Civilian Health and Medical Program (CHAMPVA) Benefits

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health benefits program in which the VA shares the cost of covered health care services and supplies.

When you separate from the military, you normally lose your spouse’s TRICARE coverage. Unfortunately, civilian health insurance can cost thousands of dollars per year – or more. This reality makes securing coverage for your spouse a key priority for separating service members. Fortunately, a low-cost option exists for the spouses of some disabled veterans: CHAMPVA. As such, we’ll use this article to explain how to get health insurance for spouses of disabled veterans with CHAMPVA.

Specifically, we’ll discuss the following:

• CHAMPVA Overview
• Who Qualifies for CHAMPVA?
• Out-of-Pocket Costs with CHAMPVA
• Applying for CHAMPVA Health Insurance
• Final Thoughts

CHAMPVA Overview

Generally speaking, only active-duty and retired service members and their families have access to TRICARE, the Department of Defense’s health insurance program. But, what about veterans who separated before full retirement? These individuals and their families don’t qualify for TRICARE. Without access to this program, veterans potentially need to pay thousands of dollars to get health insurance for their spouses and children. Fortunately, CHAMPVA solves this problem for the families of some disabled veterans.

CHAMPVA stands for the Civilian Health and Medical Program of the Department of Veterans Affairs. The program offers health insurance for qualified family members of disabled veterans. More precisely, CHAMPVA covers the cost of some health care services and supplies for enrolled members, a system known as cost sharing.

CHAMPVA Benefits & Covered Services

As a CHAMPVA beneficiary, the program will cover health services and supplies when the VA determines that they were A) medically necessary, and B) received from an authorized provider. This begs the question, what’s an authorized provider? According to the VA, any medical providers performing services within the scope of their license or certification qualify as authorized providers.

Services covered by CHAMPVA include:

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

Medical Care Facilities

CHAMPVA doesn’t have in-network providers, so family members can see their current or regular doctors and specialists as long as they accept CHAMPVA payment methods. Most healthcare facilities or providers that accept TRICARE or Medicare, will most likely accept CHAMPVA. Note: Contact your family doctor or specialist to see if they will honor CHAMPVA.

How Does CHAMPVA Differ from VA Health Care for Disabled Veterans?

The answer to this revolves around who receives service. As a disabled veteran, you’ll personally qualify for health care services provided by the VA. But, this doesn’t mean your spouse or children qualify for VA healthcare.

CHAMPVA provides health insurance coverage for spouses and children of disabled veterans – not the veterans, themselves.

Who Qualifies for CHAMPVA?

To qualify for CHAMPVA, you cannot also be eligible for TRICARE. After confirming someone doesn’t qualify for TRICARE, CHAMPVA provides coverage to the spouse or widow(er) and children of a veteran who:

• Is permanently and totally disabled (P&T) because of an adjudicated service-connected disability, or
• Died as a result of an adjudicated service-connected disability or who at the time of death was rated P&T, or
• Died while in an active duty status and in the line of duty, not due to misconduct. The term “active duty” may include periods of inactive duty for training.

NOTE: In most situations, family members in this final category will qualify for TRICARE.

Out-of-Pocket Costs with CHAMPVA

Generally, CHAMPVA will pay health care providers the associated Medicare / TRICARE rates. This means that, if civilian providers accept one of these plans, they’ll likely also accept patients with CHAMPVA coverage. But, CHAMPVA beneficiaries need to understand the out-of-pocket costs for this service.

In the military, TRICARE coverage means no payments. That is, if you go to a base clinic for treatment of an illness or injury, you don’t receive a bill. With most civilian health insurance plans, beneficiaries need to pay something (e.g. deductibles, co-pays, etc.) when they receive medical service, with insurance paying the remainder. CHAMPVA falls into this category.

CHAMPVA has two types of out-of-pocket costs:

1) An outpatient deductible ($50 per person up to $100 per family per calendar year)

NOTE: No deductible requirement exists for inpatient hospital services, ambulatory surgical centers, psychiatric partial hospitalization programs, hospice, services provided through VA facilities, or for medication received through the Meds by Mail program.

2) A cost share up to 25% of the catastrophic medical treatment cap (up to $3,000 per calendar year)

NOTE: No cost share requirement exists for hospice, services received at VA facilities, or medications obtained through the Meds by Mail program.

This is the maximum out-of-pocket expense a family can incur for CHAMPVA-covered services and supplies in a calendar year. Once you meet this limit, CHAMPVA pays 100% of the allowable amount for covered services for the remainder of the calendar year.

In other words, CHAMPVA beneficiaries won’t need to pay more than $3,100 for covered medical services in a given calendar year. While this may seem like a lot of money, medical treatments can total tens to hundreds of thousands of dollars. CHAMPVA coverage protects beneficiaries from these astronomical costs.

Applying for CHAMPVA Health Insurance

If you, your spouse, and – potentially – children meet the above requirements, you can apply for CHAMPVA health insurance by submitting the following forms:

• Application for CHAMPVA Benefits (VA Form 10-10d) (PDF), and
• Other Health Insurance Certification (VA Form 10-7959c)

However, you only need to submit the second form if the CHAMPVA applicant currently has another type of health insurance coverage (e.g. an employer-sponsored plan). You do not need to stop this additional coverage to apply for and use CHAMPVA.

If applying for CHAMPVA coverage for children of veterans, you’ll also need to submit:

• A copy of each child’s birth certificate or adoption papers
• If aged 18 – 23, a school certification of full-time enrollment

Technically, you don’t need to submit anything else with your CHAMPVA application. But, to significantly speed up the process, you should also include copies (not originals) of the following documents. If you don’t, the VA will need to independently verify this information with other federal agencies, potentially adding months to your application timeline.

• The VA letter reflecting the veteran’s permanently and totally disabled status (you can access these forms online via eBenefits)
• If the veteran is deceased, his or her death rating
• The veteran’s DD-214 (Certificate of Release of Discharge from Active Duty)

What Happens Next?

Once you submit your application and supporting documentation, the VA will review it for completeness and accuracy. If there are any issues, the application will be returned to you with further instructions. This only delays the process, so before submitting your application, make sure you’ve A) reviewed it for completeness, and B) signed in all required fields.

Once the VA receives the completed application, it typically takes around six weeks to fully process. After that time, you will receive a package from the VA including the beneficiary’s CHAMPVA ID card and informational material. This ID card serves as a beneficiary’s proof of insurance.

Final Thoughts

Separating from military service, the cost of civilian healthcare can be a nasty surprise for veterans. Fortunately, CHAMPVA offers spouses and children of certain disabled veterans a low-cost option for quality health insurance coverage.