What to Know About Medicare and CHAMPVA

CHAMPVA stands for Civilian Health and Medical Program of the Department of Veterans Affairs. It is a healthcare program for dependents of military personnel who are not eligible to sign up for TRICARE. CHAMPVA is managed by the Veterans Health Administration Office of Community Care, located in Denver, Colorado.

Dependents can combine CHAMPVA with Medicare once eligible for both programs. There are some rules in place for how the two healthcare programs function together. Overall, combining Medicare coverage with CHAMPVA coverage can lower one’s medical expenses. Learn more about CHAMPVA, Medicare, and coordinating the two healthcare programs below.

CHAMPVA stands for Civilian Health and Medical Program of the Department of Veterans Affairs. It is a healthcare program for dependents of service members who are not eligible to sign up for TRICARE. CHAMPVA is managed by the Veterans Health Administration Office of Community Care, located in Denver, Colorado.

CHAMPVA enrollees do not have to pay monthly premiums for coverage. That said, CHAMPVA does have an outpatient deductible of $50 per beneficiary every calendar year or a $100 maximum per family per calendar year. Once the deductible is met, beneficiaries will pay 25% of CHAMPVA’s allowable amount up to the catastrophic cap of $3000 per calendar year. CHAMPVA’s allowable amount is usually equivalent to Medicare and TRICARE rates.

What Health Care Services Do CHAMPVA Benefits Include?

CHAMPVA covers health care services and supplies if deemed medically necessary. Covered services include:

• Ambulance service
• Ambulatory surgery
• Durable medical equipment (DME)
• Family planning and maternity
• Hospice
• Inpatient services
• Mental health
• Outpatient services
• Pharmacy (prescription medications)
• Skilled nursing care
• Transplants

How Does CHAMPVA Eligibility Work?

As aforementioned, those eligible for CHAMPA cannot be able to enroll in TRICARE. That said, eligible persons will fall under one of the following categories in order to qualify for CHAMPVA benefits:

• A spouse or child of a veteran who is permanently and totally disabled from a service-connected event

• A widow or child of a veteran who died from a service-connected disability

• A widow or child of a veteran who was at the time of death considered permanently and totally disabled from a service-connected event

• A widow or child of a military member who died in the line of duty, not due to misconduct (Note: in most of these cases, these family members are eligible for TRICARE, not CHAMPVA)

As of October 1, 2001, CHAMPVA benefits also became available to dependents 65 years of age or older. If this is the case, a 65-year-old person must meet the following conditions:

• 65 or older before June 5, 2001, eligible for CHAMPVA, and was also entitled to Medicare Part A coverage: Beneficiary can enroll in CHAMPVA having to also have Medicare Part B coverage.

• 65 before June 5, 2001, and has Medicare Parts A and B: Beneficiary has to keep Medicare Part A and Medicare Part B to remain eligible for CHAMPVA.

• 65 on, or after, June 5, 2001: Beneficiary must have Medicare Parts A and B to be eligible for CHAMPVA.

As a refresher, Original Medicare is insurance provided by the federal government to those who are 65+, have a disability, or have end-stage renal disease (ESRD).

Medicare is comprised of both Medicare Parts A and B. Medicare Part A is Medicare’s hospital insurance. Medicare Part B is Medicare’s medical insurance. Each Medicare Part is responsible for covering different health services.

Part A

Part A is Medicare’s hospital insurance, which covers costs associated with hospital stays. Some of these services include skilled nursing care, semi-private hospital rooms, and meals during a hospital stay.

Part B

Part B is Medicare’s outpatient services insurance, which covers services related to outpatient tests, procedures, and equipment. Some of these services include blood tests, medically necessary doctor’s appointments, durable medical equipment (DME), certain lab tests, and more.

Yes, CHAMPVA coverage can be combined with Original Medicare. In fact, those who combine CHAMPVA with Medicare may see their overall medical expenses fall. That said, there are some rules in place for how the coordination of these healthcare plans will work.

As a refresher, Original Medicare is comprised of both Medicare Parts A and B. Medicare Part A is Medicare’s hospital insurance. Medicare Part B is Medicare’s medical insurance. Each Medicare Part is responsible for covering different health services. For example, Medicare Part B coverage includes outpatient services, while Medicare Part A covers services received during hospital admission.

Some dependents who are eligible for both Medicare and CHAMPVA will not need to purchase Medicare Part B. However, other dependents will need to enroll in Medicare Part B in order to keep CHAMPVA coverage.

Does Medicare Pay First or CHAMPVA?

For those who have health coverage through a CHAMPVA plan as well as a Medicare plan, Medicare will be the primary payer. This means that Medicare will cover health services first, and then CHAMPVA will cover any remaining costs. Since CHAMPA usually will also pay for copayment or coinsurance amounts, beneficiaries can expect little out-of-pocket costs. CHAMPVA will not cover Medicare Part B premiums, however.

Medicare supplement insurance consists of Medicare plans that ​“fill in the gaps” of Original Medicare coverage. Medicare supplement insurance includes various types of Medigap/​MedSupp, Dual Eligibles, or Medicare Advantage plans. All of these types of Medicare plans can be combined with CHAMPVA.

Medicare Advantage Plans and CHAMPVA

A Medicare Advantage plan is one that is provided by a Medicare-approved insurance company. A Medicare Advantage plan, also known as an MA plan or Medicare Part C, bundles both Medicare Parts A and B. A Medicare Advantage plan usually includes a prescription drug plan as well. Medicare Advantage plans also usually offer other additional benefits Original Medicare does not provide, such as vision, hearing, and even dental coverage. This will vary greatly based on the specific health insurance plan. As such, beneficiaries should always confirm what is covered before signing up for a Medicare Advantage plan.

Just like Original Medicare, Medicare Advantage plans will pay before a CHAMPVA health plan will. This means that an MA plan is the primary payer and CHAMPVA acts as the secondary payer.

Medigap Plans and CHAMPVA

Medigap/​MedSupp plans are essentially complementary health insurance policies to Original Medicare plans. A Medicare supplement plan was created to cover out-of-pocket costs of Orignal Medicare. However, CHAMPVA also will cover most out-of-pocket Medicare expenses. Because of this, beneficiaries enrolled in both CHAMPVA as well as Medicare will not need to add on a MedSupp plan. In fact, it is usually most cost-effective not to, as CHAMPVA has no premium costs while a MedSupp plan would have one.

Since Original Medicare doesn’t include prescription drug coverage, most Medicare beneficiaries will have to enroll in a Medicare prescription drug plan known as Medicare Part D. However, many Medicare Advantage plans include prescription drug coverage in their plans, though this will vary.

That said, CHAMPVA covers many prescription drugs and has more cost-effective pricing than Medicare Part D. Because of this, Medicare beneficiaries also enrolled in CHAMPVA do not have to sign up for Medicare Part D.

• CHAMPVA beneficiaries also enrolled in a Medicare plan will no longer be able to use VA facilities.

• CHAMPVA will usually pay 75% of healthcare costs. This is known as cost sharing.

• CHAMPVA requires an application. Information about this and related forms can be found here.