What is CHAMPVA?
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries.
CHAMPVA is managed by the VA’s Chief Business Office Purchased Care (CBOPC) in Denver, Colorado. CBOPC processes CHAMPVA applications, determines eligibility, authorizes benefits, and processes medical claims.
Who is eligible for CHAMPVA?
To be eligible for CHAMPVA, the beneficiary cannot be eligible for TRICARE. CHAMPVA provides coverage to the spouse or widow(er) and to the children of a veteran who:
- Is rated permanently and totally disabled due to a service-connected disability, or
- Was rated permanently and totally disabled due to a service-connected condition at the time of death, or
- Died of a service-connected disability, or
- Died on active duty and the dependents are not otherwise eligible for DoD TRICARE benefits.
Effective October 1, 2001, CHAMPVA benefits were extended to age 65 and older. To be eligible, you must also meet the following conditions:
- If the beneficiary was 65 or older prior to June 5, 2001, and was otherwise eligible for CHAMPVA, and was entitled to Medicare Part A coverage, then the beneficiary will be eligible for CHAMPVA without having to have Medicare Part B coverage.
- If the beneficiary turned 65 before June 5, 2001, and has Medicare Parts A and B, the beneficiary must keep both Parts to be eligible.
- If the beneficiary turn age 65 on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible.
What does CHAMPVA pay?
In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. CHAMPVA has an outpatient deductible ($50 per person up to $100 per family per calendar year) and a cost share of 25% up to the catastrophic cap (up to $3,000 per calendar year). You should collect the 25% allowable cost share from the patient except when the patient has other health insurance.
If the patient has other health insurance, then CHAMPVA pays the lesser of either 75% of the allowable amount after $50 calendar year deductible is satisfied, or the remainder of the charges and the beneficiary will normally have no cost share.
Can a beneficiary have other insurance and use CHAMPVA?
Yes. If the beneficiary has other health insurance (OHI), they should be billed first. The explanation of benefits (EOB) from the OHI should then be submitted with the claim for reimbursement to CHAMPVA.
By law, CHAMPVA is always secondary payer except to Medicaid, State Victims of Crime Compensation Programs and supplemental CHAMPVA policies.
How Can I Locate a Provider?
CHAMPVA does not maintain a provider listing. Most Medicare and TRICARE providers will also accept CHAMPVA (but be sure you ask the provider).
If you are having difficulty finding a provider, we recommend you visit the Medicare website HTTP://WWW.MEDICARE.GOV and use the “Search Tools” at the bottom of that page to locate a Medicare provider.
You may also visit the TRICARE website at (http://www.tricare.mil/STANDARDPROVIDER/) to locate a provider in your area.
If you choose to see a provider who does not accept CHAMPVA, you will likely have to pay the entire bill and then submit a claim for reimbursement of our cost share. Remember that CHAMPVA cost shares are based on the CHAMPVA allowable amount.
What is the impact of Medicare on CHAMPVA?
As a result of a Federal law passed June 5, 2001, CHAMPVA expanded benefit coverage to eligible family members and survivors of qualifying Veteran sponsors effective October 1, 2001.
If the beneficiary is eligible for CHAMPVA and also has Medicare Part A entitlement (premium-free hospitalization coverage) and Medicare Part B (outpatient coverage) we will cover many of the costs not covered by Medicare. CHAMPVA will pay after Medicare and any other insurance, such as Medicare HMOs and Medicare supplemental plans, for health care services and supplies.
CHAMPVA does not pay Medicare Part B premiums.
What is the difference between CHAMPVA and TRICARE (formerly CHAMPUS)?
Although similar, CHAMPVA is completely separate with a totally different beneficiary population than TRICARE – a Department of Defense healthcare program formerly called CHAMPUS.
While the benefits are similar, the programs are administered separately with significant differences in claim filing procedures and preauthorization requirements.
How can I obtain an application for CHAMPVA benefits?
There are a couple ways to obtain an Application for CHAMPVA Benefits (VA Form 10-10D):
- Fillable Application
- Call the Chief Business Office Purchased Care at 1-800-733-8387. When calling, select the Application Form option from the voice-mail menu. To help reduce the volume of telephone calls during business hours, please consider placing these calls during evening or weekend hours.
From the time an application is submitted, how long before I can expect a response from the Chief Business Office Purchased Care?
Generally, applicants can expect to receive written notification from the Chief Business Office Purchased Care within 45 days from mailing their application. To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits (VA Form 10-10D) in its entirety and to attach all required documents. As further explained on the application, required documents include a copy of each applicant’s Medicare card (if Medicare eligible) and a school certification for all applicant children between the ages of 18 and 23.
CHAMPVA School Certifications (01-02)
Why is CHAMPVA the secondary payer when beneficiaries have other health insurance (OHI)?
To answer this question, a look at CHAMPVA’s origin and the congressional intent behind its legislation may help. From the start, CHAMPVA was intended to serve as a safety net in the event other coverage was not available – rather than being the primary carrier. While families with OHI are not disqualified from CHAMPVA benefits, CHAMPVA’s safety net protection becomes available after the OHI has paid.
This includes enrollment benefits available from:
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Other health insurance
Exceptions to CHAMPVA’s secondary payer status are
- Supplemental CHAMPVA policies
- State Victims Compensation Programs
CHAMPVA becomes the primary payer in these cases.
Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage through a Health Maintenance Organization (HMO), who elect to receive HMO-covered services outside of the HMO network?
Just as beneficiaries with OHI cannot opt to waive those benefits to have CHAMPVA become the primary payer, beneficiaries enrolled in an HMO cannot elect to waive the HMO benefits without forfeiting their CHAMPVA benefits. CHAMPVA benefits, however, do apply to covered services that are not covered by the HMO.
Are healthcare services at VA facilities available to CHAMPVA beneficiaries?
Under the CHAMPVA Inhouse Treatment Initiative (CITI for short), CHAMPVA beneficiaries may receive cost-free healthcare services at participating VA facilities.
How can I find out if the local VA facility is participating in the CITI program?
Although some VA facilities are not CITI participants due to the volume of Veterans they are responsible for serving, most are. To find out if your local facility is participating, click here. However, CHAMPVA beneficiaries who are also covered by MEDICARE cannot use a VA medical center because MEDICARE does not pay for services provided by a VA Medical Center.
What out-of-pocket expenses can a CHAMPVA beneficiary expect under CITI?
None – CHAMPVA beneficiaries don’t pay a thing when receiving services under the CITI program.
Isn’t it unfair that some VA facilities are offering CITI services, while others aren’t? Shouldn’t they all participate?
VA’s authority to offer inhouse services to CHAMPVA beneficiaries is conditional providing Veteran access to care is not compromised. Unfortunately, some facilities are experiencing such a high Veteran demand for services that participation in the CITI program is not possible.
How does my annual deductible and catastrophic cap work?
The annual outpatient deductible begins over again each Jan 1st and is $50.00 per person, no more than $100.00 per family. This deductible must be paid before CHAMPVA will pay 75% of the allowable amount. As claims are processed for covered services, charges are automatically credited to individual and cumulative family deductible requirements for each calendar year.
The catastrophic cap (cat cap) begins over again each Jan 1st and is $3000.00 per family per year. Each time we pay a bill, the deductible and cost share (out of pocket expenses) are calculated and credited to the cat cap. When the cat cap reaches $3000.00 for the family, CHAMPVA will then pay at 100% of our allowable amount for the rest of the calendar year.