CHAMPVA cost shares are the the portion of the CHAMPVA allowable amount that you are required to pay.
With few exceptions, you will pay something toward the cost of your medical care.
For covered outpatient services, CHAMPVA pays up to 75% of the allowable amount after the deductible has been met.
For inpatient service cost share, please refer to the chart below. There is no cost share for hospice or for services received through VA medical facilities. This includes services received at VA facilities under the CITI program or medications obtained through the MbM program.
CATASTROPHIC CAP To provide financial protection against the impact of a long-term illness or serious injury, there is an established an annual catastrophic cap of $3,000 per calendar year. This is the maximum out-of-pocket expense you and your family can incur for CHAMPVA-covered services and supplies in a calendar year. Credits to the catastrophic cap are applied starting January 1 of each year and run through December 31. If you reach the $3,000 limit, you or your family’s cost share for covered services is waived for the remainder of the calendar year, and CHAMPVA will pay 100% of the allowable amount.
COST SUMMARY—WHEN YOU HAVE NO OTHER HEALTH INSURANCE (OHI) BENEFITS DEDUCTIBLE YOU PAY
|Procedure||What You Pay|
|Ambulatory Surgery||25% of CHAMPVA allowable amount|
|Durable Medical Equipment (DME)||25% of CHAMPVA allowable amount|
|Emergency Room Charges||The charges will be included in the inpatient charge if – once you stabilize – you are admitted to the hospital. Your payment will then be based on “inpatient services.” If you are not admitted, your payment is based on “outpatient services.”|
|Inpatient Mental Health: High Volume and Residential Treatment Centers||25% of CHAMPVA allowable amount|
|Inpatient Mental Health: Low Volume||
|Inpatient Services: Diagnosis Related Groups (DRG) Based||
|Inpatient Services: Non-DRG Based & SNF (Skilled Nursing Facility)||25% of CHAMPVA allowable amount|
|Outpatient Services (e.g., doctor visits, lab/ radiology, home health, mental health services, skilled nursing visits, ambulance)||25% of CHAMPVA allowable amount after deductible|
|Pharmacy (retail)||25% of CHAMPVA allowable amount after deductible|
|Pharmacy Services (mail order–Meds by Mail or CITI)||Nothing|
|Professional Services||25% of CHAMPVA allowable amount after deductible|