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.
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.
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, new conditions will be covered immediately.
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
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.
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?
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.
The Plan is currently not available in CO, ME, NH, OR, WA.
- The Corporate Plan Sponsor: Government Employee Association (GEA)
- Plan Administer: Selman and Company
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