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M21-1, Part IX, Subpart i, Chapter 4 – Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

Overview

In This Chapter

 This chapter contains the following topics:

1.  General Information About CHAMPVA

 


Introduction

This topic contains general information about CHAMPVA, including

Change Date

July 26, 2018

IX.i.4.1.a.  General Description of CHAMPVA

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) provides reimbursement for most medical expenses of eligible survivors and dependents, such as the cost of
  • inpatient care
  • outpatient care
  • mental health treatment
  • prescription medication
  • skilled nursing care, and
  • durable medical equipment.

IX.i.4.1.b.  Eligibility Requirements for CHAMPVA

The eligibility requirements for CHAMPVA are set forth in 38 U.S.C. 1781.
To be eligible for CHAMPVA, an individual must be
  • the spouse or child of a Veteran whom the Department of Veterans Affairs (VA) has rated as permanently and totally (100-percent) disabled based on a service-connected (SC) disability or disabilities
  • the surviving spouse or child of a Veteran who
    • died from an SC disability, or
    • at the time of death, was rated permanently and totally (100-percent) disabled, or
  • the surviving spouse or child of a service member who died, not as a result of his/her own willful misconduct, in the line of duty.
Note:  VA considers a total disability rating “permanent” if it has been in place for the time periods set forth in 38 U.S.C. 1318.  Accordingly, a grant of entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C. 1318 renders surviving dependents eligible for CHAMPVA.

IX.i.4.1.c.  Entitlement to CHAMPVA After Termination of a Remarriage

During the period October 1, 1998, through November 30, 1999, a surviving spouse who regained eligibility for DIC under 38 U.S.C. 1311(e), either upon termination of a remarriage by death, divorce, or annulment, or upon the cessation of living with another person and holding himself or herself out openly to the public as that person’s spouse, did not regain eligibility for VAOPGCPREC 13-1998.
The Veterans’ Millennium Health Care and Benefits Act, Public Law (PL) 106-117, reinstated the entitlement of surviving spouses to ancillary benefits, such as CHAMPVA, effective December 1, 1999.  Entitlement to these benefits was not made retroactive.

IX.i.4.1.d.  Entitlement to CHAMPVA for Surviving Spouses That Remarry After Age 55

The Veterans Benefits Act of 2002, PL 107-330, which went into effect February 4, 2003, provides for the retention of CHAMPVA eligibility for surviving spouses who remarry after age 55.  For those individuals who remarried after age 55 but prior to the effective date of this law, eligibility may be established only if an application was received between February 5, 2002, and February 4, 2003.

2.  RO Responsibilities With Regard to CHAMPVA


Introduction

This topic contains information on RO responsibilities with regard to CHAMPVA, including

Change Date

July 26, 2018

IX.i.4.2.a.  Requests for Information Regarding CHAMPVA Eligibility

If the Veterans Health Administration’s (VHA’s) Health Administration Center (HAC) requires information to determine the eligibility of a claimant for CHAMPVA, it routes a request for the information to the appropriate regional office (RO) through the HAC website.
Note:  If a qualifying disability was certified to VHA during the Veteran’s lifetime, HAC does not routinely make further requests concerning
  • the status of disability as of the date of death, or
  • whether or not death was SC.

IX.i.4.2.b.  Who Is Responsible for Responding to Requests for Information Regarding CHAMPVA Eligibility

Veterans Service Centers (VSCs) are responsible for processing requests from HAC for information regarding CHAMPVA eligibility that involve a living Veteran’s dependent(s).  Pension management centers (PMCs) are responsible for processing requests involving a Veteran’s survivor(s).
Designated employees within each VSC and PMC are responsible for
  • checking the HAC website on a regular basis, and
  • responding to pending requests.
Important:
  • Newly designated employees must request access to the HAC websiteby sending an e-mail to the HAC mailbox.
  • The HAC mailbox is not secure.  Do not
    • send e-mails to the mailbox containing personally identifiable information, or
    • use the mailbox for any purpose other than requesting access to the HAC website.

IX.i.4.2.c.  Instructions for Responding to Requests for Information Regarding CHAMPVA Eligibility

Follow the steps in the table below to process requests from HAC for information it requires to determine a claimant’s eligibility for CHAMPVA.
Step
Action
1
Review the cases from the HAC website that apply to the VSC or PMC.
2
Check all necessary VA systems to determine whether the requested eligibility information is available.
3
Is HAC requesting verification of the claimant’s relationship to a Veteran?
  • If yes, proceed to the next step.
  • If no, proceed to Step 5.
4
Use the criteria contained in 38 CFR 3.50 through 38 CFR 3.58 to establish the relationship of the claimant(s) to the Veteran.
5
Is HAC requesting verification that a Veteran’s death or disability renders the claimant eligible for CHAMPVA?
  • If yes, proceed to the next step.
  • If no, proceed to Step 7.
6
Respond to the request by stating whether
7
Ensure all required fields are complete on either
  • VA Form 10-3884A, Automated Exchange of Beneficiary Information and Request for Eligibility Data, or
  • VA Form 10-3884B, Exchange of Beneficiary Information and Request for Eligibility Data – CHAMPVA.
Important:  If the elements of the HAC request cannot be established, annotate the form to reflect this fact.
Note:  The forms referenced in this step are only available on the HAC website.
8
Return the form either by fax or mail to the HAC Eligibility Unit at the following address:
Health Administration Center (741/PASS)
Eligibility Unit
PO Box 469028
Denver, CO 80246-9028
Fax: (303) 370-7710
Note:  These alternative fax numbers may also be used:
  • (303) 331-7809, or
  • (303) 331-7820.
Notes:
  • HAC updates its website daily, except for holidays.
  • If HAC receives conflicting evidence/information in response to a request, it may e-mail the designated RO employee for clarification.  The RO employee is responsible for
    • clarifying any discrepant information in VA systems, and
    • responding to HAC using VA Form 10-3884A or VA Form 10-3884B.

IX.i.4.2.d.  Who Is Responsible for Notifying Claimants and Handling Disagreements

HAC is solely responsible for notifying claimants of a decision regarding their entitlement to CHAMPVA.
HAC and the Board of Veterans’ Appeals have sole jurisdiction over legacy appeals and requests for decision review under 38 CFR 3.2500 pertaining to CHAMPVA entitlement determinations.

IX.i.4.2.e.  Notifying Survivors of Their Potential Entitlement to CHAMPVA

When notifying survivors of an initial award of DIC, include as an attachment to the decision notice VA Form 21-8765, Service-Connected Death Award Attachment.  This form describes the eligibility requirements for CHAMPVA and contains instructions for applying for this benefit.

IX.i.4.2.f.  Notifying HAC of Changes in a Dependent’s Status

Notify the HAC Eligibility Unit if the status of an individual as a dependent (who is or was eligible for CHAMPVA)
  • unexpectedly ends (from a date earlier than the date provided on the VA Form 10-3884A or VA Form 10-3884B referenced in M21-1, Part IX, Subpart i, 4.2.c), or
  • is extended because the dependent (a child) remains in school beyondthe date provided on the VA Form 10-3884A or VA Form 10-3884Breferenced in M21-1, Part IX, Subpart i, 4.2.c.
Notes:
  • Fax the notice to the HAC Eligibility Unit, using one of the fax numbers referenced in Step 8 of the procedure outlined in M21-1, Part IX, Subpart i, 4.2.c.
  • Include in the notice the
    • dependent’s name
    • date and nature of the change in status, and
    • Veteran’s name and file number.

IX.i.4.2.g.  Notifying HAC After Discontinuing a Veteran’s Permanent and Total Disability Rating

After promulgating a rating decision that discontinues a Veteran’s permanent and total disability rating, fax a copy of the decision to the HAC Eligibility Unit, using one of the fax numbers referenced in Step 8 of the procedure outlined in M21-1, Part IX, Subpart i, 4.2.c.
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