The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a program that offers additional healthcare benefits to the eligible spouse, widow, or children of a veteran.
The program works with private insurance plans as well as Medicare policies to help reduce healthcare costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The Veterans Health Administration Office of Community Care administer the CHAMPVA program. The program provides additional health benefits to the spouse or widow and children of a disabled veteran.
Insurers and the government consider CHAMPVA to be supplementary, as opposed to primary, health coverage. In other words, a CHAMPVA policy should not be a person’s only form of health insurance.
Depending on their location, a person may also get healthcare at a Veterans Administration (VA) facility. This entitlement is generally based on the availability of services.
CHAMPVA covers various health services.
Some services need pre-authorization, which means that the doctor’s office or policyholder will confirm whether or not a service is covered.
A doctor must also accept CHAMPVA’s “allowable amount” for billing, which is the amount that CHAMPVA pays for a particular service. If a doctor accepts this amount, they cannot charge more.
The following are some of the services that CHAMPVA covers:
- ambulatory services
- durable medical equipment
- home health
- hospice services
- inpatient services
- limited dental services
- mental health services
- outpatient services
- pharmacy services
- skilled nursing facility
If a person has a question about coverage for a particular service, they can consult the CHAMPVA guide or contact their plan provider.
To qualify for CHAMPVA coverage, a person must be in one of the following categories:
- the spouse or child of a veteran who is declared permanently and totally disabled due to a service-related disability
- the surviving spouse or child of a veteran who has passed away due to a VA-rated, service-related disability
- the surviving spouse or child of a veteran who was, at the time of their death, permanently and totally disabled due to a service-related disability
- the surviving spouse or child of a military member whose death in the line of duty was not related to misconduct (in which case the spouse or child is ineligible for TRICARE)
A person cannot be eligible for both CHAMPVA and TRICARE, as the latter is a government-managed health plan with different beneficiaries, claims, filing procedures, and pre-authorization requirements.
If a person wishes to apply for CHAMPVA benefits, they can do so online, or they can call the Veterans Health Administration Office of Community Care at 800-733-8387.
Medicare is a federal insurance program that provides hospital and medical insurance to those aged 65 years and older.
People younger than age 65 years may also be eligible to enroll if they have end stage renal disease or amyotrophic lateral sclerosis.
Medicare has parts A, B, C, and D. The list below provides more detail on these.
- Part A covers inpatient treatment. Learn more about what Part A covers here.
- Part B provides coverage for visits to a doctor and some outpatient care. Learn more about Part B here.
- Part C, or Medicare Advantage, offers an alternative to original Medicare (Part A and Part B). Learn more about choosing a Medicare Advantage plan here.
- Part D covers prescription drugs. Learn more about Medicare Part D here.
A person can have both original Medicare (parts A and B) and CHAMPVA, and their CHAMPVA policy may help pay some of the out-of-pocket costs or services that Medicare does not cover.
In general, when a person combines the benefits of original Medicare and CHAMPVA, they will get coverage for most medical expenses. However, there may be some exceptions, such as cosmetic services or the purchase of eyeglasses.
Learn more about original Medicare (Part A and Part B) here.
For a person to be eligible for CHAMPVA, they must also be enrolled in Medicare Part B and continue to be enrolled if they:
- are under 65 years of age and enrolled in Medicare Part A
- were over 65 years of age when their spouse qualified for CHAMPVA
- were 65 years or older before June 5, 2001, could otherwise be eligible for CHAMPVA, and had coverage with Medicare Part A
- turned 65 years old on or after June 5, 2001, and were eligible for Medicare Part A
To continue to be eligible for CHAMPVA after reaching 65 years of age, a person must enroll in Medicare 90 days before their 65th birthday.
To make sure that their CHAMPVA benefits continue without a break, a person should send a copy of their Medicare card to CHAMPVA, along with a CHAMPVA Other Health Insurance Certification Form (VA Form 10-7959c).
A person can check for more details using this online guide.
Who is the primary payer?
CHAMPVA is always the secondary payer to Medicare. This means that Medicare will pay its portion of coverage first. Then, the doctor’s office or healthcare organization will bill CHAMPVA, which will cover its portion of the costs.
The remaining payment amount (if any) will be the policyholder’s responsibility.
However, there may be some times when Medicare covers a service but CHAMPVA does not. In this instance, a person will pay their Medicare copay. If Medicare does not cover a service but CHAMPVA does, a person will be responsible for the cost-sharing percentage.
CHAMPVA and Medicare Advantage can work together.
Medicare Advantage is an alternative to original Medicare (Part A and Part B) wherein a person selects a private insurance company to administer their Medicare benefits.
Medicare Advantage plans may have different copays, deductibles, and coinsurances than original Medicare. These plans may also offer expanded benefits, including vision and hearing coverage.
Medicare Advantage providers often designate in-network providers. If a person is enrolled in both a Medicare Advantage plan and with CHAMPVA, they must find a healthcare provider who accepts both.
Learn more about Medicare Advantage here.
Who is the primary payer?
Medicare Advantage is the primary payer when a person has CHAMPVA and Medicare Advantage.
CHAMPVA is almost always the secondary payer, except when a person uses any of the following:
- Indian Health Services
- Medicaid
- State Victims of Crime Compensation programs
- supplemental CHAMPVA policies
CHAMPVA is, for the most part, a cost-sharing insurance plan, and it does not have a monthly premium. However, there is an annual outpatient deductible of $50.
The percentage a person pays usually depends on the services. The table below shows examples of some costs covered by CHAMPVA, according to the VA.
| Benefits | Is there a deductible? | CHAMPVA pays | Person pays |
|---|---|---|---|
| Outpatient services | Yes | After the deductible, CHAMPVA pays 75% of the allowable amount. | 25% of the allowable amount |
| Pharmacy services | Yes | After the deductible, CHAMPVA pays 75% of the allowable amount. | 25% of the allowable amount |
| Durable medical equipment | Yes | After the deductible, CHAMPVA pays 75% of the allowable amount. | 25% of the allowable amount |
| Services through the CITI program or Meds by Mail | No | 100% of the VA cost. | Zero |
These costs are subject to change by CHAMPVA.
Also, CHAMPVA has a catastrophic spending cap of $3,000 per calendar year (starting on January 1), which is the maximum amount of out-of-pocket costs for CHAMPVA-covered supplies and services.
After a person has spent $3,000 out of pocket for their care, CHAMPVA may not require a person to pay the cost-sharing amount.
Original Medicare and CHAMPVA
If a person has both original Medicare (parts A and B) and CHAMPVA, they will usually have few out-of-pocket costs. This is because CHAMPVA often pays coinsurance or copayments after Medicare pays.
For example, a doctor may charge $200 for a visit. The doctor will then bill Medicare, which will pay 80% ($160) of this cost. The doctor will then bill CHAMPVA for the 20% copay.
CHAMPVA and Part D
Medicare Part D is the prescription drug coverage portion for Medicare. CHAMPVA generally pays the copays on covered prescriptions.
If a Part D plan does not cover a particular medication, CHAMPVA will typically pay 75% of the prescription’s costs.
CHAMPVA and Medicare Advantage
Medicare Advantage plans cover at least the same benefits as original Medicare (parts A and B). However, a person may have a different copay or coinsurance. For example, they may pay a set cost for seeing their primary care provider or specialist.
Depending on a person’s plan, CHAMPVA will usually cover the costs of copays or coinsurances related to the Medicare Advantage plan.
There may be some assistance with paying out-of-pocket costs, including the following:
- Extra Help: This Medicare program helps people with a low income pay for prescription drugs.
- Medigap: Also known as Medicare supplement insurance, Medigap is a separate policy to help cover out-of-pocket costs for people enrolled in original Medicare (parts A and B). According to a VA report, a person enrolled in both CHAMPVA and original Medicare could benefit from an additional insurance policy to cover out-of-pocket costs.
- Medicare savings programs: These income-based programs may help pay for original Medicare premiums, deductibles, and coinsurances. Because CHAMPVA does not pay for Medicare Part B premiums, these programs may help reduce costs for a person enrolled in CHAMPVA.
CHAMPVA provides healthcare payment assistance for the spouses, widows, or children of disabled veterans.
The coverage can help a person reduce out-of-pocket costs when they are enrolled original Medicare (Part A and Part B) or Medicare Advantage policies.
CHAMPVA will usually be the second payer on any healthcare costs unless Medicare does not cover them.