CHAMPVA

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.

CHAMPVA

The Civilian Health and Medical Program of the Department of Veterans Affairs (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 insurances 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

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 Department of Defense TRICARE benefits.

Additional Eligibility

A Veteran's primary caregiver under Program of Comprehensive Assistance for Family Caregivers (PCAFC) can be eligible for CHAMPVA, assuming they do not have any other health insurance coverage.

Applying

Complete the followings forms:

Also include:

Documents related to your Medicare status:
- If you qualify for Medicare for any reason, you’ll need to submit a copy of your Medicare card.
- If you’re 65 years old or older and don’t qualify for Medicare, you’ll need to send documentation from the Social Security Administration that confirms you don’t qualify for Medicare benefits under anyone’s Social Security number.

To expedite processing also include the following:

Benefits Letter - showing the Veteran is permanently and totally disabled (or the death rating if you’re a survivor)
Veteran’s DD214

If you are including dependent children:

A copy of each child’s birth certificate or adoption papers
School certification of full-time enrollment for children ages 18-23

Then submit copies of everything via fax or snail mail.

Fax

303-331-7809

Mail

VHA Office of Community Care CHAMPVA Eligibility PO Box 469028 Denver, CO 80246-9028

Finding a provider

CHAMPVA does not have a network for 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 reception tells you they don't accept CHAMPVA, ask the billing department - sometimes they are the only ones that know.

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.

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. 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

Click HERE for information on how to file a claim.

FAQ

What does CHAMPVA pay?

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.

How long will it take for me to get a response after applying?

4-6 months currently.

I need coverage NOW but it is taking forever to get approved for CHAMPVA! What can I do?

The current advise is to pay out of pocket for now and to file for reimbursement once you are finally approved.

Are health care services at VA facilities available to CHAMPVA beneficiaries?

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.