CHAMPVA: Health Coverage for a Disabled Veteran's Family

CHAMPVA, the Civilian Health and Medical Program of the Department of Veterans Affairs, is a cost-sharing health plan for the family members of certain seriously disabled or deceased veterans. It is authorized by 38 U.S. Code 1781 and run by VHA’s Office of Community Care. It covers the family, not the veteran, and it exists precisely because the veteran’s own VA health care does not reach their spouse and children.

Who qualifies

CHAMPVA follows the veteran’s service-connected disability. From VA’s CHAMPVA eligibility rules, you may qualify if you are not eligible for TRICARE and one of the following is true:

• you are the spouse or child of a veteran rated permanently and totally disabled from a service-connected disability;
• you are the surviving spouse or child of a veteran who died from a service-connected disability;
• you are the surviving spouse or child of a veteran who was rated permanently and totally disabled at the time of death; or
• in limited cases, you are the surviving spouse or child of a service member who died in the line of duty, not due to their own misconduct.

Permanent and total, or P&T, means VA rated the disability 100 percent disabling and not expected to improve. That rating is the hinge the whole program turns on, and there is more than one way to reach it. See the four roads to a 100 percent rating for how a veteran earns the P&T stamp, and, for survivors, how CHAMPVA sits alongside DIC and other survivor benefits.

CHAMPVA is not TRICARE

The two get confused constantly, and the difference decides which program you are in. TRICARE covers the families and survivors of active-duty service members and military retirees, and it is run by the Department of Defense. CHAMPVA covers families tied to a veteran’s service-connected disability who are not eligible for TRICARE, and it is run by VA. You cannot hold both: eligibility for TRICARE disqualifies you from CHAMPVA. If a military retirement or active-duty status makes you TRICARE-eligible, that is your program, and CHAMPVA is for the disabled-veteran families TRICARE does not reach.

What it covers and what it costs

CHAMPVA covers most medically necessary care: outpatient visits, inpatient hospital stays, mental health care, prescriptions through Meds by Mail and retail pharmacies, maternity care, hospice, skilled nursing, durable medical equipment, and transplants. The cost structure, set by 38 CFR 17.274, is straightforward:

• an annual deductible of $50 per beneficiary, capped at $100 per family, applied to outpatient care each calendar year;
• a 75/25 cost share after the deductible, meaning CHAMPVA pays 75 percent of its allowable amount and you pay 25 percent; and
• a catastrophic cap of $3,000 per family per calendar year. Once your out-of-pocket covered costs reach $3,000, CHAMPVA pays 100 percent of the allowable amount for the rest of the year.

The allowable amount is CHAMPVA’s own rate, so a provider who bills above it can leave a balance, the same way most insurance works.

Medicare and other insurance come first

CHAMPVA is almost always the last payer. If you have other health insurance, your provider bills that first, then CHAMPVA covers what remains on covered services. Medicare is the case to plan for: if you are eligible for Medicare, you generally must carry both Part A and Part B to keep CHAMPVA, and CHAMPVA pays secondary to Medicare. The one exception is for beneficiaries who turned 65 before June 5, 2001, who may keep CHAMPVA with Part A alone. CHAMPVA can cover some or all of your Medicare Part B deductible, but not the Part B premium. Whenever your coverage changes, send VA a CHAMPVA Other Health Insurance Certification, VA Form 10-7959c, so your claims pay correctly.

The child age rule, and the age-26 myth

A CHAMPVA child is covered until age 18. Coverage continues to age 23 only while the child is a full-time student at an approved school, and it ends at 23 or when full-time enrollment stops, whichever comes first. A child who became permanently incapable of self-support before age 18 can stay covered indefinitely. Note what is not on this list: the Affordable Care Act rule that keeps dependents on a parent’s plan until age 26 does not apply to CHAMPVA. Unlike private insurance and TRICARE Young Adult, CHAMPVA has no age-26 coverage, so a healthy non-student child ages off at 18.

How to apply: VA Form 10-10d

Apply with VA Form 10-10d, the Application for CHAMPVA Benefits, and include the supporting documents VA requests, such as the veteran’s P&T rating decision or, for survivors, the death certificate and marriage or birth records. You can submit online, by mail, or by fax. If you also carry other health insurance, file the 10-7959c alongside it.

A free VA-accredited representative or VSO can assemble a CHAMPVA application, confirm the veteran’s P&T status is documented the way VA needs it, and sort out the Medicare timing before it costs you a gap in coverage, all without a fee. VeteranPlug is an independent reference, not affiliated with VA.