The Civilian Health and Medical Program of the Department of Veterans Affairs

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides health care benefits to the eligible beneficiaries of veterans. CHAMPVA is commonly mistaken for TRICARE. The two programs are similar in that they both provide health care benefits to the military community. However, TRICARE serves active duty servicemembers and their families as well as retired servicemembers and their families. CHAMPVA eligibility is limited to the spouses, widowers, and children of veterans who are not eligible for TRICARE benefits. Individuals who are eligible for TRICARE benefits are not eligible for CHAMPVA.

What benefits does CHAMPVA provide?

CHAMPVA pays an allowable amount for specific medical services and supplies, minus a deductible and the patient’s portion of cost sharing up to the maximum annual limit, for each covered participant.

• The deductible is $50 per beneficiary per year, or $100 per family per year.
• Each beneficiary is responsible for paying 25% of the allowable amount for each medical visit up to the annual limit of $3,000.

Note that if an individual has other health insurance coverage (including coverage through Medicare) in addition to coverage through CHAMPVA, the other insurance company should be billed for medical services before CHAMPVA. After receiving an Explanation of Benefits from the other insurance company, the bill can then be submitted to CHAMPVA for reimbursement. CHAMPVA will pay the lesser of 75% of the allowable amount or the remainder of the charges – often leaving the individual with no liability outside of the calendar year deductible.

If an individual’s other health insurance coverage denies a claim for services because the services received were determined not to be covered by the plan, CHAMPVA will also deny the claim and the individual is responsible for the costs associated with that care.

Who is eligible for CHAMPVA?

First, an individual must not qualify for TRICARE benefits.

Second, participation is limited to:

• Spouses and dependent children of veterans who have been rated as permanently and totally disabled for a service-connected disability, or
• Surviving spouses and dependent children of veterans who died from a rated service-connected disability, or
• Surviving spouses and dependent children of veterans who were rated as permanently and totally disabled for a service-connected disability at their time of death, or
• Surviving spouses and dependent children of servicemembers who died in the line of duty and are not qualified to receive TRICARE benefits.

What services does CHAMPVA cover?

CHAMPVA covers medically and psychologically necessary services and supplies that are provided by an authorized medical professional who is performing services within the scope of their credentials. These may include ambulance services, ambulatory services, durable medical equipment (wheelchairs, walkers, oxygen equipment, etc.), family planning services, maternity care, hospice care, inpatient and outpatient services, mental health services, pharmacy services and prescription medications, skilled nursing care, and transplants.

How do I apply for CHAMPVA?

Applicants must fill out, sign, and submit VA Form 10-10d (Application for CHAMPVA Benefits). Individuals who have Medicare or other health insurance must also submit VA Form 10-7959c (CHAMPVA Other Health Insurance Certification).

• VA Form 10-10d asks for information about the sponsoring veteran and information about the applicant(s) including names, Social Security Numbers, addresses, and the relationship between the applicant(s) and the veteran.
• VA Form 10-7959c must be filled out for each family member who is applying for CHAMPVA. It asks for information about other health insurance plans, including the carrier name, the effective date, and what type of insurance benefits it offers. When this form is submitted, applicants must attach a copy of their Medicare card or other health insurance cards.

Children between the ages of 18 and 23 years old must also submit a School Enrollment Certification Letter as part of their CHAMPVA application.

What providers accept CHAMPVA?

CHAMPVA does not have a listed network of providers. CHAMPVA recipients should make sure that their selected provider participates in CHAMPVA before scheduling an appointment and receiving services.

Some VA facilities may offer free health care services to CHAMPVA participants under the CHAMPVA In-House Treatment Initiative (CITI). However, not all of these facilities are accepting new patients. CHAMPVA participants can call their local VA facility to determine whether it participates in CITI and is accepting new patients.

Note that individuals who have Medicare coverage in addition to CHAMPVA cannot use VA facilities; Medicare will deny claims for services obtained at a VA facility and CHAMPVA will not process claims denied by other insurance companies.