In 1973, Congress enacted the Veteran Health Care Expansion Act of 1973 ( P.L. 93-82 ), which, among other things, established effective September 1, 1973, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) as a means of providing health care services to dependents and survivors of certain veterans. CHAMPVA is fundamentally a health insurance program where certain eligible dependents and survivors of veterans (veterans rated permanently and totally disabled from a service-connected condition) obtain medical care from private health care providers. Beneficiaries usually pay 25% of the cost of medical care up to an annual catastrophic cap of $3,000 plus an annual outpatient deductible of $50 per individual or $100 per family. CHAMPVA pays the remaining 75% of the cost of the beneficiaries' medical care. The program is administered by the Veterans Health Administration (VHA), Office of Community Care, located in Denver, CO. The enactment of the Caregivers and Veterans Omnibus Health Services Act of 2010 ( P.L. Eligibility for CHAMPVA requires inclusion in one of the following categories:
the individual is the spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability; or the individual is the surviving spouse or child of a veteran who died from a VA-rated service-connected disability; or the individual is the surviving spouse or child of a veteran who was at the time of death rated permanently and totally disabled from a service-connected disability; or the individual is the surviving spouse or child of a military member who died on active duty, not due to misconduct (in most cases, these family members are eligible under TRICARE, not CHAMPVA); or the individual is designated as a "primary family caregiver" of a seriously injured veteran who qualifies under the Program of Comprehensive Assistance for Family Caregivers (PCAFC), and does not have any other form of health insurance. A child's eligibility, excluding that of a helpless child, for CHAMPVA is terminated under the following conditions:
if the child is not enrolled in an accredited school as a full-time student, the child loses eligibility at age 18; or if the child is enrolled in an accredited school as a full-time student, the child loses eligibility at age 23 or upon losing full-time student status; or if the child marries; or if the child is a stepchild, the stepchild loses eligibility upon no longer living in the household of the sponsor; or if the child is a full-time student at an educational institution, between the ages of 18 and 23, and incurred a disabling injury or illness, the child loses eligibility either (1) six months from the removal date of the disability, (2) two years from the onset of the disability or illness, or (3) on the child's 23 rd birthday, whichever occurs first. The CHAMPVA program covers most health care services and supplies that are determined to be medically necessary, including inpatient and outpatient care, prescription drugs, mental health services, and skilled nursing care. Certain types of care require advance approval, commonly known as preauthorization. Currently, preauthorization is required for
durable medical equipment, hospice services, mental health/substance abuse services, organ and bone marrow transplants, and dental procedures that are directly related to covered medical conditions. By law, CHAMPVA is generally the secondary payer for beneficiaries having any other form of health insurance.
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) was established by the Veterans Health Care Expansion Act of 1973 (P.L. 93-82). CHAMPVA is primarily a health insurance program where certain eligible dependents and survivors of veterans receive care from private sector health care providers. The program is administered by the Veterans Health Administration (VHA), Office of Community Care, located in Denver, CO.
Eligibility
To be eligible for CHAMPVA benefits, the beneficiary must be the spouse or child of a veteran who has a total and permanent service-connected disability, or the widowed spouse or child of a veteran who (1) died as a result of a service-connected disability; or (2) had a total, permanent disability resulting from a service-connected condition at the time of death; or (3) died while on active duty status and in the line of duty; and does not qualify for health care under the Department of Defense (DOD) TRICARE program. The Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) expanded CHAMPVA benefits for primary caregivers of certain seriously injured veterans if they do not have any other form of health insurance. Under current law, a child (other than a helpless child) loses eligibility when (1) the child turns 18, unless enrolled in an accredited school as a full-time student; or (2) the child, who has been a full-time student, turns 23 or loses full-time student status; or (3) the child marries. Nevertheless, a child between the ages of 18 and 23 may remain eligible for CHAMPVA benefits if the child incurs a disabling illness or injury—while enrolled as full-time student—and is unable to continue studying at his or her educational institution. The child's eligibility will end either (1) six months from the removal date of the disability, (2) two years from the onset of the disability, or (3) on the child's 23rd birthday.
Benefits
The CHAMPVA program covers most health care services and supplies that are determined to be medically necessary, including inpatient and outpatient care, prescription drugs, mental health services, and skilled nursing care. Certain types of care require advance approval, commonly known as preauthorization. Currently, preauthorization is required for durable medical equipment, hospice services, mental health/substance abuse services, organ and bone marrow transplants, and dental procedures that are directly related to covered medical conditions.
Payments
CHAMPVA beneficiaries usually pay 25% of the cost of medical care up to an annual catastrophic cap of $3,000 plus an annual outpatient deductible of $50 per individual or $100 per family. CHAMPVA pays the remaining 75% of the cost of the beneficiaries' medical care. CHAMPVA is generally a secondary payer to other health insurance coverage and Medicare. CHAMPVA is the primary payer for Medicaid, Indian Health Service, and State Victims of Crime Compensation Programs.