United States Department of Veterans Affairs

CHAMPVA


IMPORTANT NOTICES

The Affordable Care Act and CHAMPVA
The Affordable Care Act, also known as the health care law, was created to expand access to affordable health care coverage to all Americans, lower costs, and improve quality and care coordination. Under the health care law, people will have health coverage that meets a minimum standard (called "minimum essential coverage"). The health care law designates CHAMPVA as fulfilling "minimum essential coverage".

If you are enrolled in CHAMPVA, you don't need to take additional steps to meet the health care law coverage standards. The health care law does not change CHAMPVA benefits or out-of-pocket costs. For additional information, visit VA's website at http://www.va.gov/aca, or call 1-800-733-8387

New Dental Program
CHAMPVA beneficiaries have the opportunity to purchase dental insurance at reduced rates under the new Department of Veterans Affairs Dental Insurance Program.

CHAMPVA customer service representatives do not have details on premiums and benefits for these policies. Please contact MetLife at 888-310-1681or Delta Dental at 855-370-3303 directly for further information.

New Claims Process
CHAMPVA has moved from Claim Level Adjudication to Service Line Level Adjudication. More information on Service Line Level Adjudication can be found on our Service Line Level Adjudication webpage.

CHAMPVA Deductible
On January 1 of each year, the annual deductible requirement for your CHAMPVA benefits will begin again.

  • The deductible is applied to the first medical or pharmacy claims processed in a calendar year until the deductible is met.
  • The deductible is $50 per beneficiary or a maximum of $100 per family per year.

DO NOT send checks to us to satisfy your deductible requirement. It will automatically be deducted from your submitted claims.

Change of Address
If you change your address, it is vital that you update your address with CHAMPVA
You can mail a signed address change request to:

CHAMPVA
POB 469063
Denver CO 80246-9063

You can contact us to update your information via the Inquiry Routing & Information System (IRIS). IRIS is a tool that allows us to communicate in a secure format and will be used instead of our traditional email links. You can also update your address information with one of our customer service representatives by calling 800-733-8387. When calling, please have your old address information available, as our customer service representatives must verify this information before updating your file.

Denied Claims
Do you need help to reprocess a denied claim? We have compiled a list of the 10 most common denial codes for claims submitted to CHAMPVA. If you have a CHAMPVA explanation of benefits (EOB) for a denied claim, you can find the denial code at the bottom of the EOB. For additional details on the rejection and instructions to file, read the denied claims page.

Related Links

Overview

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The program is administered by Chief Business Office Purchased Care and our offices are located in Denver, Colorado.

Due to the similarity between CHAMPVA and the Department of Defense (DoD) TRICARE program (sometimes referred to by its old name, CHAMPUS) the two are often mistaken for each other. CHAMPVA is a Department of Veterans Affairs program whereas TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. In some cases a Veteran may appear to be eligible for both/either program on paper. However, if you are a military retiree, or the spouse of a Veteran who was killed in action, you are and will always be a TRICARE beneficiary, you can´t choose between the two.

Eligibility

To be eligible for CHAMPVA, you cannot be eligible for TRICARE, and you must be in one of these categories:

  1. The spouse or child of a Veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.
  2. The surviving spouse or child of a Veteran who died from a VA-rated service-connected disability.
  3. The surviving spouse or child of a Veteran who was at the time death rated permanently and totally disabled from a service-connected disability.
  4. The surviving spouse or child of a military member who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).

An eligible CHAMPVA sponsor may be entitled to receive medical care through the VA health care system based on his or her own Veteran status. If the eligible CHAMPVA sponsor is the spouse of another eligible CHAMPVA sponsor, both may now be eligible for CHAMPVA benefits. In each instance where the eligible spouse requires medical attention, he or she may choose the VA health care system or coverage under CHAMPVA for his/her health care needs.

Medicare Impact

CHAMPVA is always the secondary payer to Medicare. If you are under age 65 and eligible for CHAMPVA and Medicare, you must enroll in Medicare Part A and Medicare Part B to keep your CHAMPVA benefits. Social Security Administration documentation of enrollment in both Part A and Part B is required by CHAMPVA.

To continue to receive CHAMPVA benefits after age 65, you must meet the following conditions:

  • If you turned 65 on or after June 5, 2001, you must be enrolled in Medicare Part A and Part B to remain eligible for CHAMPVA.
  • If you turned 65 or older prior to June 5, 2001, and were otherwise eligible for CHAMPVA, and were entitled to Medicare Part A coverage, then you may eligible for CHAMPVA without having to have Medicare Part B coverage.
  • If you turned 65 before June 5, 2001, and have Medicare Part A and Part B, you must keep Part A and Part B to be eligible for CHAMPVA.
  • You are not required to enroll in Medicare Part D in order to become or remain CHAMPVA eligible.

For more information on Medicare, please visit Medicare website

Notice to New and Expectant Parents

If you are expecting and you need to establish CHAMPVA eligibility for your new child, the following must be accomplished before you can submit an application.

  1. Obtain a Social Security number for the newborn by applying to the nearest Social Security Administration office.
  2. Establish dependency of the newborn to the Veteran sponsor by contacting the local VA regional office.

Since the medical claims cannot be paid until the child is verified as eligible by CHAMPVA, we encourage you to take the above action as early as possible.

Eligibility Definitions

Term Definition
Beneficiary A CHAMPVA-eligible spouse, widow(er), or child.
Child Includes birth, adopted, stepchild, or helpless child as determined by a VA regional office (see the “Rules that Impact CHAMPVA Eligibility” section of the CHAMPVA Program Guide).
Dependents A child, spouse, or widow(er) of a qualifying sponsor.
Qualifying Sponsor A Veteran who is permanently and totally disabled from a service-connected condition, died as a result of a service-connected condition, was rated permanently and totally disabled from a service-connected condition at the time of death, or died on active duty and whose dependents are not otherwise entitled to DoD TRICARE benefits.
Service-connected A VA regional office determination that a Veteran's illness or injury is related to military service.
Spouse The wife or husband of a qualifying sponsor.
Widow(er) The surviving spouse of a qualifying sponsor.

NOTE: The eligibility of a child is not affected by the divorce or remarriage of the spouse except in the case of a stepchild. When a stepchild leaves the sponsor's household, the child is no longer eligible for CHAMPVA.

Remarried Widows/Widowers

Eligibility for CHAMPVA ends at midnight on the date of your remarriage, if you remarry prior to age 55. If you remarry on or after your 55TH birthday, The Veterans Benefit Act of 2002, Public Law 107-330, allows you to keep your CHAMPVA benefits.

Termination of Remarriage

If you are a widow(er) of a qualifying sponsor and you remarry and the remarriage is later terminated by death, divorce, or annulment you may reestablish CHAMPVA eligibility. The beginning date of your re-eligibility is the first day of the month after termination of the remarriage or December 1, 1999, whichever date is later. To reestablish CHAMPVA eligibility, copies of the marriage certificate and death, divorce, or annulment documents (as appropriate) must be provided.

CHAMPVA Eligibility Fact Sheets

Benefits

In general our CHAMPVA program covers most health care services and supplies that are medically and psychologically necessary. Upon confirmation of eligibility, you will receive a CHAMPVA Program Guide that specifically addresses covered and non-covered services and supplies.

General Exclusions

Like all health programs there are certain services and supplies that are not covered by CHAMPVA, some of these are:

  • Services and supplies obtained as part of a grant, study, or research program.
  • Services and supplies not provided in accordance with accepted professional medical standards or related to experimental/investigational or unproven procedures or treatment regimens.
  • Care for which you are not obligated to pay, such as services obtained at a health fair.
  • Care provided outside the scope of the provider's license or certification.
  • Services or supplies above the appropriate level required to provide the necessary medical care.
  • Services by providers suspended or sanctioned by any federal agency.
  • Services provided by a member of your immediate family or person living in your household.
  • For information on excluded mental health benefits, please see CHAMPVA Mental Health and Substance Use Disorder Benefits (01-01)

For a complete listing of non-covered services and supplies please consult the CHAMPVA Program Guide.

How Can I Locate a Provider?

We do not maintain a provider listing. Most Medicare and TRICARE providers will also accept CHAMPVA (but be sure you ask the provider). To find a provider, we recommend you visit the Medicare website or the TRICARE website to locate a provider in your area.

If you choose to see a provider who does not accept CHAMPVA, you will likely have to pay the entire bill and then submit a claim to CHAMPVA for reimbursement. Remember that CHAMPVA payments are based on the CHAMPVA allowable amount, and you may receive a reimbursement from CHAMPVA that is considerably less than you paid to the provider.

How to Learn More About CHAMPVA Before Your Card Arrives

You can read more about CHAMPVA by visiting the Fact Sheets posted on our website.

Contact CHAMPVA

For CHAMPVA contact information, please visit Contact Us

Important CHAMPVA News

Is Kaiser Permanente Your Primary Insurance?

Kaiser does not provide beneficiaries the necessary information needed to submit claims for reimbursement to CHAMPVA. To process a claim for a Kaiser Permanente bill, which does not include a medical diagnosis or procedure code, CHAMPVA can use code V70 for the diagnosis and code 99499 for the procedure.

So that the Purchased Care can process claims using this method, please provide a copy of your Kaiser Permanente card showing the amount of your co-payments with your claims. Although CHAMPVA is providing this method of processing claims for beneficiaries insured by Kaiser, we urge you to request a bill from Kaiser that includes the following information:

  • Tax Identification number
  • Address of the Kaiser provider
  • Date of service
  • Medical code or description for the diagnosis and the procedure
  • Patient’s responsibility or patient co-payment

Important Claims Information!

Many claims never reach CHAMPVA because they are sent to the incorrect address. Please ensure that you have the most current address information on file for CHAMPVA.

Medicare Exclusion List

The Department of Health and Human Services, Office of Inspector General (HHS OIG) maintains and publishes a monthly list of individual medical providers that are not allowed to provide medical services and supplies to Federal health care program participants. Medical providers on this list have been convicted in State or Federal court of certain felonies, criminal offenses, or have had other offenses toward Federal Agencies related to the delivery of health care. Mandatory exclusions include, but are not limited to, convictions related to patient abuse or neglect, felony convictions related to health care fraud, and controlled substances.

Excluded individual medical providers and medical institutions cannot, by law, receive payments for health care services or supplies from any Federal health care program. That exclusion includes programs funded by the Department of Veterans Affairs such as CHAMPVA, Foreign Medical Program (FMP), Spina Bifida, and the Children of Women Vietnam Veterans Health Care Program. To access the list, use either of the following link: