at a VA facility. My late husband also spent over 20 years in the Air Force. He did not use the VA, as he had other Insurance, but a neighbor, who only spent two years in the Army, became ill and until he died, he received ALL his treatment either at a VA facility, including low cost prescriptions, or it was paid for by VA.

    • Laura
      Posted at 17:59h, 03 July Reply

      I am surprised that you would not qualify for medical care at a VA facility. My late husband also spent over 20 years in the Air Force. He did not use the VA, as he had other insurance, but a neighbor, who only spent two years in the Army, became ill and until he died, he received ALL his treatment either at the VA facility, including low cost prescriptions, or it was paid for by VA.

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