She was 72 years old
CHAMPVA and MAPD?
- Thread starter kennethbroyles
- Start date
She was 72 years old
Would you ever suggest that anyone that you ran into that had essentially a free Plan D or G, switch to an MAPD...? Because that is basically what they have, except that it also has Rx included too at 75%. And I do offer MAPD's but can't imagine ever moving someone from Orig M'care and ChampVa to one... and if they insisted, I would require them to sign a disclosure stating that I advised them against this move, and they insisted on doing so in spite of my advice. Still considering whether I would require this to be notarized...
What they have for a supp is pretty darned close to that, and I can't imagine abandoning that position to adopt the restrictions of choice of an MAPD... Maybe ChampVa would pay every co-pay and all the moop and they would have fabulous coverage... but unless I could see something as to how they would coordinate benefits with an MAPD, I would be cool on the idea.
- 19,035
Would you ever suggest that anyone that you ran into that had essentially a free Plan D or G, switch to an MAPD...? Because that is basically what they have, except that it also has Rx included too at 75%. And I do offer MAPD's but can't imagine ever moving someone from Orig M'care and ChampVa to one... and if they insisted, I would require them to sign a disclosure stating that I advised them against this move, and they insisted on doing so in spite of my advice. Still considering whether I would require this to be notarized...
What they have for a supp is pretty darned close to that, and I can't imagine abandoning that position to adopt the restrictions of choice of an MAPD... Maybe ChampVa would pay every co-pay and all the moop and they would have fabulous coverage... but unless I could see something as to how they would coordinate benefits with an MAPD, I would be cool on the idea.
Only if they didn't have facilities available that they wanted to use. Not every medical facility will take ChampVA. We have a major medical facility right here in my area that will not take ChampVA. They will take some MA plans. Not all of them. They won't take Humana's PPO, for example. Nor are they in network for Anthem's PPO.
Funny thing about that medical facility, they will accept every PFFS plan.
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Could be some of that issue of not being able to recall what they did yesterday, but can clearly remember riding that bicycle 60 yrs ago....
OR that crappy health plan that they had 10 yrs ago....
Short of access or acceptance of the plan by providers, as jdeasy mentions, she should not have experienced those out of pocket costs... except for Rx... which is 25% of cost, it seems, w/o a stand along PDP.
- Thread starter
- #15
- 285
Thanks you for the opinions of all. This lady lives in a remote area of S.E.TN.....so providers can be a issue. Also after reading this.... I think some of her Rx's were not covered, because Rx costs were her main problem this past year. Also Widow 60 yrs old and 3-1-98 Medicare A&B maybe because of disabilities. I think some of her meds. were for mental anguish after spouse died.
I am going to post my resources FYI.
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Frequently Asked Questions
What is CHAMPVA?
CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries (see Eligibility Fact Sheet 01-3 for criteria for CHAMPVA coverage).
CHAMPVA is managed by the VA’s Health Administration Center (HAC) in Denver, Colorado. We process CHAMPVA applications, determine eligibility, authorize benefits, and process medical claims.
Who is eligible for CHAMPVA?
To be eligible for CHAMPVA, the beneficiary cannot be eligible for TRICARE. CHAMPVA provides coverage to the spouse or widow(er) and to the children of a veteran who:
We do not maintain a provider listing. Most Medicare and TRICARE providers will also accept CHAMPVA (but be sure you ask the provider). If you are having difficulty finding a provider, we recommend you visit the Medicare website HTTP://WWW.MEDICARE.GOV and use the "Search Tools" at the bottom of that page to locate a Medicare provider. You may also visit the TRICARE website at (TRICARE, Military Health System) 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 for reimbursement of our cost share. Remember that CHAMPVA cost shares are based on the CHAMPVA allowable amount.
What does CHAMPVA pay?
In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. CHAMPVA has an outpatient deductible ($50 per person up to $100 per family per calendar year) and a cost share of 25% up to the catastrophic cap (up to $3,000 per calendar year). You should collect the 25% allowable cost share from the patient except when the patient has other health insurance.
If the patient has other health insurance, then CHAMPVA pays the lesser of either 75% of the allowable amount after $50 calendar year deductible is satisfied, or the remainder of the charges and the beneficiary will normally have no cost share. See Payment Methodology Fact Sheet 01-11 for further information regarding payment on other than outpatient type of services.
Can a beneficiary have other insurance and use CHAMPVA?
Yes. If the beneficiary has other health insurance (OHI), they should be billed first. The explanation of benefits (EOB) from the OHI should then be submitted with the claim for reimbursement to CHAMPVA. By law, CHAMPVA is always secondary payer except to Medicaid, State Victims of Crime Compensation Programs and supplemental CHAMPVA policies.
What is the impact of Medicare on CHAMPVA?
As a result of a Federal law passed June 5, 2001, CHAMPVA expanded benefit coverage to eligible family members and survivors of qualifying veteran sponsors effective October 1, 2001.
If the beneficiary is eligible for CHAMPVA and also has Medicare Part A entitlement (premium-free hospitalization coverage) and Medicare Part B (outpatient coverage) we will cover many of the costs not covered by Medicare. CHAMPVA will pay after Medicare and any other insurance, such as Medicare HMOs and Medicare supplemental plans, for health care services and supplies.
CHAMPVA does not pay Medicare Part B premiums.
How do I get more information?
Although similar, CHAMPVA is completely separate with a totally different beneficiary population than TRICARE - a Department of Defense healthcare program formerly called CHAMPUS. While the benefits are similar, the programs are administered separately with significant differences in claim filing procedures and preauthorization requirements.
How can I obtain an application for CHAMPVA benefits?
There are a couple ways to obtain an Application for CHAMPVA Benefits (VA Form 10-10D):
Generally, applicants can expect to receive written notification from the Health Administration Center within 45 days from mailing their application. To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits (VA Form 10-10D) in its entirety and to attach all required documents. As further explained on the application, required documents include a copy of each applicant's Medicare card (if Medicare eligible) and a school certification for all applicant children between the ages of 18 and 23.
CHAMPVA School Certifications (01-02)
Why is CHAMPVA the secondary payer when beneficiaries have other health insurance (OHI)?
To answer this question, a look at CHAMPVA's origin and the congressional intent behind its legislation may help. From the start, CHAMPVA was intended to serve as a safety net in the event other coverage was not available - rather than being the primary carrier. While families with OHI are not disqualified from CHAMPVA benefits, CHAMPVA's safety net protection becomes available after the OHI has paid. This includes benefits available from the enrollment in a health maintenance organization (HMO), preferred provider organization (PPO), Medicare or other health insurance. Exceptions to CHAMPVA's secondary payer status are supplemental CHAMPVA policies, Medicaid, and State Victims Compensation Programs - CHAMPVA becomes the primary payer in these cases.
Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage through a Health Maintenance Organization (HMO), who elect to receive HMO-covered services outside of the HMO network?
Just as beneficiaries with OHI cannot opt to waive those benefits to have CHAMPVA become the primary payer, beneficiaries enrolled in an HMO cannot elect to waive the HMO benefits without forfeiting their CHAMPVA benefits. CHAMPVA benefits, however, do apply to covered services that are not covered by the HMO.
Are healthcare services at VA facilities available to CHAMPVA beneficiaries?
Under the CHAMPVA Inhouse Treatment Initiative (CITI for short), CHAMPVA beneficiaries may receive cost-free healthcare services at participating VA facilities.
How can I find out if the local VA facility is participating in the CITI program?
Although some VA facilities are not CITI participants due to the volume of veterans they are responsible for serving, most are. To find out if your local facility is participating, click here. However, CHAMPVA beneficiaries who are also covered by MEDICARE cannot use a VA medical center because MEDICARE does not pay for services provided by a VA Medical Center.
What out-of-pocket expenses can a CHAMPVA beneficiary expect under CITI?
None - CHAMPVA beneficiaries don’t pay a thing when receiving services under the CITI program.
Isn’t it unfair that some VA facilities are offering CITI services, while others aren’t? Shouldn’t they all participate?
VA’s authority to offer inhouse services to CHAMPVA beneficiaries is conditional providing veteran access to care is not compromised. Unfortunately, some facilities are experiencing such a high veteran demand for services that participation in the CITI program is not possible.
How does my annual deductible and catastrophic cap work?
The annual outpatient deductible begins over again each Jan 1st and is $50.00 per person, no more than $100.00 per family. This deductible must be paid before CHAMPVA will pay 75% of the allowable amount. As claims are processed for covered services, charges are automatically credited to individual and cumulative family deductible requirements for each calendar year.
The catastrophic cap (cat cap) begins over again each Jan 1st and is $3000.00 per family per year. Each time we pay a bill, the deductible and cost share (out of pocket expenses) are calculated and credited to the cat cap. When the cat cap reaches 3000.00 for the family, CHAMPVA will then pay at 100% of our allowable amount for the rest of the calendar year.
Forms | Publications
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U.S. Department of Veterans Affairs - 810 Vermont Avenue, NW - Washington, DC 20420
Reviewed/Updated Date: August 23, 2010
I am going to post my resources FYI.
skip to page content
» Open Advanced Search
What is CHAMPVA?
CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries (see Eligibility Fact Sheet 01-3 for criteria for CHAMPVA coverage).
CHAMPVA is managed by the VA’s Health Administration Center (HAC) in Denver, Colorado. We process CHAMPVA applications, determine eligibility, authorize benefits, and process medical claims.
Who is eligible for CHAMPVA?
To be eligible for CHAMPVA, the beneficiary cannot be eligible for TRICARE. CHAMPVA provides coverage to the spouse or widow(er) and to the children of a veteran who:
- is rated permanently and totally disabled due to a service-connected disability, or
- was rated permanently and totally disabled due to a service-connected condition at the time of death, or
- died of a service-connected disability, or
- died on active duty and the dependents are not otherwise eligible for DoD TRICARE benefits.
- if the beneficiary was 65 or older prior to June 5, 2001, and was otherwise eligible for CHAMPVA, and was entitled to Medicare Part A coverage, then the beneficiary will be eligible for CHAMPVA without having to have Medicare Part B coverage.
- if the beneficiary turned 65 before June 5, 2001, and has Medicare Parts A and B, the beneficiary must keep both Parts to be eligible.
- if the beneficiary turn age 65 on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible.
We do not maintain a provider listing. Most Medicare and TRICARE providers will also accept CHAMPVA (but be sure you ask the provider). If you are having difficulty finding a provider, we recommend you visit the Medicare website HTTP://WWW.MEDICARE.GOV and use the "Search Tools" at the bottom of that page to locate a Medicare provider. You may also visit the TRICARE website at (TRICARE, Military Health System) 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 for reimbursement of our cost share. Remember that CHAMPVA cost shares are based on the CHAMPVA allowable amount.
What does CHAMPVA pay?
In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. CHAMPVA has an outpatient deductible ($50 per person up to $100 per family per calendar year) and a cost share of 25% up to the catastrophic cap (up to $3,000 per calendar year). You should collect the 25% allowable cost share from the patient except when the patient has other health insurance.
If the patient has other health insurance, then CHAMPVA pays the lesser of either 75% of the allowable amount after $50 calendar year deductible is satisfied, or the remainder of the charges and the beneficiary will normally have no cost share. See Payment Methodology Fact Sheet 01-11 for further information regarding payment on other than outpatient type of services.
Can a beneficiary have other insurance and use CHAMPVA?
Yes. If the beneficiary has other health insurance (OHI), they should be billed first. The explanation of benefits (EOB) from the OHI should then be submitted with the claim for reimbursement to CHAMPVA. By law, CHAMPVA is always secondary payer except to Medicaid, State Victims of Crime Compensation Programs and supplemental CHAMPVA policies.
What is the impact of Medicare on CHAMPVA?
As a result of a Federal law passed June 5, 2001, CHAMPVA expanded benefit coverage to eligible family members and survivors of qualifying veteran sponsors effective October 1, 2001.
If the beneficiary is eligible for CHAMPVA and also has Medicare Part A entitlement (premium-free hospitalization coverage) and Medicare Part B (outpatient coverage) we will cover many of the costs not covered by Medicare. CHAMPVA will pay after Medicare and any other insurance, such as Medicare HMOs and Medicare supplemental plans, for health care services and supplies.
CHAMPVA does not pay Medicare Part B premiums.
How do I get more information?
- Mail: VA Health Administration Center
CHAMPVA
PO Box 409028
Denver, CO 80206-9028 - Phone: 1-800-733-8387
Monday - Friday - FAX: 1-303-331-7804
- Inquiry Routing & Information System (IRIS). For specific guidance when using IRIS for your inquiry click here.
- Website: www.va.gov/hac
Although similar, CHAMPVA is completely separate with a totally different beneficiary population than TRICARE - a Department of Defense healthcare program formerly called CHAMPUS. While the benefits are similar, the programs are administered separately with significant differences in claim filing procedures and preauthorization requirements.
How can I obtain an application for CHAMPVA benefits?
There are a couple ways to obtain an Application for CHAMPVA Benefits (VA Form 10-10D):
- Fillable Application
- Call the Health Administration Center at 1-800-733-8387. When calling, select the Application Form option from the voice-mail menu. To help reduce the volume of telephone calls during business hours, please consider placing these calls during evening or weekend hours.
Generally, applicants can expect to receive written notification from the Health Administration Center within 45 days from mailing their application. To streamline the process, applicants are encouraged to complete the Application for CHAMPVA Benefits (VA Form 10-10D) in its entirety and to attach all required documents. As further explained on the application, required documents include a copy of each applicant's Medicare card (if Medicare eligible) and a school certification for all applicant children between the ages of 18 and 23.
CHAMPVA School Certifications (01-02)
Why is CHAMPVA the secondary payer when beneficiaries have other health insurance (OHI)?
To answer this question, a look at CHAMPVA's origin and the congressional intent behind its legislation may help. From the start, CHAMPVA was intended to serve as a safety net in the event other coverage was not available - rather than being the primary carrier. While families with OHI are not disqualified from CHAMPVA benefits, CHAMPVA's safety net protection becomes available after the OHI has paid. This includes benefits available from the enrollment in a health maintenance organization (HMO), preferred provider organization (PPO), Medicare or other health insurance. Exceptions to CHAMPVA's secondary payer status are supplemental CHAMPVA policies, Medicaid, and State Victims Compensation Programs - CHAMPVA becomes the primary payer in these cases.
Are CHAMPVA benefits available to beneficiaries with other health insurance (OHI) coverage through a Health Maintenance Organization (HMO), who elect to receive HMO-covered services outside of the HMO network?
Just as beneficiaries with OHI cannot opt to waive those benefits to have CHAMPVA become the primary payer, beneficiaries enrolled in an HMO cannot elect to waive the HMO benefits without forfeiting their CHAMPVA benefits. CHAMPVA benefits, however, do apply to covered services that are not covered by the HMO.
Are healthcare services at VA facilities available to CHAMPVA beneficiaries?
Under the CHAMPVA Inhouse Treatment Initiative (CITI for short), CHAMPVA beneficiaries may receive cost-free healthcare services at participating VA facilities.
How can I find out if the local VA facility is participating in the CITI program?
Although some VA facilities are not CITI participants due to the volume of veterans they are responsible for serving, most are. To find out if your local facility is participating, click here. However, CHAMPVA beneficiaries who are also covered by MEDICARE cannot use a VA medical center because MEDICARE does not pay for services provided by a VA Medical Center.
What out-of-pocket expenses can a CHAMPVA beneficiary expect under CITI?
None - CHAMPVA beneficiaries don’t pay a thing when receiving services under the CITI program.
Isn’t it unfair that some VA facilities are offering CITI services, while others aren’t? Shouldn’t they all participate?
VA’s authority to offer inhouse services to CHAMPVA beneficiaries is conditional providing veteran access to care is not compromised. Unfortunately, some facilities are experiencing such a high veteran demand for services that participation in the CITI program is not possible.
How does my annual deductible and catastrophic cap work?
The annual outpatient deductible begins over again each Jan 1st and is $50.00 per person, no more than $100.00 per family. This deductible must be paid before CHAMPVA will pay 75% of the allowable amount. As claims are processed for covered services, charges are automatically credited to individual and cumulative family deductible requirements for each calendar year.
The catastrophic cap (cat cap) begins over again each Jan 1st and is $3000.00 per family per year. Each time we pay a bill, the deductible and cost share (out of pocket expenses) are calculated and credited to the cat cap. When the cat cap reaches 3000.00 for the family, CHAMPVA will then pay at 100% of our allowable amount for the rest of the calendar year.
Forms | Publications
This site created and maintained by the Health Administration Center (HAC)
U.S. Department of Veterans Affairs - 810 Vermont Avenue, NW - Washington, DC 20420
Reviewed/Updated Date: August 23, 2010
Last edited:
Would a Champ VA covered individual (couple in this case) ever benefit from a Plan F or Plan G ?...or are folks directing them toward MA or MA/PD assuming financial qualifications or lack thereof ?
-TriCare I get....Thank you for service, you're well covered.
but ..Champ VA I'm not clear on the thoroughness of coverage, and if MediGap is applicable to those covered by CHampVA age 65+
Any insight here is appreciated.
-Thanks
-TriCare I get....Thank you for service, you're well covered.
but ..Champ VA I'm not clear on the thoroughness of coverage, and if MediGap is applicable to those covered by CHampVA age 65+
Any insight here is appreciated.
-Thanks
- 1,199
medicare supplement with ChampVA is a complete waste of money however in some instances MA only ( no pdp)with Champ Va works because Champ Va will coordinate with MA and pay the MA medical co pays.. some people want the extra free benefits of MA such as gym membership etc. I strongly discourage it but some times folks depend it.
