CHAMPVA FAQs

[Tbird]

Frequently Asked Questions About CHAMPVA

What is CHAMPVA?

Who is eligible for CHAMPVA?

What does CHAMPVA pay?

Can a beneficiary have other health insurance (OHI) and use CHAMPVA?

How can I locate a provider?

What is the impact of Medicare on CHAMPVA?

What is the difference between CHAMPVA and TRICARE (formerly CHAMPUS)?

How can I obtain an application for CHAMPVA benefits?

From the time an application is submitted, how long before I get a response from VHA Office of Community Care?

Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage who choose to receive covered services from a provider who is not in their primary insurance's network?

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

How can I find out if the local VA facility is participating in the CITI program?

What out-of-pocket expenses can a CHAMPVA beneficiary expect under CITI?

What is CHAMPVA?

The 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 Veternas Health Administration Office of Community Care (VHA CC) in Denver, Colorado. We verify CHAMPVA eligibility, authorize benefits, and process 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 Department of Defense TRICARE benefits.

Effective October 1, 2001, CHAMPVA benefits were extended to those age 65 and older. To be eligible for CHAMPVA, 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 Medicare Parts A & B to be eligible for CHAMPVA.
• If the beneficiary turned age 65 on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible for CHAMPVA.

What does CHAMPVA pay?

In most cases, CHAMPVA's allowable amount—what we pay 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 CC 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 our allowable amount as payment in full. A provider cannot bill you for the difference between our 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. See Payment Methodology Fact Sheet 01-11 for further information regarding payment on other than outpatient type of services.

Can a beneficiary have other insurance (OHI) and use CHAMPVA?

Yes. If the beneficiary has other health insurance (OHI), the OHI 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 the secondary payer except to Medicaid, State Victims of Crime Compensation Programs, Indian Health Services, and supplemental CHAMPVA policies.

How can I locate a provider?

Information about providers can be found on our Locating a Provider page.

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 health care 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):

1. Complete the online fillable Application for CHAMPVA Benefits (VA Form 10-10d)
2. Call the VHA Office of Community Care at 1-800-733-8387. When calling, select the Application Form option from the Interactive Voice Response menu.

From the time an application is submitted, how long before I can expect a response from the VHA Office of Community Care?

Generally, applicants can expect to receive written notification from the VHA Office of Community Care within 45 days after mailing their application. To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits (see link above) 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 Enrollment Certification for all applicant children between the ages of 18 and 23.

Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage who choose to receive covered services from a provider who is not in their primary insurance's network?

CHAMPVA will deny payment on a claim if the beneficiary’s OHI denied payment because the beneficiary obtained the medical services or supplies outside the OHI (HMO, PPO, and Medicare) provider's plan.

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

Under the CHAMPVA Inhouse Treatment Initiative (CITI), CHAMPVA beneficiaries may receive cost-free health care 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, many are. To find out if your local facility is participating, view our online CITI Participating Facilities list. 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.

[jfrei]

Awesome thanks for the info