How Does Medicare Work with ChampVA?

How Does Medicare Work with ChampVA?

CHAMPVA is a type of health coverage program for some family members and dependents of veterans who don’t qualify for TRICARE.

If someone is eligible for both CHAMPVA and Original Medicare, they can use both programs together. Medicare will be your primary coverage, paying most of your out-of-pocket expenses, and CHAMPVA will be the secondary payer covering nearly all remaining costs.

When using both together, beneficiaries can significantly lower their out-of-pocket medical expenses.

Learn more about what CHAMPVA is, who qualifies, and how it works with Medicare.

What is CHAMPVA?

CHAMPVA stands for the Civilian Health and Medical Program of the Department of Veterans Affairs. This is a health benefits program in which the VA shares the costs of certain health care services and supplies with eligible beneficiaries, including spouses, widows, or children of veterans.

CHAMPVA eligibility

CHAMPVA provides coverage for the spouse or widow(er) and children of a veteran who:

·       Is permanently and totally disabled due to a service-related disability, OR

·       Was permanently and totally disabled due to a service-related condition at the time of death, OR

·       Died of a service-related disability, OR

·       Died on active duty and the dependents are not otherwise eligible for the Department of Defense TRICARE benefits

To be eligible for CHAMPVA, beneficiaries cannot also be eligible for TRICARE.

What if you’re eligible for Medicare?

If you qualify for Medicare due to being 65 years or older, you are eligible for CHAMPVA, although there are limitations if you only take Part A. (Please see the Additional resources section for links to the site.)

People who qualify for Medicare due to illness or disability AND are enrolled in Parts A and B are also eligible for CHAMPVA.

Whether you age into Medicare or qualify before turning 65, you must also otherwise be eligible for CHAMPVA (as described above) to enroll in the program.

You can apply for CHAMPVA at any time through the VA. We walk you through Medicare enrollment here.

CHAMPVA out-of-pocket costs

Typically, the amount CHAMPVA pays for covered services and supplies is equivalent to Medicare rates. Other out-of-pocket costs include:

·       A $50 outpatient deductible (per beneficiary per calendar year, or a maximum of $100 per family per calendar year)

·       25% of the allowable amount up to the catastrophic cap ($3,000 per calendar year)

There is no monthly premium for CHAMPVA coverage.

As long as the provider accepts CHAMPVA, the provider will accept the allowable amount as payment in full, meaning they cannot bill you any additional costs.

In the case that a patient has other health insurance, CHAMPVA pays either 75% of the allowable amount (after the $50 deductible), or the remainder of the charges, depending on which is less.

·       If Medicare and CHAMPVA cover the service, you will usually have no out-of-pocket costs

·       If the service is covered by Medicare and not CHAMPVA, you’ll pay the Medicare copay and/or coinsurance (20%)

·       If the service is covered by CHAMPVA but not by Medicare, you will pay the CHAMPVA cost share (typically 25%)

CHAMPVA does not cover Medicare Part B premiums.

There is no deductible for inpatient hospital services, ambulatory surgical centers, psychiatric partial hospitalization, hospice, services provided through VA facilities, or medication received through the Meds by Mail (MbM) program.

What is TRICARE?

To be eligible for CHAMPVA, beneficiaries cannot qualify for TRICARE. You can’t use CHAMPVA if you have or are eligible for TRICARE. While both are healthcare plans for certain dependents of veterans, TRICARE also services active military members and veterans.

How does Medicare coverage work with CHAMPVA coverage?

When it comes to using Medicare and CHAMPVA coverage together,

·       If a beneficiary is 65 or older prior to June 5, 2001, entitled to Medicare Part A, and eligible for CHAMPVA, they do not need to enroll in Medicare Part B

·       If a beneficiary turned 65 before June 5, 2001, and has Medicare Parts A and B, they must keep both Medicare Parts A and B to be eligible for CHAMPVA

·       If the beneficiary turned age 65 on or after June 5, 2001, they must be enrolled in Medicare Parts A and B to be eligible for CHAMPVA

If a person is eligible for CHAMPVA and also has Medicare Part A and B, CHAMPVA will cover many of the costs not covered by Medicare. Medicare will pay the Medicare-approved amount first because they serve as the primary payer. Any other insurance (such as Medicare supplement plans) would also pay their share, and then CHAMPVA will pay the remaining costs second as the secondary payer.

You can also use CHAMPVA alongside a Medicare Part C (Medicare Advantage) plan. In this case, your bill will go to your Medicare Advantage plan first and then to CHAMPVA. Note that Part C plans typically have provider networks, so you must see an in-network provider for the services to be covered.

Compare Medicare plans in your area

When a beneficiary has both Medicare and CHAMPVA, most medical needs will be covered. However, there are some benefits not provided by either (except in extreme circumstances) such as:

·       Eyeglasses

·       Cosmetic services

Additionally, CHAMPVA may cover some care, but coverage may be limited, or prior authorization may be required, such as for:

·       Medically necessary dental care

·       Durable medical equipment (DME)

An important thing to note is you cannot use a VA Medical Center (VAMC) to obtain your care if you are eligible for Medicare. If you do, Medicare will not pay the medical center for the services provided. Beneficiaries must use Medicare-approved providers.

Otherwise, between Medicare and CHAMPVA, you will have coverage for most of your healthcare needs, including:

·       Ambulatory surgery

·       Home health services

·       Hospice services

·       Outpatient services

·       Inpatient services, including inpatient hospital stays

·       Mental health services

·       Skilled nursing facility (SNF) and rehabilitation services

·       Visits to a primary care provider or specialist

·       Preventive screenings and services

·       Lab work

·       Ambulance transportation

With CHAMPVA, you do not need to enroll in Medicare Part D (prescription drug coverage). CHAMPVA pays the full cost of covered prescriptions for medications obtained through the MbM program or through CHAMPVA In-House Treatment Initiative (CITI) participation. However, if you need medications not available through those programs, you can enroll in a Part D plan and use it with your CHAMPVA coverage.

Which health plan coverage is right for me?

Knowing which coverage option is right for you depends on your personal needs and budget. Some options to consider include:

·       Original Medicare and CHAMPVA: You would pay the Medicare Part B premium, and Medicare would service as the primary payer for all covered services. CHAMPVA would serve as the secondary payer. You can also get prescriptions covered if you use the MbM program.

·       Original Medicare, Part D, and CHAMPVA: You would pay the Part B and Part D premiums. Medicare would be the primary payer for prescriptions, and CHAMPVA would pay any copay or coinsurance amounts.

·       Medicare Advantage (Part C) and CHAMPVA: You would pay the Part B premium and premium for your Part C plan. Medicare would be the primary payer, and CHAMPVA would pay additional copays or coinsurance.

To decide which is the best option for you, use our Find a Plan tool to shop for plans in your area and compare prices, networks, and covered services. Choose an option that allows you to see your preferred doctors and covers any prescriptions or services you need.

Additional resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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