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CHAMPVA

































































 

CHAMPVA is health insurance. It is provided to eligible dependents of some veterans.

To be eligible, the veteran must be 100% disabled and that rating must be "permanent and total".  VA often assigns ratings that are 100% but they may not be "permanent and total". They may be assigned as temporary.  VERY IMPORTANT--it is a requirement to enroll in Medicare Part B in order to continue to be covered by CHAMPVA

Recent change to our information:

The VA is not connected with CHAMPVA.  However, your family's eligibility for this medical benefit is determined (in the case of disabled veterans) based upon your rating from the VA.  The only way CHAMPVA benefits can be discontinued is if the spouse is no longer married to the Veteran.  The key term used in CHAMPVA eligibilty is "Permanent and Total".  A 10-year continuous and uninterrupted  "permanent and total" 100% rating applies to  DIC benefits.

Overview of 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. The program is administered by Health Administration Center and our offices are located in Denver, Colorado.

Due to the similarity between CHAMPVA and the Department of Defense (DoD) TRICARE program (sometimes referred to by its old name, CHAMPUS) the two are often mistaken for each other. CHAMPVA is a Department of Veterans Affairs program whereas TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. In some cases a veterans may look to be eligible for both/either program on paper. However, if you are a military retiree, or the spouse of a veteran who was killed in action, you are and will always be a TRICARE beneficiary, you can´t choose between the two.





 
Eligibility

To be eligible for CHAMPVA, you cannot be eligible for TRICARE/CHAMPUS and you must be in one of these categories:
    • The spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office, or
    • The surviving spouse or child of a veteran who died from a VA-rated service connected disability, or
    • The surviving spouse or child of a veteran who was at the time death rated permanently and totally disabled from a service connected disability, or
    • The surviving spouse or child of a military member who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).
An eligible CHAMPVA sponsor may be entitled to receive medical care through the VA health care system based on his or her own veteran status.

Additionally, as the result of a recent policy change, if the eligible CHAMPVA sponsor is the spouse of another eligible CHAMPVA sponsor, both may now be eligible for CHAMPVA benefits. In each instance where the eligible spouse requires medical attention, he or she may choose the VA health care system or coverage under CHAMPVA for his/her health care needs.

If you have determined you are eligible for CHAMPVA benefits and need to apply, fill out  VA 10-10d, found in our forms section.
If you have been previously denied CHAMPVA benefits and you believe you would now be qualified, please submit an application following the guidelines as listed on the “How to apply” section.






How to Apply

Provide all the required and optional documents, and if your application is complete, then it normally takes 6 weeks after they get your package until you get your CHAMPVA card and related materials.

Important Note:  If you provide only the required documents and not the optional documents, processing can take 2-8 months since they have to confirm information with other federal agencies.

Once they get your application, it will be reviewed for completeness and that all the required forms are included. If your application is not complete, they will return it to you with further instructions.

Required Documents: (these MUST be submitted)

    • Application for CHAMPVA Benefits form
    • VA Form 10-10d
    • Other Health Insurance (OHI) Certification form VA Form 10-7959c
    • Marriage / Divorce Information Letter
    • CHAMPVA Marriage Status Application Attachment
    • For individuals who are eligible for Medicare (normally those age 65 and older), we also need a copy of your Medicare card
    • If you are age 65 or older and are not entitled to Medicare, you must send documentation from the Social Security Administration, which confirms that you are not entitled to Medicare benefits under anyone's Social Security number.
Optional Documents:  (not required but recommended to send)

You can speed the processing of your application if you also send copies (do not send originals)
    • Veteran and spouse marriage license
    • Birth certificate/adoption papers for children
    • The page from the VBA rating decision that shows the veteran is permanently and totally disabled (or death rating for a survivor)
    • If you are a remarried widow/widower and are once again single, provide a copy of the legal documentation that terminated the remarriage. The legal documentation of termination of a remarriage may be a divorce decree, death certificate or annulment decree
    • Veteran's DD214 (Certificate of Release or Discharge from Active Duty) or if the veteran was a WWII or Korea veteran, the Report of Separation. The VA does not have copies of this form, you must obtain it from your veterans military service. If you do not have this form readily available, we recommend that you not spend time requesting one from the military, send your application package in without it and we will obtain it for you.
    • School certification of full-time enrollment for children ages 18-23

Mail Via Certified Mail to:

CHAMPVA-Eligibility
PO Box 469028
Denver, CO 80246-9028

Any questions call CHAMPVA Monday-Friday at 1-800-733-8387. 

We have found the customer service line very user friendly and customer service representatives very helpful.  







Fact Sheet& Info Links:

CHAMPVA Program (01-04)
The CHAMPVA Handbook

Using CHAMPVA:

Many dependents who use CHAMPVA are very happy with their health insurance coverage.

If you have recently become eligible for this benefit there are some basic things you must understand.

Not every physician will accept CHAMPVA. The general rule is that if the physician accepts Medicare, they must also accept CHAMPVA. Once you have your CHAMPVA ID card, you should find a doctor who will accept the CHAMPVA insurance. Don't wait until you get sick, do it soon.

Your new doctor may not know how to file for CHAMPVA. It's best for you if you go in to meet with the insurance and billing department before you have any services. Don't wait until you're sick and you may not feel up to doing the extra paperwork.

All hospitals accept CHAMPVA. This is because all hospitals accept Medicare.

If your veteran has been rated as 100% Permanently and Totally disabled, you should apply for CHAMPVA as soon as possible. You may be denied the benefit. VA makes many errors when awarding this benefit so be prepared to appeal.

Your pharmacy benefit will have all medications sent to you in the mail--Meds by Mail is the name of the medication mail service, the title of the form is VA 10-0426. The pharmacy relies on a formulary just like any insurance provider does today. If you currently take a medication, it may not be available to you through CHAMPVA. You will have to find a substitute medicine (maybe a generic) to use in its place. Do it now, don't wait.

The dependent may find, even though medication is on the CHAMPVA formulary, it may not be available on Meds by Mail for a period of time.  Since this is a benefit, the dependent will be instructed to fill the medication at an approved CHAMPVA local pharmacy.

A dependent, 65 or older who is enrolled in Medicare, will still get Meds By Mail as long as they does not pick up some other pharmacy coverage. Medicare offers a Part D, which gives pharmacy coverage and you will have to pay something for that. But, as long as they don't have any other drug coverage the MBM will stay the same.

For pharmacies that accept CHAMPVA, click on this locations link. 

CHAMPVA has copays for many services. Don't be surprised by this.

Overall, your CHAMPVA health care will be very good. Just how good depends on you understanding how it works and making it work for you.








Using CHAMPVA:


Many dependents who use CHAMPVA are very happy with their health insurance coverage.

If you have recently become eligible for this benefit there are some basic things you must understand.

Not every physician will accept CHAMPVA. The general rule is that if the physician accepts Medicare, they must also accept CHAMPVA. Once you have your CHAMPVA ID card, you should find a doctor who will accept the CHAMPVA insurance. Don't wait until you get sick, do it soon.

Your new doctor may not know how to file for CHAMPVA. It's best for you if you go in to meet with the insurance and billing department before you have any services. Don't wait until you're sick and you may not feel up to doing the extra paperwork.

All hospitals accept CHAMPVA. This is because all hospitals accept Medicare.
If your veteran has been rated as 100% Permanently and Totally disabled, you should apply for CHAMPVA as soon as possible. You may be denied the benefit. VA makes many errors when awarding this benefit so be prepared to appeal.

Your pharmacy benefit will have all medications sent to you in the mail--Meds by Mail is the name of the medication mail service, the title of the form is VA 10-0426. The pharmacy relies on a formulary just like any insurance provider does today. If you currently take a medication, it may not be available to you through CHAMPVA. You will have to find a substitute medicine (maybe a generic) to use in its place. Do it now, don't wait.

The dependent may find, even though medication is on the CHAMPVA formulary, it may not be available on Meds by Mail for a period of time.  Since this is a benefit, the dependent will be instructed to fill the medication at an approved CHAMPVA local pharmacy.

A dependent, 65 or older who is enrolled in Medicare, will still get Meds By Mail as long as they does not pick up some other pharmacy coverage. Medicare offers a Part D, which gives pharmacy coverage and you will have to pay something for that. But, as long as they don't have any other drug coverage the MBM will stay the same.

For pharmacies that accept CHAMPVA, click on this locations link. 

CHAMPVA has copays for many services. Don't be surprised by this.
Overall, your CHAMPVA health care will be very good. Just how good depends on you understanding how it works and making it work for you.






Frequently Asked ?'s of CHAMPVA

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).

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.

From the time an application is submitted, how long before I can expect a response from the Health Administration Center?

Generally, applicants can expect to receive written notification from the Health Administration Center 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.

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.

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.

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