CHAMPVA Benefits & Long Term Care for the Elderly

CHAMPVA for Life Definition

CHAMPVA is a health insurance and care program provided by the U.S. Department of Veterans Affairs (VA) for spouses and / or children of veterans permanently disabled or killed in the line of duty. This program is for those who are not eligible for TRICARE. CHAMPVA for Life (CFL) is an extension of CHAMPVA benefits for those 65 years and older. CFL serves as the secondary payer to minimize out-of-pocket expenses by covering Medicare’s coinsurance and deductibles.

CHAMPVA is an acronym for Civilian Health and Medical Program of the Department of Veterans Affairs, and is administered by the Veterans Health Administration (VHA) Office of Community Care (OCC).

Long Term Care Coverage Overview

Like most health insurance, CHAMPVA for Life (CFL) is not a solution for long-term or non-medical aging care. However, it does help to cover some of the cost. Much like Medicare Supplemental insurance, CFL picks up where Medicare leaves off. CFL will pay co-insurance and deductibles but does not pay for monthly Medicare Part B premiums. What follows are CFL’s benefits for specific types of long-term care.

Assisted Living – CFL does not pay for assisted living or senior living care as defined by assistance with activities of daily living such as bathing, dressing, feeding or supervision of the cognitively impaired. This type of care is sometimes called custodial care and is not a covered benefit.

Skilled Nursing Home Care – CFL will pay for skilled nursing care to an extent. Like Medicare, there must be a medical condition that was treated in a hospital for three consecutive days, and the senior must be admitted to a skilled nursing facility within 30 days of hospital discharge. Medicare has a 100-day limit on skilled nursing, and CFL will be the primary payer after that 100-day limit, but will not cover the full amount. A co-payment in the amount of $150-$250 / day should be expected. Therefore, nursing home care is a large out-of-pocket expense and CHAMPVA is not a long-term solution.

Home Health Care – CHAMPVA will cover intermittent skilled care for a homebound person, but not personal / custodial care at home. A physician must declare skilled care to be medically necessary.

Adult Day Care – CFL does not pay for either medical care or supervision in adult day care centers.

Hospice – With prior authorization and coupled with Medicare’s benefits, CHAMPVA for Life will cover hospice care for terminally ill persons with a life expectancy of less than six months. Hospice care can be in-home or inpatient.

Alzheimer’s Care – CFL does cover inpatient mental health care which might be necessary for persons with advanced stages of dementia related to Alzheimer’s. Again, this is not a long term solution. Nor are CFL’s benefits different for individuals with Alzheimer’s or dementia specifically.

CHAMPVA for Life Qualifications

Some of the following eligibility requirements refer to the veteran, and others to their spouse.

Age – The spouses of veterans must be at least 65 years old to be eligible for CHAMPVA for Life. Seniors who turned 65 before June 5, 2001, require only Medicare Part A. One exception is seniors that turned 65 before June 5, 2001, and already had Medicare Part A & B. If this is the case, they must continue to keep both. Those who turn 65 on or after that date are also required to have both Medicare A & B. (Medicare Part A is Medicare’s hospital insurance and Medicare Part B is Medicare’s medical insurance.) 

Disabilities Requirements – The spouse of a veteran qualifies if the veteran meets one of the following three conditions:

1) Has a service-connected disability rating of 100%, meaning they are permanently and totally disabled or died with that rating.
2) Has died from a VA-rated service connected disability.
3) Has died in the line of duty. Note that often these individuals are eligible for TRICARE and if so that disqualifies them for CHAMPVA.

Marital Status – A spouse will lose their eligibility for CHAMPVA for Life if they become divorced from the veteran. A widow or widower who remarries prior to the age of 55 will also lose their eligibility. For those who remarried before 55 years of age, should the re-marriage terminate, they would then become eligible again.

Veteran Status – Veterans cannot have been dishonorably discharged.  Also read the Disability Requirements above.

Factors Not Affecting Eligibility – The financial resources and monthly income of the spouse of a veteran or of the veteran him- or herself does not impact eligibility. Nor is their geographic location or state of residence a factor in determining eligibility. 

Benefits

The types of care that are covered are discussed in the Overview Section above.

In addition to care, CFL also covers some durable medical equipment (DME) and home care supplies. The reasoning behind what is and what is not covered is not intuitive to the policyholder. One should always check with CFL directly to determine if an item will be covered. All DME and supply purchases must be medically necessary as determined by a doctor, and larger purchases require pre-authorization.

Benefit payments are made directly to the medical providers. Veterans at no point receive cash or checks from CHAMPV for Life.

Costs

There are no enrollment fees or monthly premiums for CFL. However, the spouses of veterans must purchase Medicare Part B and pay those monthly premiums in order to be eligible for CFL. In addition, they are responsible for co-pays.

How to Apply

If the individual is already a CHAMPVA beneficiary, before the age of 65, they will need to provide CHAMPVA a copy of their Medicare card that shows their enrollment in Medicare Parts A & B. They also are required to provide information about any other health insurance under which they are covered by completing VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification. CHAMPVA will reach out 90 days before the participant’s 65th birthday through the mail with instructions.

If the individual is not a CHAMPVA beneficiary, then they must complete an application, a form detailing any other health insurance they have, and provide a copy of their Medicare Part A & B card. Providing copies of optional documents, such as marriage licenses and terminations, or the veteran’s VBA disability rating, can greatly accelerate the processing time. If all of the proper documentation is provided, including optional documentation, the enrollment process generally takes approximately six weeks. If not, processing can take as long as eight months.  

Detailed information regarding the application process is available on the VA.gov website here.