CHAMPVA Benefits Guide

CHAMPVA — the Civilian Health and Medical Program of the Department of Veterans Affairs — is a healthcare benefits program that covers the cost of medical services and supplies for eligible dependents of certain veterans. It is administered by the VA's Office of Integrated Veteran Care.

CHAMPVA is not the same as TRICARE. TRICARE is a Department of Defense program for active-duty service members, retirees, and their families. CHAMPVA is a VA program specifically for dependents of veterans who meet certain disability or death criteria. If you are eligible for TRICARE, you cannot receive CHAMPVA benefits.

You may be eligible for CHAMPVA if you are the spouse, surviving spouse, or child of a veteran who meets one of the following criteria:

• Permanently and totally disabled: The veteran has been rated by the VA as permanently and totally disabled due to a service-connected disability.
• Died from a service-connected disability: The veteran's death was the result of a VA-rated service-connected condition.
• Died on active duty: The service member died in the line of duty and the dependents are not otherwise eligible for TRICARE.
• Rated P&T at time of death: The veteran was rated permanently and totally disabled at the time of death, even if the death was not from the service-connected condition.

Important eligibility notes:

• You cannot receive CHAMPVA if you are eligible for TRICARE benefits.
• Surviving spouses who remarry before age 55 lose CHAMPVA eligibility. If the remarriage ends (by death, divorce, or annulment), eligibility may be restored.
• Children are eligible until age 18, or until age 23 if enrolled full-time in school. Children who became permanently incapable of self-support before age 18 may remain eligible indefinitely.

CHAMPVA covers most medically necessary healthcare services and supplies, including:

• Inpatient hospital services: Room and board, surgeries, nursing care, lab tests, and other hospital-based treatments
• Outpatient services: Doctor visits, diagnostic tests, X-rays, lab work, and outpatient procedures
• Mental health care: Individual and group therapy, psychiatric services, substance use disorder treatment, and inpatient psychiatric care
• Prescription drugs: Covered at in-network pharmacies or through the Meds by Mail program
• Durable medical equipment (DME): Wheelchairs, hospital beds, oxygen equipment, and other medically necessary equipment
• Skilled nursing care: Skilled nursing facility services when medically necessary
• Hospice care: End-of-life care services including pain management, counseling, and support
• Ambulance services: Emergency transport when medically necessary
• Maternity care: Prenatal care, delivery, and postnatal care
• Family planning and reproductive services
• Prosthetics and orthotics: Artificial limbs, braces, and corrective devices

Certain services and treatments are excluded from CHAMPVA coverage:

• Cosmetic surgery: Procedures performed solely for cosmetic or aesthetic purposes (reconstructive surgery following injury or illness may be covered)
• Dental care: Routine dental care is generally not covered. Exceptions may apply for dental treatment related to a covered medical condition, or for treatment of injuries to teeth from an accident
• Long-term or custodial care: Custodial care (help with daily living activities without skilled medical need) is not covered. Skilled nursing is limited and may not extend beyond 30 days in some circumstances without further authorization
• Non-medically necessary services: Any treatment or service that is not considered medically necessary by CHAMPVA standards
• Services covered by other insurance: When another health insurance plan (including Medicare) is the primary payer, CHAMPVA only covers remaining eligible costs
• Experimental or investigational procedures: Treatments not yet approved or widely accepted as standard medical practice

CHAMPVA uses a cost-sharing model with an annual deductible, a cost share percentage, and a catastrophic cap:

Once your family's out-of-pocket costs (deductible plus cost shares) reach $3,000 in a calendar year, CHAMPVA pays 100% of the allowable amount for covered services for the rest of that year.

No enrollment fees or monthly premiums. CHAMPVA does not charge beneficiaries a premium to participate in the program. Your only costs are the deductible and cost share described above.

If you have both CHAMPVA and Medicare, the two programs coordinate benefits:

• Medicare pays first. When you have Medicare, it is the primary payer. CHAMPVA then acts as the secondary payer and may cover remaining costs that Medicare does not pay (such as deductibles and coinsurance).
• Medicare Part A (hospital insurance): If you are entitled to Medicare Part A, you must also have Medicare Part B to remain eligible for CHAMPVA. If you turn down Part B when you are first eligible, you may lose CHAMPVA eligibility.
• Medicare Part B (medical insurance): You must enroll in and maintain Medicare Part B to keep your CHAMPVA benefits if you are Medicare-eligible.
• Medicare Part D (prescription drugs): Enrolling in a Part D plan is optional. CHAMPVA can act as your prescription drug coverage, or you can have both.

Having both Medicare and CHAMPVA can effectively eliminate most out-of-pocket costs, as CHAMPVA often covers what Medicare does not.

The CHAMPVA In-house Treatment Initiative (CITI) allows CHAMPVA beneficiaries to receive healthcare services at participating VA medical centers. Under CITI:

• You can receive inpatient and outpatient care at VA facilities on a space-available basis.
• No cost share and no deductible when receiving care through CITI at a VA facility — this can save significant money compared to using civilian providers.
• Not all VA medical centers participate in CITI. Contact your nearest VA facility to ask whether they accept CHAMPVA beneficiaries under the CITI program.
• Prescription medications filled at VA pharmacies through CITI are provided at no cost to the beneficiary.

CHAMPVA beneficiaries can use the Meds by Mail program to receive prescription medications by mail at reduced cost:

• Prescriptions are filled through the VA's Consolidated Mail Outpatient Pharmacy (CMOP) and shipped directly to your home.
• No cost share for medications obtained through Meds by Mail — you only pay the applicable deductible (if not yet met for the year).
• Most maintenance medications (drugs you take regularly for ongoing conditions) can be filled through Meds by Mail.
• Your provider sends the prescription to Meds by Mail, or you can mail in a paper prescription along with the Meds by Mail order form.
• Typical processing and delivery time is 7 to 10 business days for new prescriptions, and about 5 to 7 business days for refills.

To apply for CHAMPVA, complete VA Form 10-10d (Application for CHAMPVA Benefits) and submit it with the required supporting documents.

Supporting documents you will need:

• DD-214: The veteran's Certificate of Release or Discharge from Active Duty
• VA rating decision: The letter from the VA showing the veteran's permanent and total disability rating (or documentation of service-connected death)
• Marriage certificate: For spouses applying for benefits
• Birth certificate(s): For dependent children applying for benefits
• Death certificate: If the veteran is deceased
• Medicare card: If the applicant is entitled to Medicare (both Part A and Part B enrollment is required)
• Other health insurance information: Documentation of any other health coverage you carry (OHI)

Where to send your application:

VHA Office of Integrated Veteran Care
CHAMPVA Eligibility
PO Box 469028
Denver, CO 80246-9028

Processing time: Allow approximately 6 to 8 weeks for your application to be processed. You can check the status of your application by calling 1-800-733-8387 (the CHAMPVA helpline), Monday through Friday, 8:05 a.m. to 7:30 p.m. ET.

• Report other health insurance changes immediately. If you gain or lose other health insurance (including Medicare, employer coverage, or Medicaid), you must notify CHAMPVA. Failure to report can result in claims being denied or benefits being delayed.
• Pre-authorization is required for some services. Certain procedures and treatments require pre-authorization from CHAMPVA before you receive them. This includes organ transplants, dental care related to a medical condition, durable medical equipment over a certain cost, and some mental health and substance abuse treatments. If you skip pre-authorization, CHAMPVA may deny the claim.
• Keep copies of everything. Keep copies of your application, all correspondence with CHAMPVA, Explanation of Benefits (EOB) statements, and medical bills. If a claim is denied or delayed, having documentation on hand makes the appeals process much easier.
• Not all providers accept CHAMPVA. CHAMPVA does not have a formal provider network. Most providers who accept Medicare will also accept CHAMPVA, but always confirm before your appointment that the provider will accept CHAMPVA and bill it directly.
• Filing deadlines: Claims must be filed within one year of the date of service (or the date of the Explanation of Benefits from another insurer, if CHAMPVA is the secondary payer).
• Turning 65 and Medicare: When you become eligible for Medicare, you must enroll in both Part A and Part B to keep CHAMPVA. Missing the Part B enrollment window can create a coverage gap.

• VA CHAMPVA Benefits Page — Official overview of the CHAMPVA program, eligibility, and how to apply
• VA Form 10-10d — Application for CHAMPVA Benefits
• CHAMPVA Guide (PDF) — Comprehensive beneficiary handbook with detailed coverage and claims information
• CHAMPVA Meds by Mail — Information on how to use the mail-order prescription program
• CHAMPVA helpline: 1-800-733-8387, Monday through Friday, 8:05 a.m. to 7:30 p.m. ET