CHAMPVA Insurance – Good or Bad?

CHAMPVA insurance provides eligible beneficiaries with high-quality healthcare coverage, to include healthcare services and supplies, at almost no cost.

But, you might be wondering if CHAMPVA insurance is good or bad?

In our experience at VA Claims Insider, CHAMPVA is a fantastic healthcare benefits program with very few, if any, drawbacks.

In general, CHAMPVA covers the cost of most healthcare services and supplies that are medically necessary for beneficiaries.

CHAMPVA currently has an outpatient deductible cost of $50 per calendar year and a cost share of 25% of the CHAMPVA allowable charge, up to the catastrophic cap, which is $3,000 per calendar year.

What is CHAMPVA?

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

CHAMPVA is managed by the Veterans Health Administration Office of Community Care (VHA OCC) in Denver, Colorado.

The VHA OCC verifies CHAMPVA eligibility, authorizes benefits, and processes medical claims for beneficiaries.

>> Click HERE to download the official CHAMPVA program guide <<

CHAMPVA Eligibility Criteria

To be eligible for CHAMPVA, the beneficiary CANNOT be eligible for TRICARE.

Click HERE to download the official CHAMPVA eligibility factsheet

CHAMPVA provides coverage to the spouse or widow AND to the children of a veteran who:

• Is rated 100% Permanently and Totally (P&T) disabled due to a service-connected disability, OR
• Was rated permanently and totally disabled due to a service-connected condition at the time of death, OR
• Died of a service-connected disability, OR
• Died on active duty and the dependents are not otherwise eligible for Department of Defense TRICARE benefits.

Effective October 1, 2001, CHAMPVA benefits were extended to those age 65 and older.

To be eligible for CHAMPVA, you must also meet the following conditions:

• If the beneficiary was 65 or older prior to June 5, 2001, and was otherwise eligible for CHAMPVA, and was entitled to Medicare Part A coverage, then the beneficiary will be eligible for CHAMPVA without having to have Medicare Part B coverage.
• If the beneficiary turned 65 before June 5, 2001, and has Medicare Parts A and B, the beneficiary must keep both Medicare Parts A & B to be eligible for CHAMPVA.
• If the beneficiary turned age 65 on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible for CHAMPVA.

What services does CHAMPVA cover?

CHAMPVA covers most medically necessary health care services, including ambulance service, ambulatory surgery, durable medical equipment (DME), family planning and maternity, hospice, inpatient services, mental health services, outpatient services, pharmacy, skilled nursing care and transplants.

With CHAMPVA, you’ll be covered for services and supplies when we determine they are medically necessary and were received from an authorized provider.

When providers are performing services within the scope of their license or certification, we consider them to be authorized.

List of 11 services covered by CHAMPVA insurance

• #1. Ambulance service
• #2. Ambulatory surgery
• #3. Durable medical equipment (DME)
• #4. Family planning and maternity
• #5. Hospice
• #6. Inpatient services
• #7. Mental health services
• #8. Outpatient medical services
• #9. Pharmacy (prescription medicines)
• #10. Skilled nursing care
• #11. Transplants

CHAMPVA pays for covered services and supplies when they are determined to be medically necessary and are received from an authorized provider.

When providers are performing services within the scope of their license or certification, we consider them to be authorized.

The most common providers for CHAMPVA are: anesthesiologist, audiologist, certified clinical social worker, certified nurse midwife, certified nurse practitioner (NP or CNP), certified registered nurse anesthetist (CRNA), certified physician assistant (PA), certified psychiatric nurse specialist, clinical psychologist (Ph.D.), doctor of osteopathy (DO), licensed clinical speech therapist (LCST), licensed practical nurse (LPN), marriage and family counselor/therapist, medical doctor (MD), occupational therapist (OT), pastoral counselor, physical therapist (PT), physiologist, podiatrist (DPM), psychiatrist and registered nurse (RN).

You have many choices when selecting a provider for CHAMPVA!

Medical services may be available to you at your local VA Medical Center (VAMC) or clinic through the CHAMPVA In-house Treatment Initiative (CITI).

You may also choose to obtain medical services from non-VA providers.

List of 9 services NOT covered by CHAMPVA insurance

The following is a list of services that are NOT covered under CHAMPVA (this list is not all-inclusive):

• #1. Acupuncture
• #2. Chiropractic services
• #3. Most dental care, including dentures or partial dentures
• #4. Non-FDA-approved drugs
• #5. Routine hearing exams
• #6. Routine eye exams and glasses
• #7. Laser eye surgery
• #8. Experimental and investigational procedures
• #9. Health club memberships

Does CHAMPVA have an approved list of providers?

CHAMPVA does NOT have a network of medical providers.

However, most TRICARE providers will also accept CHAMPVA patients.

Use the TRICARE Find a Doctor feature to help you locate a provider in your area.

Ask that provider if they also accept CHAMPVA patients.

Most Medicare providers will also accept CHAMPVA patients.

Medicare providers can be located through their website at http://www.medicare.gov  

Do I have to use the CHAMPVA provider network to see a doctor?

No! Beneficiaries have many choices when selecting a provider for CHAMPVA.

Unlike other health insurance plans, CHAMPVA does NOT have a network of “approved” medical providers.

However, it is recommended that the Primary Family Caregiver ask the provider if they accept CHAMPVA insurance.

If the provider accepts CHAMPVA, the provider will then bill CHAMPVA directly.

Most Medicare and TRICARE providers WILL accept CHAMPVA patients.

The following websites can be used to help you locate a CHAMPVA medical provider:

• Medicare website at http://www.medicare.gov. Use the “Search Tools” at the bottom of the page to locate providers.
• TRICARE providers can be found on the TRICARE website at http://www.tricare.mil           

Can I use a VA Doctor or VA Facility for CHAMPVA?

Yes, but you’ll need to call your local VA medical facility to ensure they participate in the CHAMPVA In-House Treatment Initiative (CITI).

The CHAMPVA CITI is a voluntary program that allows treatment of beneficiaries of the Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA) at Veterans Affairs medical centers (VAMCs) that have elected to participate in CITI.

To find out if your local VA medical center or clinic participates in CITI, please contact the VA facility you’d like to use directly OR call 1-800-733-8387.

A link to a list of participating facilities with direct contact phone numbers is located in the RESOURCES section at the bottom of this page.

You may also contact the VHA Office of Community Care (VHA OCC) and ask for more information about CITI VA medical centers.

Do I need to get pre-authorization for services under CHAMPVA?

No, you do NOT need advance approval for care from CHAMPVA, unless the care relates to one of the medical services listed below.

Although CHAMPVA does NOT require authorization for most medical care, your physician may seek to obtain authorization for services other than those listed below.

In that case, your physician should call CHAMPVA regarding the service(s) in question.

List of 10 services that require CHAMPVA pre-authorization

• #1. Durable Medical Equipment (DME) with a purchase price or total rental of $2,000 or more
• #2. Mental health care (Contact CHAMPVA for required approval)
• #3. Inpatient mental health care
• #4. Care at residential treatment facilities (RTF)
• #5. Alcohol/substance abuse
• #6. Care in Partial Hospital Programs (PHP)
• #7. Requests for extensions to our yearly limits on inpatient mental health care
• #8. Outpatient mental health visits in excess of 23 per year
• #9. Dental care coverage (Dental coverage is very limited and under most circumstances is not covered)
• #10. Organ transplants

Exceptions to the CHAMPVA pre-authorization requirement

Mental health services and durable medical equipment (DME) provided through the VA CITI program do NOT require pre-authorization.

How much will CHAMPVA cover?

In most cases, CHAMPVA’s allowable amount—what it will pay for specific services and supplies—is equivalent to current Medicare and TRICARE rates.

CHAMPVA has an outpatient deductible ($50 per beneficiary per calendar year or a maximum of $100 per family per calendar year) and a patient cost share of 25% of our allowable amount up to the catastrophic cap ($3,000 per calendar year).

Beneficiaries should NOT send checks to VHA OCC for their annual deductible; as claims are processed, charges are automatically credited to individual and family deductible requirements for each calendar year.

If your provider accepts assignment, which means the provider accepts CHAMPVA, the provider agrees to accept our allowable amount as payment in full.

A provider cannot bill you for the difference between our allowable amount and their normally billed amount.

If the patient has other health insurance, then CHAMPVA pays the lesser of either 75% of the allowable amount after the $50 calendar year deductible is satisfied, or the remainder of the charges and the beneficiary will normally have no cost share.

Can I have other insurance and use CHAMPVA?

Yes! If the beneficiary has Other Health Insurance (OHI), the OHI should be billed first.

The VA Explanation of Benefits (EOB) from the OHI should then be submitted with the claim for reimbursement to CHAMPVA.

By law, CHAMPVA is always the secondary payer except to Medicaid, State Victims of Crime Compensation Programs, Indian Health Services, and Supplemental CHAMPVA Policies.

Medicare versus CHAMPVA

As a result of a federal law passed June 5, 2001, CHAMPVA expanded benefit coverage to eligible family members and survivors of qualifying Veteran sponsors effective October 1, 2001.

If the beneficiary is eligible for CHAMPVA and has Medicare Part A entitlement (premium-free hospitalization coverage) and Medicare Part B (outpatient coverage), we will cover many of the costs not covered by Medicare.

CHAMPVA will pay after Medicare and any other insurance, such as Medicare HMOs and Medicare supplemental plans, for health care services and supplies.

CHAMPVA does NOT pay Medicare Part B premiums.

CHAMPVA versus TRICARE

Although similar, CHAMPVA is a separate and unrelated program with a totally different beneficiary population than TRICARE (a Department of Defense health care program formerly called CHAMPUS).

While the benefits are similar, the programs are administered separately with significant differences in claim filing procedures and preauthorization requirements.

CHAMPVA Application

In 2020, there are two primary ways to obtain the CHAMPVA application:

• #1. Complete the online fillable Application for CHAMPVA Benefits, VA Form 10-10d
• #2. Call the VHA Office of Community Care at 1-800-733-8387

How long does it take to get my CHAMPVA application approved?

Applicants can expect to receive written notification from the VHA Office of Community Care within 45 calendar days (or 6 weeks) after mailing their application.

To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits 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 eligible for Medicare) and a School Enrollment Certification Letter for all applicant children between the ages of 18 and 23 years.

CHAMPVA Required Application Documents

To apply for CHAMPVA benefits, you must submit the following documents:

• Application for CHAMPVA Benefits, VA Form 10-10d
• Other Health Insurance (OHI) Certification, VA Form 10-7959c
• For individuals who are eligible for Medicare for any reason, you will need a copy of your Medicare card
• If you are age 65 or older and not entitled to Medicare, you must send documentation from the Social Security Administration that confirms you are not entitled to Medicare benefits under anyone’s social security number

To speed up the processing of your CHAMPVA application, you can also send copies (do NOT send originals) of these optional documents:

• Your VA Benefits Summary Verification Letter showing your Veteran is permanently and totally disabled (or the death rating if you’re a survivor)
• Your Veteran’s DD214 (Certificate of Release or Discharge from Active Duty)—or, if the Veteran was a World War II or Korean War Veteran, the Report of Separation. If you don’t have a copy of the necessary form, you can request it by submitting a Standard Form 180, Request Pertaining to Military Records, from the National Archives
• Documents related to any dependent children you’re including in your application such as a copy of each child’s birth certificate or adoption papers

Optional CHAMPVA Application Documents

You can speed the processing of your application if you also send copies of (do not send originals):

• The page from the VBA rating decision showing the Veteran is permanently and totally disabled (or death rating for a survivor). >> Click HERE to learn how to download a copy of your VA Benefits Summary Letter <<
• 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. If you do not have a copy of the necessary form, you may request it by submitting a Standard Form 180, Request Pertaining to Military Records, from the National Archives.
• 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.
• Birth certificate/adoption papers for children.

CHAMPVA School Enrollment for Dependents Ages 18-23

Children between 18 and 23 years of age must submit a school enrollment certification letter confirming full-time student status.

Click HERE for the CHAMPVA school enrollment factsheet for children ages 18-23

This is required in order to continue eligibility for CHAMPVA benefits.

Questions should be sent to the VHA Office of Community Care (VHA CC) at the address listed above or via the CHAMPVA toll-free customer service number: 1-800-733-8387, Monday through Friday from 8:00 a.m. to 7:30 p.m., Eastern Standard Time.

VHA Office of Community Care can also be contacted by email using the VA Inquiry Routing and Information System (IRIS).

Please go to the IRIS website https://iris.custhelp.com/app/ask/ and complete the online form.

To submit a student’s full-time enrollment status, please have a school official complete this form and submit it to the address listed above.

Click HERE to download the CHAMPVA School Enrollment Certification Letter

For immediate processing, have the school FAX the enrollment certification to (303) 331-7809.

SPECIAL NOTE: School enrollment certification letters MUST be faxed directly from the school in order to be considered valid.

CHAMPVA Contact Information Card

CHAMPVA Mailing Address

The 2020 CHAMPVA mailing address is:

VHA Office of Community Care
CHAMPVA Eligibility
PO Box 469028
Denver CO 80246-9028

DON’T FORGET to sign and date the application BEFORE mailing in the forms!

Also, if applying for a spouse, please include the date of marriage on the application.

CHAMPVA Fax Number

The 2020 CHAMPVA fax number is:

(303) 331-7809

About The Author

Brian Reese is a VA disability claim expert, former United States Air Force captain, and founder of VA Claims Insider – “The Most Trusted Name in Education-Based Resources for Veterans.”

His frustration with the 8-step VA disability claims process led him to create “VA Claims Insider,” which provides U.S. military veterans with tips, strategies, and lessons learned for successfully submitting or re-submitting a winning VA disability compensation claim.

Brian is also the CEO of Military Disability Made Easy, which is the world’s largest free searchable database for all things related to DoD disability and VA disability, and has served more than 5,000,000 military members and veterans since its founding in 2013.

His eBook, the “9 Secrets Strategies for Winning Your VA Disability Claim” has been downloaded more than 300,000 times in the past three years and is the #1 rated free VA disability claims guide for veterans.

He is a former active duty Air Force officer with extensive experience leading hundreds of individuals and multi-functional teams in challenging international environments, including a combat tour to Afghanistan in 2011 supporting Operation ENDURING FREEDOM.

Brian is a Distinguished Graduate of Management from the United States Air Force Academy, Colorado Springs, CO and he holds an MBA from Oklahoma State University’s Spears School of Business, Stillwater, OK, where he was a National Honor Scholar (Top 1% of Graduate School class).