Article at a glance
CHAMPVA is a fantastic healthcare benefits program. It is a cost-sharing health benefits program run by the Department of Veteran Affairs, assisting dependents of disabled veterans with various medical costs.
Select dependents are eligible for CHAMPVA based on a set of qualifications. Those eligible for TRICARE are not eligible for CHAMPVA.
CHAMPVA can be used alongside Original Medicare, Medicare Advantage (MA) plans, and Medicare Part D prescription drug plans.
There is no annual or monthly premium for CHAMPVA, although it does require a small annual deductible for outpatient services.
This article will discuss CHAMPVA drawbacks, CHAMPVA eligibility, how to apply for CHAMPVA, and more.
What is CHAMPVA?
CHAMPVA stands for the Civilian Health and Medical Program of the Department of Veterans Affairs that is managed by the Veterans Health Administration Office of Community Care (VHA OCC). The Department of Veteran Affairs (VA) assists eligible beneficiaries with the cost of their health care services and/or medical supplies.
Difference Between TRICARE & CHAMPVA
CHAMPVA is occasionally referred to by its previous name CHAMPUS and is often confused to be the same program as TRICARE. It’s important to note that any dependent eligible for TRICARE is not eligible for CHAMPVA.
TRICARE is a Department of Defense (DoD) health care program for active-duty members and retired veterans of the U.S. military and their dependents or survivors. Meanwhile, CHAMPVA is a VA health care program that often serves the dependents of disabled veterans.
Services Covered by CHAMPVA
When individuals receive certain health care services from an authorized provider that are deemed medically necessary, CHAMPVA will cover the cost. Covered services may include but are not limited to:
Durable Medical Equipment (DME)
Family Planning or Maternity Services
Mental Health Services
Skilled Nursing Care
Note: To learn more about the benefits of CHAMPVA and browse the full list of covered services, visit page 18 of this source.
In order for the dependent child or spouse of a veteran to be eligible for CHAMPVA, the veteran must:
Be permanently and totally disabled due to their service.
Be permanently and totally disabled due to service at their time of death.
Suffer death due to a service-connected disability.
Suffer death while actively serving.
Note: Dependents that are eligible for TRICARE are not eligible for CHAMPVA.
How to Apply for CHAMPVA
In order to apply for CHAMPVA benefits, eligible beneficiaries must send in an application along with various supplementary materials.
Necessary Application Materials
The necessary documents for application include:
- Medicare Status Documents:
If one is eligible for Medicare, send a copy of one’s Medicare card.
If one is 65 years old or older and is not eligible for Medicare, send documentation from the Social Security Administration (SSA) that certifies the individual is not eligible for Medicare under anyone’s Social Security number.
Note: Individuals who only send these required documents may wait two to eight months to hear back about their CHAMPVA benefits.
Optional Documents for Rapid Processing
Certain individuals wish to speed up the process of their CHAMPVA benefits application and they can do so by sending these documents in addition to the required documents listed above:
VBA rating decision page declaring your Veteran as permanently disabled or deceased.
The Certificate of Release or Discharge from Active Duty (DD214), or the Report of Separation if your Veteran served in WWII or the Korean War.
- Documents Pertaining to Child Dependents:
A copy of each child’s birth certificate.
Certification of full-time enrollment in school for children ages 18–23.
Note: Individuals who submit these optional documents are likely to hear back about their CHAMPVA benefits within six weeks.
CHAMPVA Mailing Address
All documents and application materials listed here can be mailed together to the following address for processing:
VHA Office of Community Care
PO Box 469028
How CHAMPVA Works With Medicare
When it comes to Medicare coverage with CHAMPVA benefits, beneficiaries have a few options of how to pair their health insurance. Other health insurance such as Original Medicare, Medicare Advantage, and Medicare Part D plans can all be used alongside one’s VA benefits for CHAMPVA coverage. Once a beneficiary turns 65, they must be enrolled in at least Medicare Parts A and B in order to keep their CHAMPVA benefits.
CHAMPVA & Original Medicare Coverage
When Medicare and CHAMPVA are paired, Medicare acts as the primary insurance while CHAMPVA covers the rest. However, it’s important to note that CHAMPVA will not cover one’s Medicare Part B premiums. When one is covered by both Medicare and CHAMPVA, they can expect to pay:
No Out-of-Pocket Fees: Services approved and covered by both Medicare and CHAMPVA.
20% Coinsurance: Services covered by Medicare but not CHAMPVA.
25% Copayment: Services covered by CHAMPVA but not Medicare.
CHAMPVA & Medicare Advantage
Medicare Advantage (MA) plans are supplemental plans that work to cover the gaps in Original Medicare coverage. MA plans bundle Parts A and B while often including additional benefits such as Part D benefits and coverage for vision, dental, and/or hearing.
Individuals can combine MA plans with their CHAMPVA benefits where the MA plan acts as the primary insurance and CHAMPVA acts as the secondary payer. When an MA plan bundles Part D benefits, CHAMPVA will cover the cost of copayments for an individual’s prescription.
It’s important to note that Medicare Advantage plans are provided by Medicare-approved private insurance companies. Most MA plans require their beneficiaries to have a primary care provider and to see providers that are in-network. If a beneficiary sees an out-of-network provider, CHAMPVA will cover up to 75% of the cost for out-of-network services.
CHAMPVA & Medicare Part D
Medicare Part D prescription drug plans are provided by Medicare-approved private insurance companies and offer beneficiaries coverage on their prescription medications. When CHAMPVA is combined with Part D plans, CHAMPVA covers the cost of prescription copayments. When it comes to drugs not included in a plan’s formulary, CHAMPVA will cover up to 75% of the cost.
Beneficiaries should be sure to present both their Part D plan card and their CHAMPVA ID when they visit their pharmacy to pick up and pay for their prescriptions.
CHAMPVA & Medigap
Medigap, also known as MedSupp, is a supplementary plan that works to cover the gaps in Original Medicare coverage. If an individual has their Medicare paired with a Medigap plan, CHAMPVA can be combined as well. However, CHAMPVA will act as the secondary payer to the Medicare and Medigap pairing; covering all costs that aren’t covered by Medicare or Medigap.
CHAMPVA is a cost-sharing insurance plan meaning it does not require a premium, costing patients little to nothing. However, CHAMPVA does require an outpatient deductible of $50 annually.
Note: To learn more about the cost of CHAMPVA, one can visit federal government websites such as the one at this source.
Advantages of CHAMPVA
There are many advantages when it comes to CHAMPVA that may include but are not limited to:
Little to no cost annually for the plan itself.
Cost coverage for in and out-of-network providers or services.
Cost coverage for prescription drugs.
Flexibility to operate alongside Original Medicare, MA plans, or Part D prescription drug plans.
Drawbacks of CHAMPVA
There are a few drawbacks when it comes to CHAMPVA such as:
Eligibility qualifications may be confusing, including the notion that if an individual is eligible for TRICARE, they are not eligible for CHAMPVA.
It can take many months for CHAMPVA applications to be processed and put into effect.
Does CHAMPVA cover mental health treatment?
Yes. CHAMPVA does provide coverage for mental health services, so long as it is deemed to be medically necessary.
What does CHAMPVA not pay for?
CHAMPVA does not cover dental care, chiropractic services, routine eye exams, or corrective lenses.