How It Works

Here's how the ChampVA Supplement Program

works to help pay what Champva doesn't pay

Covered Care Required	CHampVA Pays	Supplement Pays
INPATIENT Services Facility Services DRG* Based	DRG rate less beneficiary cost share	The lesser of (1) $535 /day times number of inpatient days.  (2) 25% of billed amount or (3) DRG rate
INPATIENT Services Non-DRG Based	75% of Allowable Amount	25% of Allowable Amount
INPATIENT Physician Services:  Visits, Surgeon Anesthesiologist, etc.	75% of Allowable Amount	25% of Allowable Amount
OUTPATIENT Services:  Office Visits, clinics, lab, Pharmacy Services, Durable Medical Equipment (Non-VA source)	75% of Allowable Amount after the ChampVA annual Outpatient Deductible	25% of Allowable Amount

*Diagnosis-Related Groups (DRG) – An agreement with most hospitals with CHAMPVA to accept a fixed rate for inpatient care regardless of the billed amount.

In-patient and outpatient covered medical expense are subject to a fiscal year plan deductible of $250 per person, $500 family maximum.  Expenses incurred to satisfy the CHAMPVA deductible cannot be used to satisfy the CHAMPVA Supplement deductible.

The Plan does not pay charges in excess of the CHAMPVA allowed amount, nor does it reimburse the CHAMPVA outpatient deductible.

Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness, including treatment of congenital defects and birth abnormalities, for 31 days.  You must notify the Plan Administrator in writing and pay the additional premium within 31 days of birth for coverage to continue beyond this period.  Insured children who are incapable of self-sustaining employment because of mental retardation or physical disability – and who are unmarried and chiefly dependent on the insured member for support and maintenance – may continue coverage past policy age limits, with requested proof.  Otherwise, each dependent child's insurance terminates on the premium due date following the date he or she is no longer a dependant.

Premiums increase based on your effective date of coverage and as you move from one age bracket to another.  The insurance company reserves the right to change premiums on a group wide basis.

Guranteed Acceptance - Satisfaction Guaranteed

It's easy to enroll in the ChampVA Extra Standard Supplement Plan. Just complete the Enrollment Form Application – making sure to provide all the information requested – and return it with your check for the first premium payment.  That's all there is to it!  You cannot be turned down for coverage, although a pre-existing condition may initially limit the extent of your coverage.  After your completed Enrollment Form and first premium payment have been processed, you'll receive a certificate of insurance which you can examine for 30 days risk-free. Return it for a full refund if you are not completely satisfied (less any claims paid).

Eligibility
The spouse or surviving spouse of a veteran (sponsor), under age 65, whose eligibility for CHAMPVA benefits has been determined by the Department of Veterans Affairs.  Widow (er)s eligible for CHAMPVA benefits under age 65 may also enroll.
Beneficiaries over age 65 and eligible for Medicare may enroll by submitting documentation from Social Security Administration certifying their non-entitlement to exhaustion of Medicare Part A Benefits to the enrollment form.
Eligible dependent and unmarried children under age 18 (23 if a full-time college student) may also enroll.

Effective Date

Your coverage and that of your covered dependents becomes effective on the first day of the month following receipt of your Enrollment Form and first premium payment.  If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital.

Renewability

Your coverage is renewable to age 65.  As long as premiums are paid on time, everyone remains eligible, and the Master Policy remains in effect, no one can be individually canceled. So, even if you or a covered dependant develops a serious health condition in the future, their coverage will not terminate, provided these three conditions are met.

Exclusions (Medical Care/Services/Cost Not Covered By CHAMPVA)

Treatment or confinement not ordered by a physician or necessary for medical care; intentionally self-inflicted injury; suicide or attempted suicide, whether sane or insane; sickness or injury resulting from acts of war, whether declared or undeclared; routine physical exams, hearing exams, eye exams, eye refractions and immunizations, except for well baby care covered by CHAMPVA; custodial care, care received in a retirement or rest home, halfway house or domiciliary; rest cures; hearing aids, orthopedic footwear, eyeglasses or contact lenses; cosmetic procedures, except those resulting from sickness or injury occurring while a covered person; drugs (other than insulin) and other diabetic supplies which do not require a prescription; any confinement, service or supply not covered by CHAMPVA as contained in regulations – 38 CFR 17.272, or for expenses paid in full by CHAMPVA; expenses in excess of the CHAMPVA Cap; expenses in excess of the CHAMPVA allowed amount; the CHAMPVA outpatient deductible; care of the mentally retarded or physically handicapped which is required due to the mental retardation or physical handicap; any part of a covered expense which the covered Person is not legally obligated to pay; care as part of a grant, study or research program; care considered experimental or investigational.

Limitations

Routine newborn and well baby care, hospital nursery charges for a well newborn, dental care, treatment for prevention or cure of alcoholism or drug addiction, and prosthetic devices are limited to expenses covered by Tricare. INPATIENT treatment for mental, nervous, or emotional disorders in excess of 45 days if under age 19, or 30 days if age 19 or older, is limited to 90 days (if approved by Tricare) in a calendar year. OUTPATIENT benefits for mental, nervous or emotional disorders, drug addiction or alcoholism are limited to a maximum of $500 in a 12-month period.

Pre-Existing Conditions Limitations

Any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6 month period preceding the effective date of his or her insurance will not be covered until the coverage has been in effect for 6 months.  However, new conditions will be covered immediately.