M21-1 Manual / Part XIII, Subpart i, Chapter 3, Section I

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Eligibility Determinations

M21-1, Part XIII, Subpart i, Chapter 3, Section I

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	General Information About CHAMPVA
2	Regional Office (RO) Responsibilities With Regard to CHAMPVA

1. General Information About CHAMPVA

Introduction

This topic contains general information about CHAMPVA, including

general description of CHAMPVA
eligibility requirements for CHAMPVA, and
entitlement to CHAMPVA
- after termination of a remarriage, and
- for surviving spouses that remarry after age 55.

Change Date

January 11, 2021

XIII.i.3.H.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.

XIII.i.3.H.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 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 disabled, or
- the surviving spouse or child of a service member who died in the line of duty, not as a result of willful misconduct.
Notes:
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 a surviving spouse and/or child(ren) eligible for CHAMPVA.
Eligibility for CHAMPVA does not exist if a permanent and total (P&T) disability rating, or a rating of service connection (SC) for the cause of death, is based entirely or partially on a grant of SC under 38 U.S.C. 1151 or 38 U.S.C. 1160 for an otherwise non-service-connected disability or disabilities.

XIII.i.3.H.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 oneself 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.

XIII.i.3.H.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

requests for information regarding CHAMPVA eligibility
responsibility for
- responding to requests for information regarding CHAMPVA eligibility, and
- notifying claimants and handling disagreements, and
notifying
- Veterans of dependents’ potential entitlement to CHAMPVA
- survivors of potential entitlement to CHAMPVA
- the Health Administration Center (HAC) of changes in a dependent’s status, and
- HAC after discontinuing a Veteran’s P&T disability rating.

Change Date

January 11, 2021

XIII.i.3.H.2.a. Requests for Information Regarding CHAMPVA Eligibility

If the Veterans Health Administration’s Health Administration Center (HAC) requires information to determine the eligibility of a claimant for CHAMPVA that it cannot obtain from Share or the Veterans Benefits Management System, HAC emails a request for the information to the appropriate regional office (RO).

XIII.i.3.H.2.b. Responsibility for Responding to Requests for Information Regarding CHAMPVA Eligibility

Veterans Service Centers are responsible for processing requests from HAC for information regarding CHAMPVA eligibility that involve a living Veteran’s dependent(s). Pension management centers are responsible for processing requests involving a Veteran’s survivor(s).

XIII.i.3.H.2.c. Responsibility for Notifying Claimants and Handling Disagreements

HAC is solely responsible for notifying claimants of a decision regarding the 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.

XIII.i.3.H.2.d. Notifying Veterans of Dependents’ Potential Entitlement to CHAMPVA

When claims processors use Redesigned Automated Decision Letter (RADL) to generate a decision notice regarding a VA decision to rate a Veteran permanently and totally disabled due to SC disabilities, RADL automatically inserts text into the notice that

informs the Veteran that dependents may be eligible for benefits under CHAMPVA, and
provides instructions for obtaining more information about CHAMPVA.

When using Personal Computer Generated Letters to generate a decision notice for the same type of decision, claims processors must select the following paragraph for insertion into the decision notice: Your dependents may be eligible for benefits under CHAMPVA. CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain healthcare and supplies with eligible beneficiaries. To be eligible for the CHAMPVA program, a dependent must be the spouse or child of a veteran who is permanently and totally disabled from a service-connected disability. The Health Administration Center in Denver, Colorado, administers the CHAMPVA program. You should call 1‑800‑733‑8387 if additional information is needed.Important: The text in the preceding paragraph is not an exact match of the text RADL automatically inserts; claims processors do not need to add this text to decision notices generated using RADL.

XIII.i.3.H.2.e. Notifying Survivors of Potential Entitlement to CHAMPVA

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

XIII.i.3.H.2.f. Notifying HAC of Changes in a Dependent’s Status

Notify the HAC Eligibility Unit by fax ((303)-331-7809) or email (CBOPCEEVSprvs@va.gov) if the status of an individual as a dependent (who is or was eligible for CHAMPVA)

unexpectedly ends, or
is extended because the dependent (a child) remains in school.

Note: Include in the notice the
dependent’s name
date and nature of the change in status, and
Veteran’s name and file number.

XIII.i.3.H.2.g. Notifying HAC After Discontinuing a Veteran’s P&T Disability Rating

After promulgating a rating decision that discontinues a Veteran’s P&T disability rating, fax a copy of the decision to the HAC Eligibility Unit, using the fax number (303) 331-7809.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part XIII, Subpart i, Chapter 3, Section I (U.S. government work, reproduced for reference). Browse all sections →