CHAMPVA Supplemental Insurance Plan | Benefits
Here's how the CHAMPVA Supplement Insurance Plan works to Help Pay After CHAMPVA Pays.
|Covered Care Required||CHAMPVA Pays||CHAMPVA Supplement Insurance Plan Pays|
|Inpatient Services Confinement in civilian hospital or skilled nursing facility||DRG* rate, less the beneficiary cost share||The lesser of (1) $535 per day, times number of inpatient days (2) 25% of the billed amount, or (3) the DRG* rate|
|Inpatient Services Non-DRG* based||75% of the Allowable Amount||25% of the Allowable Amount|
|Inpatient Physician Services Visits, surgeons, anesthesiologist, etc||75% of the Allowable Amount||25% of the Allowable Amount|
|Outpatient Services Office visits, clinics, laboratory and pharmacy services, durable medical equipment (non-VA source)||75% of the Allowable Amount, after the CHAMPVA Annual Outpatient Deductible||25% of the Allowable Amount|
|We will pay the Inpatient and Outpatient covered medical expenses once the Calendar Year plan deductible of $250 per person and $500 family maximum has been satisfied. Expenses incurred to satisfy the CHAMPVA Calendar Year Outpatient deductible cannot be used to satisfy the CHAMPVA Supplement Plan deductible.|
- Effective Date
Eligible Spouse: "Spouse" means your spouse who is under age 65 and a CHAMPVA benefits recipient, but not a spouse from whom you are legally separated or divorced. "Spouse" also means widow(er) if he or she is a member of the Participating Organization.
Spouses over age 65 are also eligible if documentation from the Social Security Administration certifying their non-entitlement to Medicare Part A benefits is submitted with their enrollment form.
Eligible dependent and unmarried children under age 18 (23 if a full-time college student) may also enroll.
Your coverage under the Policy will cease on the ﬁrst to occur of:
- The date the Policy terminates, or the date the AMRA ceases to be a Participating Organization of the Policyholder;
- The date the required premium is not paid, subject to the Grace Period provision;
- The ﬁrst day of the month on or next following the date you cease to be a member of the Policyholder;
- The date you or your widow(er) terminates membership in the Participating Organization;
- The date you or your widow(er) terminates membership in the Participating Organization;
- The date we or the group cancel coverage for a class of Eligible Person to which he or she belongs;
- The first premium due date on or next following the date he or she ceases to be covered by CHAMPVA;
- if a spouse, the date he or she attains age 65;
- if a child, the date he or she attains age 18, or age 23 if enrolled full-time in a school of higher learning.
- The date you become eligible for Medicare unless you reside in an area where Medicare is not available, in which case coverage will not terminate until you return to residency in an area where Medicare is available. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.
The Policy does not cover:
- 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, eye exams, hearing exams and immunizations, except when considered Well Baby Care covered by CHAMPVA;
- Eye refractions;
- Custodial care, care received in a retirement home, rest home or halfway house, or domiciliary care;
- Rest cures;
- Hearing aids;
- Orthopedic footwear;
- Eyeglasses or contact lenses;
- Cosmetic procedures except those resulting from sickness or injury occurring while a Covered Person under the Policy;
- 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 CFR17.272;
- Expenses paid in full by CHAMPVA;
- Expenses in excess of the CHAMPVA Allowed Amount;
- Expenses in excess of the CHAMPVA Cap;
- Care for the mentally or physically incapacitated if the care is required because of the mental or physical incapacitation;
- Any part of a covered expense which the Covered Person is not legally obligated to pay;
- Care received as part of a grant, study or research program;
- Care considered experimental or investigational.
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.
Deferred Effective Date: If on the date that You are to become covered under the Policy you are conﬁned in a Hospital, your coverage will be deferred until the ﬁrst day after You are discharged.
Deferred Effective Date (Dependent): If on the date that an Eligible Dependent is to become covered under the Policy he or she is conﬁned at home, in a Hospital or elsewhere because of injury or sickness, coverage of such person will be deferred until the ﬁrst day after he or she is discharged from the Hospital or place of conﬁnement.
Nervous, Mental, Emotional Disorder, Alcoholism, and Drug Addiction Limits The coverage provided under the Inpatient Benefit of the CHAMPVA Supplement plan for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to:
- 30 Inpatient treatment days for a Covered Person age 19 or older; or
- 45 Inpatient treatment days for a Covered Person under age 19; or
- 150 Inpatient treatment days in a CHAMPVA authorized Residential Treatment Center for a Covered Person under age 21; per Calendar Year.
This Inpatient limit is based on the number of days CHAMPVA normally provides each Calendar Year for such confinements. In rare instances, CHAMPVA extends these daily limits.
If this occurs, we will limit the number of days that we provide for such confinement to the lesser of:
- the number of days CHAMPVA pays for such Inpatient treatment during the Calendar Year; or
- 90 Inpatient days per Calendar Year.
Pre-Existing Conditions Limitation
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.
The Pre-existing condition limitation may be waived under the following conditions:
For individuals who were previously enrolled in a non-TRICARE Supplement Employer Group Plan and loses that coverage due to involuntary termination. Such individuals must enroll in the Supplement Plan within 31 days following the termination date of the prior insurance plan. Application for coverage under the Supplement Plan should include a copy of the Certificate of Creditable Coverage for the prior group insurance plan.
CHAMPVA Supplemental Benefits FAQ's
|Q1.||Is there a maximum limit on benefits (lifetime, annual, etc.)?|
|No maximum limit.|
|Q2.||Will the plan cover amounts beyond what CHAMPVA allows?|
|The CHAMPVA Supplement does pay cost share amounts, however; it does not pay additional charges above CHAMPVA’s allowed amount.|
|Q3.||Does the plan pay for services that aren’t covered by CHAMPVA?|
|Q4.||Will the plan pay the CHAMPVA outpatient deductible?|
|The CHAMPVA outpatient deductible is not covered by the CHAMPVA Supplement Plan. The CHAMPVA Supplement plan has a fiscal year Plan deductible of $250 per person and $500 family maximum.|
|Q5.||How will the plan require premium payments?|
|Premiums may be paid monthly by deduction from checking account (Check-o-matic) or direct bill - quarterly, semi-annually or annually. Credit cards may not be used to pay premiums.|
|Q6.||Does my Medicare status impact eligibility for CHAMPVA benefits?|
|Yes, your Medicare status has an impact on your eligibility for CHAMPVA benefits.
Medicare automatically enrolls the vast majority of eligible
beneficiaries 90 days prior to their 65th birthday. When you
receive your initial information from Medicare, you also receive a Medicare card
indicating both Medicare Part A and Medicare Part B coverage. To continue your
CHAMPVA eligibility, you MUST enroll in, and remain enrolled in, Medicare Part
Upon enrollment in Medicare Part B, CHAMPVA changes to CHAMPVA for Life and becomes the secondary payor to Medicare. As a result, the CHAMPVA Supplement Plan will automatically end.
|Q7.||Will the plan cover you overseas?|
|Yes, if you live or travel overseas (excluding Iraq, North Korea and Cuba), the
supplement provides the same benefits as if you were in the U.S. Reimbursement for
health care claims in foreign countries is based on reasonable and customary billed
amounts. Your deductible and cost share will be the same as if you were in the
Medicare does not provide benefits for services provided overseas. However, if you are 65 or over, you must enroll in Medicare Part B. CHAMPVA will continue as your primary benefit option for the period of time you are overseas. As a result, the CHAMPVA Supplement Plan will also continue. You will receive the same level of benefits provided to those under age 65.
|Q8.||Can premium payments be increased? Under what conditions?|
|Premiums increase as a person moves from one 5-year age bracket to another (40, 45, 50, 55, 60). The company reserves the right to change premiums on a group wide basis to maintain the financial solvency of the plan.|
|Q9.||What are the membership fees (annual, lifetime, etc.), if any, when you join the organization that sponsors the plan?|
|GEA $24 annual membership fees.|
|Q10.||Does the plan cover the service member when he/she retires?|
|The service member is not covered by CHAMPVA.|
|Q11.||If you’re retired military and have a health care plan (which pays before CHAMPVA) through a civilian job, do you still need a CHAMPVA supplement if, between them, your employer’s plan and the CHAMPVA health care option you’ve chosen will pay most or all of your civilian medical bills?|
|You will need to look at your individual situation and review your primary health plan benefits to determine if the CHAMPVA Supplement Plan will be necessary. In most cases, an individual with a primary health plan, CHAMPVA and a CHAMPVA Supplement Plan will be over insured.|
|Q12.||When does a spouse lose eligibility?|
|When there is a divorce or annulment from the qualifying Veteran sponsor. Eligibility for CHAMPVA ends at midnight of the effective date of the divorce decree or annulment.|
|Q13.||When does a child lose eligibility?|
|Q14.||How are claims filed with the Supplement?|
|All claims are filed first with CHAMPVA. After CHAMPVA has processed
your claim, they will send you an Explanation of Benefit Statement (EOB). You will
need to file a claim with the Supplement Plan only if the provider has not agreed to
file one on your behalf. To file a supplement claim, simply write your certificate
(member ID) number on the EOB and also, write "Pay Provider" if you would
like the benefits paid directly to the provider, otherwise the benefits will be paid
Claims may be mailed to: ASI, P.O. Box 2510, Rockville, MD 20847
|Q15.||What happens when I reach age 65?|
|At age 65, eligibility under the CHAMPVA Supplement ends for members and their spouses. If at age 65, you are eligible for Medicare Part A and enrolled in Medicare Part B your CHAMPVA eligibility will continue. Medicare will be your primary carrier and you will have supplemental coverage under CHAMPVA for Life.|
*Diagnosis-Related Groups (DRG)- An agreement between most hospitals and CHAMPVA to accept a fixed rate for inpatient care regardless of the billed amount.
CHAMPVA SUPPLEMENTAL INSURANCE
Confined or confinement means being an inpatient in a hospital (or skilled nursing facility) due to sickness or injury. And skilled nursing facility does not mean:
- a hospital; or
- a place for rest, custodial care, or the aged; or
- a place for the treatment of mental disease, drug addicts or alcoholics
Rates and/or benefits are based on the attained age of the Insured Person and increase as you enter each new age category. Rates and/or benefits may be changed on a class basis.
It's So Easy To Enroll in the CHAMPVA SUPPLEMENT Enrollment Form
The Plan is currently not available in CO, ME, NH, NV, OR, WA.