How the CHAMPVA Supplement to Help Pay After CHAMPVA Pays
We will pay the Inpatient and Outpatient covered medical expenses once the Calendar Year plan deductible of $250 per person and $500 family maximum has been satisfied. Expenses incurred to satisfy the CHAMPVA Calendar Year Outpatient deductible cannot be used to satisfy the CHAMPVA Supplement Plan deductible.
Eligibility
Eligible Spouse: “Spouse” means your spouse who is under age 65 and a CHAMPVA benefits recipient, but not a spouse from whom you are legally separated or divorced. “Spouse” also means widow(er) if he or she is a member of the Participating Organization.
Spouses over age 65 are also eligible if documentation from the Social Security Administration certifying their non-entitlement to Medicare Part A benefits is submitted with their enrollment form.
Eligible dependent and unmarried children under age 18 (23 if a full-time college student) may also enroll.
How claims are filed with the Supplement EOB
All claims are filed first with CHAMPVA. After CHAMPVA has processed your claim, they will send you an Explanation of Benefit Statement (EOB). You will need to file a claim with the Supplement Plan only if the provider has not agreed to file one on your behalf. To file a supplement claim, simply write your certificate (member ID) number on the EOB and also, write “Pay Provider” if you would like the benefits paid directly to the provider, otherwise the benefits will be paid to you. Claims may be mailed to: GEA Administrator, 6110 Parkland Blvd., Cleveland, OH 44124 FAX: 800-311-3124
Limitations
Nervous, Mental, Emotional Disorder, Alcoholism, and Drug Addiction Limits The coverage provided under the Inpatient Benefit of the CHAMPVA Supplement plan for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to:
- 30 Inpatient treatment days for a Covered Person age 19 or older; or
- 45 Inpatient treatment days for a Covered Person under age 19; or
- 150 Inpatient treatment days in a CHAMPVA authorized Residential Treatment Center for a Covered Person under age 21; per Calendar Year.
This Inpatient limit is based on the number of days CHAMPVA normally provides each Calendar Year for such confinements. In rare instances, CHAMPVA extends these daily limits.
If this occurs, we will limit the number of days that we provide for such confinement to the lesser of:
- the number of days CHAMPVA pays for such Inpatient treatment during the Calendar Year; or
- 90 Inpatient days per Calendar Year.
FAQs
Q1. Is there a maximum limit on benefits (lifetime, annual, etc.)?
No maximum limit.
Q2. Will the plan cover amounts beyond what CHAMPVA allows?
The CHAMPVA Supplement does pay cost share amounts, however; it does not pay additional charges above CHAMPVA’s allowed amount.
Q3. Does the plan pay for services that aren’t covered by CHAMPVA?
No.
Q4. Will the plan pay the CHAMPVA outpatient deductible?
The CHAMPVA outpatient deductible is not covered by the CHAMPVA Supplement Plan. The CHAMPVA Supplement plan has a calendar year Plan deductible of $250 per person and $500 family maximum.
Q5. Can premium payments be increased? Under what conditions?
Premiums increase as a person moves from one 5-year age bracket to another (40, 45, 50, 55, 60). The company reserves the right to change premiums on a group wide basis to maintain the financial solvency of the plan.
Q6. What are the membership fees (annual, lifetime, etc.), if any, when you join the organization that sponsors the plan?
GEA $24 annual membership fees.
Q7. When does a spouse lose eligibility?
When there is a divorce or annulment from the qualifying Veteran sponsor. Eligibility for CHAMPVA ends at midnight of the effective date of the divorce decree or annulment.
Q8. When does a child lose eligibility?
At age 18, unless enrolled in an accredited school as a full-time student. At age 23 or loses full-time student status whichever comes first. He/she marries. A stepchild no longer lives in the household of the sponsor. An incapacitated dependent will continue coverage past age 18 or 23 as long as incapacity occurred while enrolled in the plan.
Q9. What happens when I reach age 65?
At age 65, eligibility under the CHAMPVA Supplement ends for members and their spouses. If at age 65, you are eligible for Medicare Part A and enrolled in Medicare Part B your CHAMPVA eligibility will continue. Medicare will be your primary carrier and you will have supplemental coverage under CHAMPVA for Life.
*Diagnosis-Related Groups (DRG)- An agreement between most hospitals and CHAMPVA to accept a fixed rate for inpatient care regardless of the billed amount.
Effective Date
Your coverage and that of your covered dependents becomes effective on the first day of the month following receipt of your enrollment form and first premium payment. If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital.
Deferred Effective Date: If on the date that You are to become covered under the Policy you are confined in a Hospital, your coverage will be deferred until the first day after You are discharged.
Deferred Effective Date (Dependent): If on the date that an Eligible Dependent is to become covered under the Policy he or she is confined at home, in a Hospital or elsewhere because of injury or sickness, coverage of such person will be deferred until the first day after he or she is discharged from the Hospital or place of confinement.
Pre-Existing Conditions Limitation
Any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6-month period preceding the effective date of his or her insurance will not be covered until the coverage has been in effect for 6 months. However, covered expenses due to new conditions will be covered immediately.
Confinement or Confined
Confinement or Confined means being an inpatient in a hospital (or skilled nursing facility) due to sickness or injury.
Skilled Nursing Facility
Does not mean:
a) a hospital; or
b) a place for rest, custodial care, or the aged; or
c) a place for the treatment of Mental Illness, drug addicts or alcoholics.
Exclusions
The Policy does not cover:
1) injury or sickness resulting from war or act of war, whether war is declared or undeclared;
2) intentionally self-inflicted injury;
3) suicide or attempted suicide, whether sane or insane.
Limitations
The Policy limits coverage for:
1) routine physical exams and immunizations, except when: a. rendered to a child up to 6 years from the child’s birth; or b. required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; 2) domiciliary or custodial care; 3) eye refractions and routine eye exams except when rendered to a child up to 6 years from the child’s birth;
4) eyeglasses and contact lenses; 5) prosthetic devices, except those covered by TRICARE; 6) cosmetic procedures, except those resulting from Sickness or Injury, while a Covered Person; 7) hearing aids; 8) orthopedic footwear; 9) care for the mentally or physically incapacitated if the care is required because of the mental or physical incapacitation; 10) drugs which do not require a prescription, except insulin; 11) dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; 12) any confinement, service, or supply that is not covered under TRICARE; 13) Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; 14) any routine newborn care except Well Baby Care; 15) expenses in excess of the TRICARE Catastrophic Cap; 16) that part of any Covered Expense which is in excess of the TRICARE Allowed Amount, except as otherwise stated in the plan benefits; 17) expenses which are paid in full by TRICARE; 18) any expense or portion thereof applied to the TRICARE Outpatient Deductible, except as otherwise stated in the plan benefits; 19) any part of a Covered Expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; 20) any claim under more than one of the TRICARE Supplement Plans. If a claim is payable under more than one plan or benefit, payment will only be made under the provision that provides the highest coverage.
Termination
Insured Person:
Coverage under the Policy will cease on the first to occur of:
1. the date The Policy terminates or the Participating Organization ceases to participate in The Policy; 2. the first day of the month following the date You are no longer in a class eligible for coverage; 3. the date The Policy no longer covers Your class; 4. the date the required premium is due but not paid, subject to the Individual Grace Period or Policyholder Grace Period; 5. the first day of the month following the date You Request We terminate Your coverage; 6. the date You cease to be covered under TRICARE; 7. the date You cease to be a Member of the Policyholder or a Participating Organization; 8. the date You become eligible for Medicare (unless You reside in an area where Medicare is not available. Coverage will not terminate until You reside in an area where Medicare is available); 9. the date You attain Age 65 unless You are not eligible for Medicare and can provide documentation of such from the Social Security Administration; unless continued under the Continuation Provisions. In addition to the events listed, if Your coverage was continued in accordance with the Widow or Widower’s Continuation provision, Your coverage will end on the Premium Due Date on or next following the date You remarry or enter or enter into a legal relationship recognized as a spouse. Termination of coverage will be without prejudice to any claims which originated before the effective date of termination.
Termination of Your Dependents’ Coverage:
Coverage for Your Dependent(s) will end on the earliest of the following:
1) the date The Policy terminates or the Participating Organization ceases to participate in The Policy; 2) the first day of the month following the date Your Dependent is no longer in a class eligible for coverage; 3) the date The Policy no longer covers Your Dependent’s class; 4) the date Your Dependent ceases to be covered under TRICARE; 5) the date the required premium is due but not paid, subject to the Individual Grace Period or Policyholder Grace Period; 6) the first day of the month following the date You cease to be a Member of the Policyholder or a Participating Organization; 7) the date We or the Policyholder terminate Dependent coverage; 8) the first date of the month following the date You Request We terminate Dependent coverage; 9) the date Your Dependent’s coverage ends in accordance with the Newborn or Newly Adopted Child Coverage provision; 10) the date Your Spouse attains Age 65 unless he or she is not eligible for Medicare and can provide documentation of such from the Social Security Administration; 11) the date Your Dependent becomes eligible for Medicare unless he or she resides in an area where Medicare is not available. Coverage will not terminate until Your Dependent resides in an area where Medicare is available; 12) the date Your Spouse no longer satisfies the definition of Spouse; or 13) the date Your child no longer satisfies the definition Dependent Child(ren); unless coverage is continued under the Continuation Provisions. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.
Important Notice:
Although the Plan works in all 50 States, the Plan is currently not available in CO, ME, NH, OR, UT, WA. * Services are covered up to the legal limit maximum.
- The Corporate Plan Sponsor: Government Employee Association (GEA)
- Plan Administer: SelmanCo
- Underwritten by: Harford Life and Accident Insurance Company, Harford, CT 06155
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