CHAMPVA and Medicare: Which Is Primary?

Health Line

20 hours ago

You can use CHAMPVA and Medicare at the same time. When you use Medicare together with CHAMPVA, Medicare is the primary payer.
CHAMPVA is a cost-sharing health coverage program for some military families who don't qualify for TRICARE. You can use CHAMPVA with Medicare when you're eligible for both programs.
CHAMPA will be the secondary payer to Medicare and will pay most of your out-of-pocket costs.
Since there are no additional premiums if you qualify for CHAMPVA, using it alongside Medicare can significantly lower your healthcare costs.
Glossary of common Medicare terms
Out-of-pocket cost: This is the amount you pay for care when Medicare doesn't pay the full cost or offer coverage. It includes premiums, deductibles, coinsurance, and copayments.
Premium: This is the monthly amount you pay for Medicare coverage.
Deductible: This is the annual amount you must spend out of pocket before Medicare begins to cover services and treatments.
Coinsurance: This is the percentage of treatment costs you're responsible for paying out of pocket. With Medicare Part B, you typically pay 20%.
Copayment: This is a fixed dollar amount you pay when receiving certain treatments or services. With Medicare, this often applies to prescription medications.
What is CHAMPVA?
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a healthcare plan for certain dependents of veterans. CHAMPVA is a different program from TRICARE, which also services military members, veterans, and their families.
TRICARE eligibility is open to people who are:
active or retired uniformed service members
spouses or children of active or retired uniformed service members
members of the Army National Guard or Reserve
spouses or children of Army National Guard or Reserve members
spouses or children of deceased military members
certain former spouses of military members
Medal of Honor recipients
spouses and children of Medal of Honor recipients
You can't use CHAMPVA if you have or are eligible for TRICARE. CHAMPVA helps cover certain dependents who aren't eligible for TRICARE.
For example, service members who leave active duty under certain conditions might not qualify for TRICARE. However, if they have a disability caused by their service, their family may be able to enroll in CHAMPVA.
How does CHAMPVA work with Medicare?
Since 2001, CHAMPVA beneficiaries have been able to use their coverage after turning 65 years old. This means CHAMPVA can be used alongside Medicare.
You'll need to be enrolled in Medicare to keep your CHAMPVA coverage. Here are the rules for how that works:
If you turned age 65 before June 5, 2001, and did not have Medicare Part B at the time, you only need to be enrolled in Medicare Part A to keep your CHAMPVA coverage.
If you turned age 65 before June 5, 2001, and were already enrolled in Part B at that time, you need to be enrolled in both Part A and Part B to keep your CHAMPVA coverage.
If you turned 65 years old after June 5, 2001, you need to be enrolled in parts A and B to keep your CHAMPVA coverage.
Example
For example, let's say you turned 65 years old in 1999 and enrolled in Medicare parts A and B. You won't be able to drop your Part B coverage and keep your CHAMPVA coverage.
However, if you turned age 65 in 1999 and enrolled in only Part A, you wouldn't need to sign up for Part B to keep your CHAMPVA coverage.
You can use CHAMPVA alongside:
Original Medicare (parts A and B)
Medicare Advantage (Part C)
Medicare Part D, which is prescription drug coverage
It's important to note that CHAMPVA won't pay for the cost of your Part B premium.
You should also know that you can no longer use VA healthcare facilities or healthcare professionals once you're enrolled in Medicare.
What services does CHAMPVA cover?
CHAMPVA is a cost-sharing health insurance program. This means it will pay a portion of the cost of health services you receive, and you'll pay the remaining amount.
You won't pay a premium for CHAMPVA, but there is a $50 deductible before coverage kicks in.
After you pay your deductible, CHAMPVA will pay what's known as the 'allowable amount' for all covered services. Generally, CHAMPVA will pay 75% of the allowable amount, and you'll pay the other 25%.
Covered services include:
hospital stays
primary care doctor visits
specialist visits
lab work
skilled nursing care
home care
ambulance transportation
mental health services
prescription drugs
There are two other completely covered benefits:
Hospice care from any provider is 100% covered under CHAMPVA.
You can also get prescription coverage at no cost to you if you use the Department of Veterans Affairs (VA) Meds by Mail program, if you have no other prescription drug coverage.
Coverage works differently if you use CHAMPVA alongside another health insurance plan, including Medicare. When you use CHAMPVA with another insurance plan, CHAMPVA becomes what's called a secondary payer.
This means your other insurance plan will be billed first, and CHAMPVA will then pay the remaining cost. This can save you a lot of money on out-of-pocket medical expenses like copayments or coinsurance amounts.
Who pays first for healthcare costs?
Medicare is the primary payer when you use it with CHAMPVA. This means Medicare will be the first to pay the cost of any service you receive, and then CHAMPVA will pay the rest.
You'll have very few out-of-pocket costs using CHAMPVA and Medicare together since CHAMPVA will generally pay any copayments or coinsurance amounts.
You can expect to pay:
nothing out of pocket for any service that both Medicare and CHAMPVA cover
your Medicare coinsurance cost of 20% for a service Medicare covers, but CHAMPVA doesn't
your CHAMPVA cost sharing of 25% for anything CHAMPVA covers, but Medicare doesn't
The same rules apply to Medicare Part D. CHAMPVA will pick up your copayments on all covered prescriptions. It will also pay 75% of the cost of prescriptions that your Medicare Part D plan doesn't cover.
Present both your Medicare Part D plan card and your CHAMPVA ID card at your in-network pharmacy for coverage.
Getting your coverage questions answered
If you're not sure who will pay for a service, you can check ahead of time by:
calling Medicare's Benefits Coordination & Recovery Center at 855-798-2627 (TTY: 855-797-2627)
calling CHAMPVA customer care at 800-733-8387, Monday through Friday from 8:05 a.m. to 7:30 p.m. Eastern Standard Time
What about Medicare Advantage?
You can use your CHAMPVA coverage with a Medicare Advantage plan. Since Medicare Advantage plans replace Original Medicare, having an Advantage plan still meets the requirement to be enrolled in Medicare to keep CHAMPVA once you're age 65.
Your Medicare Advantage plan will be the primary payer, just like when you have Original Medicare. CHAMPVA will pay your copayments and other out-of-pocket costs.
Your bill will go to your Medicare Advantage plan first and then to CHAMPVA. In most cases, you won't have any out-of-pocket costs.
Many Medicare Advantage plans also include Part D coverage. When you use a Medicare Advantage plan that includes Part D along with CHAMPVA, your CHAMPVA benefits will pick up the cost of your prescription copayments.
Medicare Advantage plans often have networks. The network includes all the providers that your Medicare Advantage plan will cover healthcare services. In many cases, you'll need to pay out of pocket for any services you receive from an out-of-network provider.
However, when you use CHAMPVA along with your Medicare Advantage plan, you can often get 75% of the cost of out-of-network services covered.
How do I choose the right coverage options for me?
You need to enroll in Original Medicare (parts A and B) to keep your CHAMPVA coverage. You can also choose to enroll in additional Medicare parts, such as:
Medicare Advantage
Medigap
Medicare Part D
The best option for you will depend on your personal needs and budget.
Medicare Advantage, Medigap, and Medicare Part D plans have their own premiums, deductibles, and other costs. CHAMPVA can cover some of these costs, but not your premiums.
You might not even need additional Medicare parts if you're using CHAMPVA.
For example, Medigap plans are designed to cover the out-of-pocket costs of Medicare parts A and B. However, since CHAMPVA already does this when you use it alongside Medicare, you might not need a Medigap plan.
Here are some other common scenarios to consider:
Original Medicare + CHAMPVA
Let's say you have CHAMPVA and Medicare parts A and B, and you choose not to enroll in any other Medicare plans.
You'd pay the Medicare Part B premium, and Medicare would be your primary payer for all covered services. You could get prescriptions for 25% of the allowable amount at a pharmacy or completely covered if you use the Meds by Mail program using only CHAMPVA.
Original Medicare + Part D + CHAMPVA
You have CHAMPVA, Medicare parts A and B, and a Part D plan. You'd pay the Medicare Part B premium and the premium for your Part D plan.
Medicare would be the primary payer for services and prescriptions. CHAMPVA would pick up your copayments and coinsurance amounts.
Medicare Advantage + CHAMPVA
You have CHAMPVA and a Medicare Advantage plan that includes Part D coverage. You'd pay the Medicare Part B premium plus the premium for your Medicare Advantage plan.
Medicare would be the primary payer for your services and prescriptions. CHAMPVA would pay your copayments and coinsurance.
Ways to save on Medicare coverage
It's worth noting that you may be able to find Medicare Advantage or Medigap plans in your area with $0 premiums.
You can shop for plans in your area on the Medicare website and compare prices, networks, and covered services before you commit to a plan.
You can also look for savings on your Medicare coverage. You might qualify for programs to help lower your costs if you have a limited income. These programs include:
Extra Help, which lowers your prescription drug costs
Medicare savings programs, which can lower your costs for parts A and B
Ultimately, the right plan for you depends on your needs and your budget. You'll want to select a plan that includes:
the doctors you want to see
any prescriptions you take
any services you need
You can also search for premiums in your price range, and those with out-of-pocket costs you can manage.
How do I know if I'm eligible for CHAMPVA?
You're eligible for CHAMPVA if you're the dependent child or the current or widowed spouse of a veteran who meets one of these conditions:
is permanently and totally disabled from a service-related injury or disability
was permanently and totally disabled from a service-related injury or disability at the time of their death
died from service-related injury or disability
died during active duty
is not eligible for TRICARE
There is no premium cost for CHAMPVA coverage.
You can apply for CHAMPVA at any time. You'll need to send in an application along with documents that prove your eligibility. Depending on your circumstances, these might include:
service records
marriage records
birth certificates
You'll also need to send in information about any other insurance plan you currently have.
Your application will generally be processed in 3 to 6 weeks. If your application is approved, you will receive a CHAMPVA card in the mail. As soon as your card arrives, you can start using CHAMPVA coverage.
The takeaway
When you use CHAMPVA with Medicare, CHAMPVA acts as the secondary payer. CHAMPVA doesn't cover Medicare premiums but will cover most of your other out-of-pocket healthcare expenses. CHAMPVA pays 75% of the cost of most services.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.