CHAMPVA is short for the Civilian Health and Medical Program of the Department of Veterans Affairs. It is a health coverage program for dependents of qualifying veterans. CHAMPVA works similarly to private health insurance policies; however, it has specific rules to CHAMPVA and there are important differences between these.
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Overview of the CHAMPVA Program
The CHAMPVA health benefits program:
- Is available to spouses, surviving spouses and children of qualifying veteran sponsors
- Covers most medically necessary and appropriate services and supplies
- Covers outpatient, inpatient and pharmacy services
- Shares in the cost of these covered services and supplies, generally paying 75% of the amount it allows providers to charge
- Has a patient cost share or co-payment– usually 25% — which is what you pay providers if CHAMPVA is your only insurer and you haven’t met the catastrophic cap
- Has an annual catastrophic cap which limits the amount of out-of-pocket expenses you can incur each year — presently to $3,000
- Has no premiums — you don’t pay the VA to get CHAMPVA benefits
- Has no preexisting medical condition clause — you are covered as soon as you are found eligible
- Has an annual deductible for outpatient care, which is out-of-pocket expenses you must pay providers before CHAMPVA starts to share in your costs
- Costs nothing if you use VA services such as the CITI program or Meds by Mail.
Enrolling in CHAMPVA is easy. You submit the required forms and documents that prove your eligibility. Once approved, coverage begins immediately from the date of eligibility and you receive a CHAMPVA card.
Coverage can be retroactive. For example, if you get married in January 2011 to a qualifying sponsor, but don’t get approved for CHAMPVA until June of that year, you can file claims for reimbursement for any covered medical expenses you incurred in that time (so long as it’s been less than a year since the date of service).
When you get enrolled in CHAMPVA and your provider has an agreement with the VA, you will usually pay nothing upfront. Instead, you wait if you have any cost share to pay after CHAMPVA and any other health insurance you have have paid. Then you pay your cost share, if there is any left.
How CHAMPVA Works
1. You see your provider and give your health insurance information.
When you see a provider who accepts CHAMPVA, you will be asked for your health insurance details. You then show your CHAMPVA authorization card and provide your Social Security Number, which is also your CHAMPVA ID number.
Make sure your provider agrees to “accept assignment”; that is, request payment directly from CHAMPVA. This is most likely to lower your out-of-pocket costs.
2. The provider bills your insurance(s).
Usually, when you have health insurance, you see a provider and the latter sends the bill to your insurance company first. You pay nothing initially. If you have more than one insurer, the provider will bill the primary first, and then the secondary payer, and then the tertiary (if you have three). Some providers will deal only with the primary payer though.
CHAMPVA can be either the primary, secondary or tertiary payer depending on what other health coverage you have. For example, CHAMPVA is always secondary payer to Medicare (unless it’s for treatment overseas, which Medicare doesn’t cover), and primary payer to a CHAMPVA supplement plan.
3. CHAMPVA verifies that the patient (you) is a beneficiary and that the services/supplies are covered.
Provider claims go to the VA Health Administration Center. The VA checks to make sure you are in their records as a current beneficiary. You are identified by your personal information, including your Social Security Number.
The VA examines the provider’s itemized billing to verify that the services and supplies charged for are covered. This is done with the use of a standard coding system that identifies each service/supply. CHAMPVA will cover only medically necessary services and equipment.
4. CHAMPVA pays its share of the costs, and so do you.
Next, CHAMPVA computes the dues. Your annual deductible is subtracted from it (if it’s a deductible expense) and the allowable amount calculated. What’s an allowed amount? If a provider requests payment directly from CHAMPVA, they are obliged to accept what’s called the CHAMPVA allowable amount as payment in full. The allowed amount is the CHAMPVA- determined price for a particular service.
Normally, CHAMPVA will pay 75% of its allowed charges. After it pays, CHAMPVA will send you an Explanation of Benefits detailing the process.
If you have no other health insurance, the provider will then bill you for the remaining 25%. That is your CHAMPVA cost share or co-payment.
If you have other health insurance, that together with CHAMPVA may be enough to pay for the entire bill.
5. If you reach your annual catastrophic cap, CHAMPVA pays in full.
In the event you get charged more than $3,000 in a single year for medical expenses, CHAMPVA will waive your co-payment responsibility. For the rest of the calendar year, the VA will pay 100% of its allowed amount for covered services and supplies.
Also if you use services at a VA medical facility or get supplies from a VA source, you pay nothing out of pocket.
6/ If you see a provider who doesn’t accept CHAMPVA, you can ask CHAMPVA for reimbursement.
Should you go to a health care provider who does not bill CHAMPVA directly, you must pay upfront to them (unless you have other insurance). Afterward, you can file a claim for it. If it’s a covered service or supply, CHAMPVA will reimburse you up to its allowable amount, which will probably be smaller than what you actually paid the provider.
This website, CHAMPVAbenefits.com, is NOT affiliated with the Department of Veterans Affairs or any part of the U.S. government. Please DO NOT send us information about yourself such as your SSN, name, address, etc. for help with CHAMPVA…. The pharmacy network for CHAMPVA now is Catamaran (formerly SXC)…. Further, we cannot guarantee that the information here is accurate and up-to-date. To ensure you have the latest information, please visit the official CHAMPVA home page at http://www.va.gov/hac/forbeneficiaries/champva/champva.asp. Your use of this site means you agree to and understand this disclaimer. Thank you!
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