Know the Rules: CHAMPVA 100% Coverage for Veteran Spouses

The Civilian Health and Medical Program of the Department of Veteran's Affairs (VA) (CHAMPVA) provides veteran health insurance for spouses and dependents of military personnel who meet specific eligibility requirements.

These health benefits help protect the spouses and/or children of disabled personnel both during the disabled veteran’s lifetime and after he/she has passed on.

However, while CHAMPVA can provide excellent benefits, it alone may not be enough to provide the comprehensive coverage that some military spouses need.

If your clients or their spouses have CHAMPVA, it’s up to you as their insurance agent to inform them of their insurance options, and often, describe why additional types of insurance are necessary for total coverage.

It’s also important to note that many clients will look to you for help (even if you know nothing about how CHAMPVA works). This article will give you some insight into the limitations of CHAMPVA and how the general process works.

NOTE: If you are not an insurance agent and are looking for help regarding CHAMPVA, here are some resources for you:

  • CHAMPVA eligibility information from the official U.S. Department of Veteran Affairs
  • CHAMPVA direct line: 800-733-8387 (available from 8:05am to 7:30pm EST, M-F)

Here’s what we will cover in this article:

CHAMPVA Eligibility

The VA determines whether a veteran is fully disabled. In order for the veteran’s spouse and dependents to be eligible for CHAMPVA benefits, the veteran must be deemed 100% fully disabled.

I’d like to make it clear here that CHAMPVA is only for the spouse and dependents of the disabled veteran. The veteran’s health insurance and disability compensation is entirely different from CHAMPVA.

Disabled military personnel can learn more information about eligibility and compensation on the VA website, but here are some basic cliffnotes so that we’re all on the same page:

  • In order to be eligible for benefits, the veteran must be disabled because of their military service.
  • Disability compensation is a monthly, tax-free benefit paid to the veteran that is at least 10% disabled because of injuries or diseases that have occurred during active duty or active duty for training.
  • The amount of compensation you receive is entirely dependent on the degree of your disability. You can view the compensation rate tables here.
  • If you’re deemed to be more than 30% disabled and you have dependents, an additional monthly allowance may be added to your disability compensation.
  • If you are a disabled veteran, you can apply for disability compensation online.

Now, in order for spouses and dependents to be eligible for CHAMPVA coverage, the veteran must be deemed 100% service-connected disabled.

Meeting this requirement can include any kind of physical condition or mental health condition. Here are some examples:

  • Diabetes
  • Heart conditions
  • Hearing loss
  • Chronic knee conditions
  • PTSD
  • Stroke
  • Severe burns
  • Blindness
  • Certain types of cancer

It’s also important to note that those eligible for CHAMPVA must not be eligible for TRICARE. You can read more about that here.

How you can lose your CHAMPVA eligibility

There are 6 circumstances where you may lose your CHAMPVA coverage.

  1. If you’re eligible for Medicare Part A, but you either decline or drop Medicare Part B.
  2. If you divorce the veteran. (Note that this does not impact the eligibility of a birth or adopted child.)
  3. When a child turns 18, unless the child is enrolled as a full-time student.
  4. When a child, who has been a full-time student, turns 23 or loses full-time student status.
  5. When a child marries.
  6. If you are a stepchild of a disabled veteran, your parents divorce and you lose dependent status.

Where to get care

If a client is overwhelmed or confused and asks you where they can get care, give the following instructions:

  • Ask your healthcare provider if they accept CHAMPVA.
  • If you need to find a provider that accepts CHAMPVA, try Medicare or TRICARE providers. You can locate Medicare providers here, and you can find TRICARE providers here.

Medicare and CHAMPVA

Medicare and CHAMPVA do impact each other. If your client is turning 65, ensure that they sign up for Part B. If they decline Part B, they will lose their CHAMPVA benefits.

When your client receives his or her Medicare card, they need to send a copy with a CHAMPVA Other Health Insurance Certification Form. Once this is taken care of, a new CHAMPVA ID card will be sent with an extended expiration date.

When a client has both Medicare and CHAMPVA, Medicare is considered the primary insurance. All medical bills will first be sent to Medicare. From there, Medicare will electronically forward claims for CHAMPVA beneficiaries after they have been processed.

If a client also carries a Medicare Supplement, CHAMPVA will process the remaining portion of the bill after they receive the Med Supp’s EOB.

Medicare Part D does not affect CHAMPVA. Please note that there is a program available called Meds by Mail, which can provide maintenance medications at no charge. There are a few limitations, and we’ll cover that in the next section.

What CHAMPVA Covers (and Doesn’t Cover)

If your client ONLY has CHAMPVA and no other health insurance, CHAMPVA is considered the primary insurance. In these cases, the client will be responsible for a 25% coinsurance. There is a yearly cap of $3,000, so once that cap is met, CHAMPVA covers the rest of the medical bills in full.

However, if a client has two types of insurance – say CHAMPVA and Medicare – there are no deductibles or coinsurance payments. Medicare will pay for its 80%, and CHAMPVA will cover the remaining amount.

There are only a few exceptions to this rule.

  1. Chiropractors are not covered by CHAMPVA. If your client sees a chiropractor often, he or she may consider adding a Medicare Supplement to cover the costs.
  2. Certain drugs are not covered by CHAMPVA. For example, certain painkillers cannot be shipped through the mail. In these cases, a Part D plan is the best option. Otherwise, the Meds by Mail program, which covers prescriptions in full, would be the best option.

A few other types of care are NOT covered by CHAMPVA.

Adding long-term care

Long-term care is NOT covered by CHAMPVA or Medicare. Any care you might need provided by a nursing home, assisted living facilities, adult day care, or home health care is not covered.

It’s important that you highlight this with your clients.

Adding life insurance

Life insurance is also not provided by CHAMPVA. It can often be a great option to present a life w/ long-term care policy to kill 2 birds with 1 stone. You can read some tips on how to pitch this product here.

Adding cancer care

Like Medicare, CHAMPVA only covers medical claims. We know that two-thirds of cancer-related costs are non-medical, so presenting a cancer plan to your clients is extremely important. You can read about sales techniques, product information, and carrier-specifics here.

At the end of the day, make sure you at least speak with your clients about their options regarding the gaps in their Medicare + CHAMPVA coverage. In many cases, they may not be aware of CHAMPVA’s limitations and will want to stick with the free benefits they receive.

Additional Resources

How to Apply for CHAMPVA

How to File a CHAMPVA Claim

CHAMPVA Guide

Summary of VA Disability Benefits for Disabled Veterans

Note: The information from this article was taken from the official Department of Veterans Affairs website,  www.va.gov, the literature provided by the VA and CHAMPVA, and phone calls with representatives of CHAMPVA. If you have any specific questions about CHAMPVA, we recommend calling their direct line at 800-733-8387. Our wait times were less than 5 minutes, but they also have a callback option.



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