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The CHAMPVA Benefits Program: Everything You Need to Know

Did you know that the CHAMPVA benefits program helps eligible beneficiaries with certain medically necessary supplies and procedures?

The life of a US armed services veteran can be a complicated one. Returning from deployment with a gift that keeps on giving in the form of a service-connected disability means having a constant reminder of what you’ve lost. But the Veterans Administration provides help for some spouses and children with the CHAMPVA benefits program.

The added issues you can face like difficulties finding and keeping a job and providing for your family, all while coping with the chaos that comes with leaving the service and trying to “re-integrate” into civilian society, is enough to make you miss the sandbox.

champva benefits program

Yet the Department of Veterans Affairs does have your back. When it comes to taking the pressure off of providing your family for the things you need, the VA is there for you. There are programs that are available to you that can have a direct beneficial impact on your family, especially if you’re a veteran with a service-connected disability. One of the most important of these is the CHAMPVA benefits program.

What Is CHAMPVA?

The Civilian Health and Medical Program of Veterans Affairs, often shortened to CHAMPVA or even CHAMP, is a program that provides medical health care support to the spouses and children of veterans suffering from certain types of disabilities. In other words, if you became disabled while serving, your immediate family has access to this medical program pretty much in perpetuity. CHAMPVA benefits continue to be provided to your spouse and children even after you’re not around anymore.

CHAMPVA is a comprehensive health care program for veteran spouses and children. It’s similar to TRICARE, but there are some major differences; CHAMP is run by the VA, while TRICARE is administrated by the Department of Defense. There may be some overlap between the two, but TRICARE is for military retirees and the spouses of veterans killed in action. CHAMP is exclusively for disabled veterans’ families.

More CHAMPVA Benefits Eligibility Details

Because CHAMPVA and TRICARE are so similar, it’s helpful to have as much information about when your family may be eligible for one and not the other. Here’s what you need to know about whether your family meets CHAMPVA benefits eligibility requirements.

Permanent and Totally Disabled

First, you need to be rated permanently and totally disabled as a result of a service-connected disability. This determination has to be made at a regional VA office. It’s important to note, though, that CHAMPVA benefits can be extended to your family after your death, though — if you die from that same VA-rated service-connected disability, your spouse and children qualify. Even if you simply die from some other cause while suffering from that disability, your family qualifies as well.

Veterans must be rated permanently and totally disabled as a result of a service-connected disability, in order for their family to receive CHAMPVA benefits.

Make a note here: this extends to if you die in the line of duty as well, as long as it’s not due to misconduct. In almost every case this means that TRICARE would cover your family’s medical care, not CHAMPVA, but there’s always some instances where the reverse is true. It’s rare, but it does happen sometimes.

CHAMPVA Benefits and Costs

The good news is that if your family qualifies for CHAMPVA, then the medical benefits they will receive are fairly comprehensive. Anything the VA considers medically necessary from authorized providers is covered. This includes everything on the list:

  • Ambulance transportation service
  • Ambulatory surgery
  • Durable medical equipment (DME)
  • Family planning and maternity
  • Hospice care
  • Inpatient services
  • Mental health services
  • Outpatient services
  • Pharmacy prescription medicine coverage
  • Skilled nursing care
  • Transplant surgery

Deductibles and Coverage

In many cases, your family may need to bear the costs of these services. Good news, though, is that many CHAMPVA benefits are either covered completely or have relatively low deductible rates in many instances. While this will vary, in most cases these are annual $50 deductibles for individuals or $100 deductibles for families in the case that CHAMPVA is your primary payer. Additionally, in cases where there is no deductible, CHAMPVA pays for 75% of the cost of care, leaving your family responsible for only 25%.

If CHAMPVA is your family’s secondary or tertiary payer, however, the cost to your family is almost always nothing.

If you’re looking for an even more comprehensive list, complete with what’s covered, deductible amounts, and cost shares, take a look at section 4 of the CHAMPVA Guide.

Understanding Allowable Amount

On the subject of CHAMPVA benefits and how much your family may or may not need to pay for medical care, you’ll have to understand the concept of “allowable amount”. When CHAMPVA foots 75% of the bill for a procedure, service, or piece of durable medical equipment for your spouse or children, that’s 75% of what the VA has determined to be the maximum allowable amount they are willing to pay. This means that, even after you pay your 25% of the share, there are some instances where you may have additional fees left over.

Yet this only takes place in certain circumstances. Medical providers who accept CHAMPVA are considered to be “accepting assignment” when they do so, which means that even if a procedure or service would normally cost more than the allowable amount, the bill is considered paid in full. The problem of additional leftover cost only comes into account when providers do not accept CHAMPVA. You can file a claim with CHAMP and they will pay up to 75% of their allowable amount, but the rest, no matter how much that may be, is your family’s responsibility.

There is a cap on your annual costs when it comes to allowable amount, though. If you pay more than $3,000 in cost-shares over the course of an entire year, the VA will waive any more cost shares for the rest of that year and will pay 100% of the allowable amount. This could still mean that your family will be responsible for any costs above that if your provider does not accept assignment, so always ensure your provider accepts CHAMPVA.

CHAMPVA Benefits and Other Insurance Cover

In many instances, families receive CHAMPVA benefits as their primary source of medical insurance. That’s not always the case, though, as CHAMP can also be used as a secondary or even tertiary insurance provider for your spouse, your children, or both.

CHAMPVA acts as a primary insurance provider in the event that your family is covered under Medicaid, if they’re eligible under a State Victims of Crime Compensation Program, or if they’re eligible under Indian Health Services. Additionally, there are supplemental health insurance programs designed specifically to work with CHAMPVA that can help address any out-of-pocket expenses for your family, such as your cost-share under CHAMP’s allowable amount payment.

Supplemental Health Insurance Programs

The fact that CHAMPVA benefits don’t cover more than 75% of the cost of a number of medical procedures or services means that a number of families feel it’s necessary to find ways to supplement CHAMP coverage. This is almost a necessity when you have CHAMPVA as your primary insurance, as these gaps simply must be filled.

The Department of Veterans Affairs acknowledges this, and also points out that there are a number of organizations that provide supplemental health insurance programs that are specifically designed to work with CHAMPVA. However, the VA doesn’t endorse any of these programs over another. A resource for comparing some of these plans can be found at Federal Publishing. This resource isn’t affiliated with the VA, but it recommends families looking for supplemental insurance information to begin their search there.

CHAMPVA as Secondary Insurance

In other instances, CHAMP acts as a secondary insurance provider, picking up the cost of medical care after you exceed your primary insurer’s ability to pay. In fact, CHAMPVA was originally designed to work very well as a secondary insurance policy, as the CHAMP program permits families to have any other primary health plan. It can be through your employer or that of your spouse, and it can also be from Medicare or any other government program.

In the majority of cases, if you have a primary insurance and also CHAMP as secondary insurance, there is no cost to you when using your CHAMPVA benefits. The only time you may encounter costs is when your primary insurance benefits have already been exhausted. At that point, CHAMP will pay up to the allowable amount under the program.

CHAMPVA Benefits and Medicare

If you have Medicare, CHAMPVA will always act as a secondary provider. This means that when you age into Medicare while covered under CHAMP, then CHAMPVA will switch from your primary provider to your secondary provider. Again, this is part of how CHAMP was designed in the first place, as it works well to fill the gaps of primary insurance providers whether they’re from employment or from any other government source.

Be aware, though, that there are some requirements that you’ll have to meet if you want to gain the fullest benefits of both Medicare and CHAMPVA once you reach the age of 65. If you want to keep both, you will need to be enrolled in Medicare Parts A and B and maintain that enrollment for the length of time you wish to preserve your CHAMPVA benefits. It’s your choice whether to enroll in Medicare Part D, as this has no effect on whether you can retain your CHAMPVA benefits.

Claiming Benefits in Other Circumstances

For the most part, there are only a few other circumstances where your CHAMPVA benefits come into play. If a member of your family needs treatment for a work-related injury, for example, CHAMP does not pay for that medical care if there’s a workers’ compensation program that you can rely upon. However, if you apply for those benefits and eventually exhaust them under your employer’s workers’ compensation program, CHAMP will pay for any covered services and supplies.

Likewise, injuries sustained in an accident, like in the wake of a car crash, CHAMPVA may pay for any extended medical costs. Again, this is rare, as it will only happen in the event that your coverage from your car insurance provider (or the insurer for the responsible party) is inadequate to cover all your costs and leaves you with a remaining balance.

Contacting the VA and Making Claims

It’s a well-established truth that the Department of Veterans Affairs is overworked and understaffed. As a result, contacting the CHAMPVA can be a frustrating experience; even simply making a phone call to have a question answered can sometimes result in very long hold times. Your best bet, whenever trying to interact with the VA, is to make use of as many of their automated systems as possible.

This goes double when making claims. When it’s possible, have your provider make CHAMPVA claims, as they have the expertise to do so as quickly and accurately as possible. If this isn’t possible, you can make claims yourself.

Keep in mind that it’s not advisable to make a manual claim against your CHAMPVA benefits, as this can often take months longer than if you went through their online submittal process.

The Final Word on CHAMPVA Benefits

No insurance policy is perfect, but then neither is life. If you’re a disabled veteran that has concerns about providing access to health care for your family, the CHAMPVA program can help provide you with some peace of mind.

For more information, consult the VA’s complete CHAMPVA Guide, visit the Department of Veterans Affairs Community Care website, or call the CHAMPVA benefits hotline at 1-800-733-8387.

Elizabeth Crane

Elizabeth Crane grew up not wearing a helmet, drinking from the hose and not wearing a seat belt. She managed to survive and now spends her time developing websites, drinking coffee, and eating chocolate.

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