CHAMPVA and TRICARE

Spouses and dependent children of veterans who are rated as “permanently and totally disabled” by the VA because of a service-connected condition are eligible for CHAMPVA. Some survivors also are eligible for CHAMPVA. CHAMPVA allows caregivers to access VA health care services and private doctors who contract through CHAMPVA. It is an insurance program, so copayments might apply. CHAMPVA is a second payer to other health insurance programs, including Medicare, which means your existing insurance has to pay first. Then, CHAMPVA may pick up remaining costs. To enroll in CHAMPVA, fill out VA Form 10-10d.

For the most part, you will be looking for an outside medical provider who takes CHAMPVA, but some participating VA clinics have extra capacity and can provide cost-free medical services to CHAMPVA enrollees under the CHAMPVA In-House Treatment Initiative. Those enrolled in both Medicare and CHAMPVA cannot take advantage of this program because Medicare must be the first payer and will not pay for services provided by a VA medical center.

If you as a caregiver become eligible for Medicare because of age, you will need to pay for Medicare Part B insurance to remain on CHAMPVA. If you become disabled and unable to continue service as a family caregiver of a veteran, you might lose CHAMPVA coverage, but as described above, you still might be eligible for CHAMPVA as a spouse of a permanently and totally disabled veteran. If you are eligible for both TRICARE and CHAMPVA you must use your TRICARE benefit. Should you lose TRICARE eligibility and still retain CHAMPVA eligibility, you can then use CHAMPVA.


CHAMPVA COVERAGE FOR FAMILY MEMBERS OF QUALIFYING VETERANS

CHAMPVA

Description

CHAMPVA is a fee-for-service plan under which the VA provides coverage through civilian doctors for certain veterans’ family members.

CHAMPVA patients may find their own doctors.

Visits with other doctors, including specialists, do not require pre-approval in most cases.

It might be difficult to find doctors who will accept new CHAMPVA patients in some localities.

Eligibility

To be eligible for CHAMPVA, you cannot be eligible for TRICARE (the health care program for currently serving and retired military members and families) or other health insurance and you must be in one of these five categories:

  • The spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.
  • The surviving spouse or child of a veteran who died from a VA-rated service-connected disability.
  • The surviving spouse or child of a veteran who was at the time death rated permanently and totally disabled from a service-connected disability.
  • The surviving spouse or child of a servicemember who died in the line of duty, not because of misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).
  • The approved primary family caregiver of a veteran, participating in the Program of Comprehensive Assistance for Family Caregivers.

Enrollment Fee/Premium

None
(Note: If a beneficiary is eligible for Medicare, CHAMPVA eligibility is contingent on enrollment in Medicare Part B, which has a premium of $100 a month or more, depending on income; See “Impact of Medicare Eligibility” below. Medicare premiums are auto-deducted from Social Security.)

Annual Outpatient Deductible

$50 an individual
$100 a family

Outpatient Visit Copayment

25 percent of CHAMPVA-allowed charges

Inpatient Copayment

25 percent of CHAMPVA-allowed charges

Impact of Medicare Eligibility

For a CHAMPVA-eligible person who is also eligible for Medicare and enrolled in Medicare Part A and Part B, CHAMPVA covers all costs Medicare doesn’t for Medicare-covered services. Beneficiaries in this category have no deductibles or copayments for inpatient or outpatient Medicare-covered services.

Catastrophic Cap (Maximum out-of-pocket payment for CHAMPVA-allowed charges)

$3,000 a family per year

TRICARE Coverage for Family Members of Qualifying Veterans

TRICARE is the health insurance program for military beneficiaries. Active duty servicemembers' and their dependents are mostly exempt from TRICARE fees; however, this changes with a change in status (e.g. retired, National Guard/Reserve, or TRICARE Young Adult). Coverage and fees vary with regard to the TRICARE coverage elected, and depend on whether:

(a) the military sponsor is on active duty or retired,
(b) the beneficiary is eligible for Medicare, or
(c) the beneficiary uses military or civilian facilities for health care and medications.

TRICARE Standard will be changing to TRICARE Select in January of 2018, please visit here to read about how this new change will affect your healthcare insurance.

Why do I need health insurance?

TRICARE PROGRAMS FOR ACTIVE DUTY SERVICEMEMBERS AND FAMILY MEMBERS STARTING JANUARY 2018

TRICARE PRIME

TRICARE SELECT

Description

TRICARE Prime is an HMO-style plan that uses a specific network of doctors. It guarantees appointments with participating providers within specific time standards. In most cases, TRICARE Prime care is delivered through military hospitals or clinics.

TRICARE Prime is the only option available to active duty servicemembers.

Active duty family members are enrolled in Prime automatically unless they specifically request TRICARE Standard.

Appointments to see specialists or doctors other than a primary care manager (PCM) require a referral from the PCM.

A special program, TRICARE Prime Remote, provides Prime coverage for active duty family members who have been sent on military orders to locations without reasonable access to military facilities.

Family members may choose coverage under TRICARE Select, a fee-for-service plan under which beneficiaries find civilian doctors.

Visits with other doctors, including specialists, do not require PCM referrals in most cases.

TRICARE Standard has an annual deductible of $150 a person or $300 a family and 20-percent cost shares for active duty or 25-percent for retirees.

Those who use a network provider called TRICARE Extra get a 5-percent discount.

Enrollment Fee

None

None

Annual Outpatient Deductible

None

E-1 to E-4: $50 an individual/$100 a family
E-5+: $150 an individual/$300 a family

Outpatient Visit Copay

None

20 percent of TRICARE-allowed charges

Inpatient Copay

None

$17.35 a day ($25 minimum)

Catastrophic Cap (Maximum out-of-pocket payment for TRICARE-allowed charges)

$1,000 a family per year

$1,000 a family per year

What are the TRICARE Pharmacy benefits?
Beneficiaries have four ways to fill prescriptions, listed below in the order of least to most costly to beneficiaries. Please note: Class III narcotics are not covered.

  • Pharmacies at military treatment facilities fill prescriptions for both 30 and 90 days at no cost as long as they carry your medication.
  • TRICARE Pharmacy Home Delivery provides a 90-day prescription, filled by mail, with a zero-dollar copay for formulary generic, $13 for brand name, and $43 for non-formulary,
  • Retail pharmacies provide a 30-day prescription fill with cost shares of $5 for generic, $17 for brand name, or $44 for non-formulary.
  • The most costly is a non-network pharmacy that provides a 30-day prescription fill for $44 or of 20 percent of the cost of the drug.

Initial medication prescriptions should be filled in military or retail pharmacies. TRICARE Pharmacy Home Delivery is for refills of longer-term maintenance medications.

Beneficiaries without regular access to military pharmacies would benefit from home delivery, which offers 67-percent or greater savings on refills compared to retail drug stores.

TRICARE declares certain drugs as “non-formulary” if they are no more effective than other available drugs for the same purpose but cost more for the military to buy. If your doctor prescribes a non-formulary drug, talk to him or her about substituting a generic or brand-name drug that’s equally effective for you but has lower copayment. If your doctor believes a non-formulary drug is medically necessary for you, the doctor can request that TRICARE grant a waiver to give you the drug at the regular, lower copayment.

Visit the TRICARE website for additional details.

Use the TRICARE Formulary Search Tool to determine the point-of-delivery options available for your prescription and the copayment as well as any applicable medical necessity or preauthorization forms.

Once you become eligible for Medicare Part B, which happens when you reach the 24th month of being rated 100-percent disabled by the Social Security Administration (not DoD or the VA,) you must enroll in Medicare Part B to keep TRICARE eligibility, with one exception: Medicare-eligible active duty servicemembers and/or their Medicare-eligible Social Security Disability Insurance family members enrolled in a TRICARE Prime option are allowed a special enrollment period for the servicemember’s remaining time on active duty. They can delay their enrollment in Medicare Part B until their service retirement or medical retirement. People in this situation must request an active duty certificate of creditable coverage from the Defense Manpower Data Center Support Office to use the special enrollment period. But they must enroll in Medicare Part B before they retire or are medically retired from active duty or receive activation orders to avoid a break in medical coverage and a Medicare penalty. It is highly advisable to accept Medicare when it is offered and pay the monthly enrollment fee early and start paying Medicare premiums when servicemember retires

The U.S. Family Health Plan (USFHP) is a TRICARE Prime option available to active duty and retired servicemembers and families who live in certain areas of the country, mainly the northeast (including all or parts of states from northern Virginia to New York and Maine), the Puget Sound area of Washington state, and Southeast Texas and Southwest Louisiana.

The USFHP is administered through six major facilities that have a separate, unique TRICARE Prime contract; maintain their own networks of doctors (separate from the regular TRICARE networks); and provide certain enhanced services.

One unique aspect of the program is some enrollees can continue TRICARE Prime coverage under USFHP even after they have attained Medicare eligibility. This continued coverage into Medicare eligibility applies only to people who already were enrolled in the USFHP as of Oct. 1, 2012. People who enrolled after that date must switch to Medicare and TRICARE For Life upon attaining Medicare eligibility.


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