Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

SEPTEMBER 2002 NICA NEWS

ISSUES

CHAMPVA

Recently the NICA program has received questions regarding CHAMPVA for Life (CFL) eligibility. Most inquiries question the need for a Medigap policy in addition to CFL.The short answer is: Most people who are covered by both CFL and Medicare, do not need a supplemental policy. This is because when all payment calculations are made by CFL and Medicare, you will normally have no out of pocket expenses if the services are covered by both programs. Individuals with a supplement in place should not cancel their coverage before receiving their CHAMPVA card.

Here is more information regarding the issue:

CHAMPVA is a healthcare benefits program for

dependents of veterans who have been rated by VA as having a total and permanent disability,
survivors of veterans who died from VA-rated service-connected conditions, or who at the time of death, were rated permanently and totally disabled from a VA-rated service-connected condition; and
survivors of persons who died in the line of duty and not due to misconduct who are not otherwise entitled to DOD Tricare benefits. Under CHAMPVA, VA shares the cost of covered healthcare services and supplies with eligible beneficiaries.

The administration of CHAMPVA is centralized to the Health Administration Center in Denver, Colorado. Due to the similarity between CHAMPVA and TRICARE (formally known as CHAMPUS--a program administered by the Department of Defense for military retirees as well as families of active duty, retired, and deceased service members), the two programs are easily and often mistaken for each other. Please note that CHAMPVA is separate from TRICARE and that there are distinct differences between them. To be eligible for CHAMPVA, you cannot be eligible for TRICARE/CHAMPUS.

Benefits

In general, CHAMPVA covers most healthcare services and supplies that are medically and psychologically necessary. Upon confirmation of eligibility, applicants will receive program material that specifically addresses covered and noncovered services and supplies.

General Exclusions

services determined by VA to be medically unnecessary
care as part of a grant, study, or research program
care considered experimental or investigational
care for persons eligible for benefits under other government agency programs, except Medicaid and State Victims of Crime Compensation programs
care for which the beneficiary is not obligated to pay, such as services obtained at a health fair
care provided outside the scope of the provider's license or certification
custodial, domiciliary, or rest cures
dental care except treatment related to certain covered medical conditions
medications that do not require a prescription (insulin excluded)
personal comfort and convenience items
services rendered by providers suspended or sanctioned by other Federal entities

To be eligible for CHAMPVA, you must meet the following conditions for benefits to be extended past age 65:

if you turned 65 before June 5, 2001, and only have MEDICARE Part A, you will be eligible for CHAMPVA without having to have MEDICARE Part B coverage.
if you turned 65 before June 5, 2001, and have MEDICARE Parts A and B, you must keep both Parts to be eligible.
if you turned 65 on or after June 5, 2001, you must be enrolled in MEDICARE Parts A and B to be eligible.

Eligibility Definitions

Service-connected condition/disability
- refers to a VA determination that a veteran's illness or injury was incurred or aggravated while on active duty in military service and resulted in some degree of disability.

Sponsor
- refers to the veteran upon whom CHAMPVA eligibility for the applicant is based.

Spouse
- refers to a wife/husband or widow(er) of an eligible CHAMPVA sponsor. In some instances, may include a remarried surviving spouse whose remarriage is either terminated by annulment or legally determined void when supported by appropriate documentation.

Child
- includes legitimate, adopted, illegitimate, and stepchildren. To be eligible, the child must be unmarried and:

under the age of 18; or
who, before reaching age 18, became permanently incapable of self-support as rated by a VA regional office; or
who, after reaching age 18 and continuing up to age 23, is enrolled in a full-time course of instruction at an approved educational institution.

NOTE: The eligibility of children is not affected by divorce or remarriage of the spouse or surviving spouse.

CHAMPVA For Life and Remarried Widows/Widowers

If you remarried after your first veteran-sponsor died, and the remarriage ended, you may be eligible for CHAMPVA for Life or CHAMPVA. To be eligible, your first marriage must have been to a veteran who was 100% permanently and totally disabled or who died from a service connected condition. It does not matter if the veteran was retired from the military.

MEDICARE Annual Deductibles and CFL

CHAMPVA does not have an annual deductible for inpatient care, so it will cover the MEDICARE deductible that is paid by the beneficiary. Currently, there is a $792 MEDICARE deductible for inpatient stays of 1 - 60 days. CHAMPVA would pay you $792.

The MEDICARE deductible for outpatient services is $100. CHAMPVA will pay you $37.50 of the $100.

CFL Does Not Pay for MEDICARE Part B Premiums. You are responsible for these monthly premiums.

Call the VA Health Administration Center, 1-800-733-8387, or go to their website www.va.gov/hac under CHAMPVA for Life.