CHAMPVA Benefits May Be For You

By: Glenn Johnson
Chief of Public Affairs
DVAHealth Administration Center
Denver CO

As many of you have heard, the Department of Veterans Affairs is actively seeking Ex-Prisoners of War and requesting them to be reevaluated so that they can receive the compensation that they deserve and have earned. For many of you this will mean a rating of 100% disability for others less, either way you may be eligible for the Civilian Health and Medical Program of the Department of Veterans Affairs, or CHAMPVA.

The CHAMPVA program is a health care program entitlement (meaning it is an actual law and is not subject to repeal and will never be taken a way like some other benefits) that is designed to be a major coverage plan for the spouse and dependents (children up to the age of 18) of a veteran who has been rated Permanently and Totally (P&T) disabled. There is a nasty rumor that the veteran has to have a rating of 100% disability, but this is not true, only the rating of Permanently and Totally disabled. You can determine this by looking on the back page of your rating decision. The very last line should say that Chapter 35 Benefits have been granted. These are educational benefits that can only be granted if a veteran is P&T.

Other ways that a veteran’s spouse or child can be eligible is if the veteran died from a service-connected disability, or had a P&T rating at the time of death. One thing that many widows of veterans don’t know is that this rating can be determined after the death of the veteran. This allows the widow(er) to enroll even after the veteran has passed away.

CHAMPVA is a full coverage program, meaning it covers almost everything a commercial insurance policy covers only there is no premium to pay (remember CHAMPVA is an entitlement that was earned by the veteran.) There are several things such as eye glasses, dental and hearing aids which the CHAMPVA does not cover and for a complete list of non-covered procedures please consult the CHAMPVA handbook.

The CHAMPVA program is also a non-network health care system, meaning, you can visit any doctor you desire, unlike an HMO which dictates who you can visit and who you can’t. Once enrolled simply present your CHAMPVA ID card to the office manager at whichever doctor you happen to be seeing.

Similarly the CHAMPVA program has an excellent pharmacy benefit. You can either take the CHAMPVA ID card to your local pharmacy and have it filled, then send us the bill with the national drug code attached, or you can call the free Medical Matrix service at (817) 738-1398 and they will tell you a pharmacy in your specific geographical area which will bill CHAMPVA directly. Better still is the Meds by Mail program that will deliver you medication to your door via the U.S. mail, in 90 day batches FOR FREE! That’s right, FOR FREE, no bills no co-pays, just your medication to your home FOR FREE. Similarly CHAMPVA can provide durable medical equipment at no cost to the beneficiary as well. However, to participate in the Meds by Mail program you cannot have another health insurance policy that that has a pharmacy benefit. In many cases, especially with someone who has Medicare, the extra policy is a redundancy and can be dropped making Meds by Mail a free alternative for their pharmacy needs.

CHAMPVA is also designed to used in conjunction with Medicare, in fact if you have both Medicare and CHAMPVA you should have little or no out of pocket expenses for your medical treatments.

Below are some frequently asked questions that may answer any questions or concerns you have about the CHAMPVA program.

What is the difference between CHAMPVA and TRICARE (formerly CHAMPUS)?
Although similar, CHAMPVA is completely separate with a totally different beneficiary population than TRICARE—a Department of Defense healthcare program formerly called CHAMPUS. While the benefits are similar, the programs are administered separately with significant differences in claim filing procedures and preauthorization requirements.

How do I get my medical provider to bill CHAMPVA directly, and what do I do if they say they don’t take CHAMPVA?
Frequently medical providers confuse CHAMPVA with the old precursor to TRICARE, CHAMPUS. Many doctors and have had a bad experience with TRICARE/CHAMPUS and do not wish to except it as a payment method. In the vast majority of these cases they are just ignorant to what CHAMPVA is. On the HAC website, under fact sheets is one called Fact Sheet 01-16, Fact Sheet for Office Managers. This fact sheet explains to the office manager at your medical facility exactly what CHAMPVA is (not TRICARE) and how they bill us and how they will be paid. In the vast majority of cases the doctor will then accept CHAMPVA once they understand how it works.

What do I do if my hospital says they don’t take CHAMPVA?
Hospitals do not have the luxury of declining CHAMPVA. If they receive Medicare payments, then by law they have to accept CHAMPVA. If you are ever turned down for CHAMPVA at a hospital please call us immediately at (303) 331-7500 and ask for the Policy and Compliance Office. Severe penalties are connected to refusing CHAMPVA at a hospital.

How can I obtain an application for CHAMPVA benefits?
There are a couple ways to obtain an Application for CHAMPVA Benefits (VA Form 10-10D)— Download it from: www.hac.gov/hac/forms/forms/10-10d.pdf, or Call the Health Administration Center at 1-800-733-8387. When calling, select the Application Form option from the voice-mail menu. To help reduce the volume of telephone calls during business hours, please consider placing these calls during evening or weekend hours.

From the time an application is submitted, how long before I can expect a response from the Health Administration Center?
Generally, applicants can expect to receive written notification from the Health Administration Center within 45 days from mailing their application. To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits (VA Form 10-10D) 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 Medicare eligible) and a school certification for all applicant children between the ages of 18 and 23.

What are the Health Administration Center's customer service telephone hours for CHAMPVA?
The business hours are 8:15AM-7:00PM Eastern Standard Time, Monday through Friday, excluding federal holidays.

Why is CHAMPVA the secondary payer when beneficiaries have other health insurance (OHI)? Fact Sheet - CHAMPVA-OHI (01-23)
To answer this question, a look at CHAMPVA's origin and the congressional intent behind its legislation may help. From the start, CHAMPVA was intended to serve as a safety net in the event other coverage was not available—rather than being the primary carrier. While families with OHI are not disqualified from CHAMPVA benefits, CHAMPVA's safety net protection becomes available after the OHI has paid. This includes benefits available from the enrollment in a health maintenance organization (HMO), preferred provider organization (PPO), Medicare or other health insurance. Exceptions to CHAMPVA's secondary payer status are supplemental CHAMPVA policies, Medicaid, and State Victims Compensation Programs—CHAMPVA becomes the primary payer in these cases.

Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage through a Health Maintenance Organization (HMO), who elect to receive HMO-covered services outside of the HMO network?
Just as beneficiaries with OHI cannot opt to waive those benefits to have CHAMPVA become the primary payer, beneficiaries enrolled in an HMO cannot elect to waive the HMO benefits without forfeiting their CHAMPVA benefits. CHAMPVA benefits, however, do apply to covered services that are not covered by the HMO.

Are healthcare services at VA facilities available to CHAMPVA beneficiaries?
Under the CHAMPVA Inhouse Treatment Initiative (CITI for short), CHAMPVA beneficiaries may receive cost-free healthcare services at participating VA facilities.

How can I find out if the local VA facility is participating in the CITI program?
Although some VA facilities are not CITI participants due to the volume of veterans they are responsible for serving, most are. To find out if your local facility is participating, click here. However, CHAMPVA beneficiaries who are also covered by MEDICARE cannot use a VA medical center because MEDICARE does not pay for services provided by a VA Medical Center.

What out-of-pocket expenses can a CHAMPVA beneficiary expect under CITI?
None—CHAMPVA beneficiaries don’t pay a thing when receiving services under the CITI program.

Isn’t it unfair that some VA facilities are offering CITI services, while others aren’t? Shouldn’t they all participate?
VA’s authority to offer inhouse services to CHAMPVA beneficiaries is conditional providing veteran access to care is not compromised. Unfortunately, some facilities are experiencing such a high veteran demand for services that participation in the CITI program is not possible.

For more information on the CHAMPVA program and to find out if you qualify, please call 1-800-733-8387 or visit our website at http://web.archive.org/web/20041022052401/http://www.va.gov/hac. Any of our benefits advisors can answer your questions or supply you with any of our program publications (brochures or handbooks or forms.) You can also download any of our publications from our website.