CHAMPVA

CHAMPVA is the Civilian Health and Medical Program of the Department of Veterans Affairs, a cost sharing program the Veterans Health Administration runs for certain family members of veterans. It is not insurance, and there is no premium and no policy. 38 CFR 17.270(a) provides that VA shares the cost of medically necessary services and supplies with eligible beneficiaries, and the family pays the rest up to an annual ceiling.

Eligibility runs through a decision the VA has already made about a veteran rather than through anything about the applicant. 38 CFR 17.271(a) sets four routes: the spouse or child of a veteran adjudicated permanently and totally disabled from a service-connected condition; the surviving spouse or child of a veteran who died of an adjudicated service-connected condition, or who was adjudicated permanently and totally disabled at the time of death; the surviving spouse or child of someone who died on active military service in the line of duty; and a person designated as a Primary Family Caregiver who has no other health plan coverage. One condition governs all four, and it sits in the opening line of the section: the person must not be eligible under Title 10 for TRICARE and must not be entitled to Medicare Part A, except where the regulation provides otherwise.

The money side sits in regulation rather than in a table that resets each year. 38 CFR 17.274 sets the outpatient deductible at $50 per beneficiary or $100 per family per calendar year, the beneficiary cost share at 25 percent of the amount CHAMPVA determines the care is worth, and the annual out of pocket ceiling at $3,000 per family per calendar year. Because CHAMPVA is not an insurance plan it has no network, so whether a provider bills VA directly is settled appointment by appointment.