38 C.F.R. §§ 17.270–17.278

9 sections in range

§17.270. General provisions and definitions.

38 C.F.R. § 17.270

(a)

Overview of CHAMPVA. CHAMPVA is the Civilian Health and Medical Program of the Department of Veterans Affairs (VA). Generally, CHAMPVA furnishes medical care in the same or similar manner, and subject to the same or similar limitations, as medical care furnished to certain dependents and survivors of active duty and retired members of the Armed Forces under chapter 55 of title 10, United States Code (CHAMPUS), commonly referred to as the TRICARE Select plan. Under CHAMPVA, VA shares the cost of medically necessary services and supplies with eligible beneficiaries within the 50 United States, the District of Columbia, the U.S. territories, and abroad. Under CHAMPVA, medical services and supplies may be provided as follows:

(1)

By an authorized non-VA provider.

(2)

By a VA provider at a VA facility, on a resource-available basis through the CHAMPVA In-house Treatment Initiative (CITI) to CHAMPVA beneficiaries who are not also eligible for Medicare.

(3)

Through VA Medications by Mail (MbM).

(i)

Only CHAMPVA beneficiaries who do not have any other type of health insurance that pays for prescriptions, including Medicare Part D, may use MbM.

(ii)

Smoking cessation pharmaceutical supplies will only be provided through MbM and only to CHAMPVA beneficiaries that are not also eligible for Medicare.

(b)

Definitions. The following definitions apply to CHAMPVA (§§ 17.270 through 17.278):

Accepted assignment refers to the action of an authorized non-VA provider who accepts responsibility for the care of a CHAMPVA beneficiary and thereby agrees to accept the CHAMPVA determined allowable amount as full payment for services and supplies rendered to the beneficiary. (The provider's acceptance of the CHAMPVA determined allowable amount extinguishes the beneficiary's payment liability to the provider with the exception of applicable cost-shares and deductibles.)

Authorized non-VA provider means an individual or institutional non-VA provider of CHAMPVA-covered medical services and supplies that meets any of the following criteria:

(i)

Is licensed or certified by a state to provide the medical services and supplies; or

(ii)

Where a state does not offer licensure or certification, is otherwise certified by an appropriate national or professional association that sets standards for the specific medical provider.

Calendar year means January 1 through December 31.

CHAMPVA beneficiary means a person enrolled under § 17.271.

CHAMPVA-covered services and supplies mean those medical services and supplies that are medically necessary and appropriate for the treatment of a condition and that are not specifically excluded under § 17.272(a)(1) through (84).

CHAMPVA determined allowable amount has the meaning set forth in § 17.272(b)(1).

CHAMPVA In-house Treatment Initiative (CITI) means the initiative under 38 U.S.C. 1781(b) under which participating VA medical facilities provide medical services and supplies to CHAMPVA beneficiaries who are not also eligible for Medicare, subject to availability of space and resources.

Child has the definition established in 38 U.S.C. 101.

Claim means a request by an authorized non-VA provider or by a CHAMPVA beneficiary for payment or reimbursement for medical services and supplies provided to a CHAMPVA beneficiary.

Fiscal year means October 1 through September 30.

Medications by Mail (MbM) means the initiative under which VA provides outpatient prescription medications through the mail to CHAMPVA beneficiaries.

Other health insurance (OHI) means health insurance plans or programs (including Medicare) or third-party coverage that provide coverage to a CHAMPVA beneficiary for expenses incurred for medical services and supplies.

Payer refers to OHI, as defined in this section, that is obligated to pay for CHAMPVA-covered medical services and supplies. In a situation in which, in addition to CHAMPVA, one or more payers is/are responsible to pay for such services and supplies (i.e., a “double coverage” situation), there would be a primary payer (i.e., the payer obligated to pay first), secondary payer (i.e., the payer obligated to pay after the primary payer), etc. In double coverage situations, CHAMPVA would be the last payer.

Service-connected has the definition established in 38 U.S.C. 101.

Spouse refers to a person who is married to a veteran and whose marriage is valid as determined under 38 U.S.C. 103(c).

Surviving spouse refers to a person who was married to and is the widow(er) of a veteran as determined under 38 U.S.C. 103(c).

(c)

Discretionary authority. When it is determined to be in the best interest of VA, VA may waive any requirement in §§ 17.270 through 17.278, except any requirement specifically set forth in 38 U.S.C. 1781, or otherwise imposed by statute. Such discretionary authority would be used only under very unusual and limited circumstances and not to deny any individual any right, benefit, or privilege provided to him or her by statute or these regulations. Any such waiver will apply only to the individual circumstance or case involved and will in no way be construed to be precedent-setting.

Notes, amendments, and revision history

Amendments

[87 FR 41599, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Authority: 38 U.S.C. 501, and as noted in specific sections. Section 17.30 also issued under 38 U.S.C. 1701. Section 17.32 also issued under 38 U.S.C. 7331-7334. Section 17.35 is also issued under 38 U.S.C. 1724. Section 17.37 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1720J, 1721, 1722. Section 17.38 is also issued under 38 U.S.C. 1701 and 1703. Section 17.43 also issued under 38 U.S.C. 109, 1784, 8111, and 8153. Section 17.44 also issued under E.O. 10122, 15 FR 2173, 3 CFR, 1949-1953 Comp., p. 313, E.O. 10400, 17 FR 8648, 3 CFR, 1949-1953 Comp., p. 900, and E.O. 11733, 38 FR 20431, 3 CFR, 1971-1975 Comp., p. 792. Section 17.46 is also issued under 38 U.S.C. 1710. Section 17.47 is also issued under 38 U.S.C. 1701, 1710, 1721, 1722, 1729, 3104(a)(9), 7333, Pub. L. 99-272; 42 U.S.C. 1396 et seq. Section 17.52 is also issued under 38 U.S.C. 1701, 1703, 1710, 1712, and 3104. Section 17.55 is also issued under 38 U.S.C. 513, 1703, and 1728. Section 17.56 is also issued under 38 U.S.C. 1703 and 1728. Sections 17.61 through 17.74 are also issued under 38 U.S.C. 1730. Section 17.86 also issued under 38 U.S.C. 1785. Section 17.101 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1721, 1722, 1729. Section 17.102 also issued under 38 U.S.C. 109, 1711, 1729, 1784, 1784A, 1785, 8111, 8153. Section 17.105 is also issued under 38 U.S.C. 501, 1721, 1722A, 1724, and 1725A. Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 1725A, 1720J, and 1730A. Section 17.110 is also issued under 38 U.S.C. 501, 1703, 1710, 1720D, 1720J, 1722A, and 1730A. Section 17.111 is also issued under 38 U.S.C. 101(28), 501, 1701(7), 1703, 1710, 1710B, 1720B, 1720D, 1722A, and 1730A. Section 17.125 is also issued under 38 U.S.C. 7304. Sections 17.156 and 17.157 are also issued under 38 U.S.C. 3901 and 3902. Section 17.158 is also issued under 38 U.S.C. 3902 and 3903. Section 17.169 is also issued under 38 U.S.C. 1712C. Sections 17.243 through 17.248 are also issued under 38 U.S.C. 7302 note. Sections 17.270, and 17.272 through 17.277 are also issued under 38 U.S.C. 1781. Section 17.271 is also issued under 38 U.S.C. 1720G(a)(7)(A) and 1781. Section 17.278 is also issued under 38 U.S.C. 1781 and 42 U.S.C. 2651. Section 17.279 is also issued under 5 U.S.C. 552 and 552a; 38 U.S.C. 1781, 5701, and 7332. Sections 17.380, 17.390 and 17.412 are also issued under sec. 260, Pub. L. 114-223, 130 Stat. 857, and sec. 236, Public Law 115-141, 132 Stat. 348, and sec. 236, div. J, Pub. L 115-141, 132 Stat. 348. Section 17.395 is also issued under 38 U.S.C. 1788. Section 17.410 is also issued under 38 U.S.C. 1787. Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, and 7403. Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). Section 17.450 is also issued under 38 U.S.C. 1703E. Sections 17.525 through 17.531 are also issued under 38 U.S.C. 7691 through 7697. Sections 17.545 through 17.553 are also issued under 38 U.S.C. 7698, 7699, 7699A, and 7699B. Sections 17.600 through 17.612 are also issued under 38 U.S.C. 7601-7619, 7633, 7634, 7636, and sec. 104(a), div. V, Public Law 117-328. Sections 17.613 through 17.618 are also issued under Pub. L. 115-182, sec. 304. Sections 17.640 and 17.647 are also issued under sec. 4, Pub. L. 114-2, 129 Stat. 30. Sections 17.641 through 17.646 are also issued under 38 U.S.C. 501(a) and sec. 4, Pub. L. 114-2, 129 Stat. 30. Section 17.655 also issued under 38 U.S.C. 501(a), 7304, 7405. Sections 17.1200 through 17.1230 are also issued under 38 U.S.C. 1720J. Section 17.3200 also issued under 38 U.S.C. 1162, 1701, 1707, 1710, 1714, 1717, 3901. Section 17.3210 also issued under 38 U.S.C. 1701, 1710. Section 17.3220 also issued under 38 U.S.C. 1701(6)(F), 1710. Section 17.3230 also issued under 38 U.S.C. 1701(6)(F), 1710, 1714(a). Section 17.3250 also issued under 38 U.S.C. 1701, 1710, 1725, 1728. Section 17.3500 is also issued under Pub. L. 102-139 sec. 101. Sections 17.4000 through 17.4040 also issued under 38 U.S.C. 1703, 1703B, and 1703C. Section 17.4100 et seq. is also issued under 38 U.S.C. 1703A. Section 17.4600 is also issued under 38 U.S.C. 1725A and 1730A.

Amendments

[87 FR 41599, July 13, 2022]

§17.271. Eligibility.

38 C.F.R. § 17.271

(a)

General entitlement. The following persons are eligible for CHAMPVA benefits provided that they are not eligible under Title 10 for the TRICARE Program or Part A of Title XVIII of the Social Security Act (Medicare) except as provided in paragraph (b) of this section.

(1)

The spouse or child of a veteran who has been adjudicated by VA as having a permanent and total service-connected disability;

(2)

The surviving spouse or child of a veteran who died as a result of an adjudicated service-connected condition(s); or who at the time of death was adjudicated permanently and totally disabled from a service-connected condition(s);

(3)

The surviving spouse or child of a person who died on active military service and in the line of duty and not due to such person's own misconduct;

(4)

An individual designated as a Primary Family Caregiver, under 38 CFR 71.25(f), who is not entitled to care or services under a health-plan contract (as defined in 38 U.S.C. 1725(f)(2)); and

(5)

An eligible child who is pursuing a full-time course of instruction approved under 38 U.S.C. Chapter 36, and who incurs a disabling illness or injury while pursuing such course (between terms, semesters or quarters; or during a vacation or holiday period) that is not the result of his or her own willful misconduct and that results in the inability to continue or resume the chosen program of education must remain eligible for medical care until:

(i)

The end of the six-month period beginning on the date the disability is removed; or

(ii)

The end of the two-year period beginning on the date of the onset of the disability; or

(iii)

The twenty-third birthday of the child, whichever occurs first.

(b)

CHAMPVA and Medicare entitlement.

(1)

Individuals under age 65 who are entitled to Medicare Part A and enrolled in Medicare Part B, retain CHAMPVA eligibility as secondary payer to Medicare Parts A and B, Medicare supplemental insurance plans, and Medicare HMO plans.

(2)

Individuals age 65 or older, and not entitled to Medicare Part A, retain CHAMPVA eligibility.

(3)

Individuals age 65 on or after June 5, 2001, who are entitled to Medicare Part A and enrolled in Medicare Part B, are eligible for CHAMPVA as secondary payer to Medicare Parts A and B, Medicare supplemental insurance plans, and Medicare HMO plans for services received on or after October 1, 2001.

(4)

Individuals age 65 or older prior to June 5, 2001, who are entitled to Medicare Part A and who have not purchased Medicare Part B, are eligible for CHAMPVA as secondary payer to Medicare Part A and any other health insurance for services received on or after October 1, 2001.

(5)

Individuals age 65 or older prior to June 5, 2001, who are entitled to Medicare Part A and who have purchased Medicare Part B must continue to carry Part B to retain CHAMPVA eligibility as secondary payer for services received on or after October 1, 2001.

Notes, amendments, and revision history

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 67 FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, 2008; 87 FR 41600, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 67 FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, 2008; 87 FR 41600, July 13, 2022]

§17.272. Benefits limitations/exclusions.

38 C.F.R. § 17.272

(a)

Benefits cover allowable expenses for medical services and supplies that are medically necessary and appropriate for the treatment of a condition and that are not specifically excluded from program coverage. Covered benefits may have limitations. The fact that a physician may prescribe, order, recommend, or approve a service or supply does not, of itself, make it medically necessary or make the charge an allowable expense, even though it is not listed specifically as an exclusion. The following are specifically excluded from program coverage:

(1)

Services, procedures or supplies for which the beneficiary has no legal obligation to pay, or for which no charge would be made in the absence of coverage under a health benefits plan.

(2)

Services and supplies required as a result of an occupational disease or injury for which benefits are payable under workers' compensation or similar protection plan (whether or not such benefits have been applied for or paid) except when such benefits are exhausted and the services and supplies are otherwise not excluded from CHAMPVA coverage.

(3)

Services and supplies that are paid directly or indirectly by a local, State or Federal government agency, including court-ordered treatment. In the case of the following exceptions, CHAMPVA assumes primary payer status:

(i)

Medicaid.

(ii)

State Victims of Crime Compensation Programs.

(iii)

Indian Health Service.

(iv)

CHAMPVA supplemental policies.

(4)

Services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered condition (including mental disorder) or injury.

(5)

Radiology, laboratory, and pathological services and machine diagnostic testing not related to a specific illness or injury or a definitive set of symptoms.

(6)

Services and supplies above the appropriate level required to provide necessary medical care.

(7)

Services and supplies related to an inpatient admission primarily to perform diagnostic tests, examinations, and procedures that could have been and are performed routinely on an outpatient basis.

(8)

Postpartum inpatient stay of a mother for purposes of staying with the newborn infant (primarily for the purpose of breast feeding the infant) when the infant (but not the mother) requires the extended stay; or continued inpatient stay of a newborn infant primarily for purposes of remaining with the mother when the mother (but not the newborn infant) requires extended postpartum inpatient stay.

(9)

Therapeutic absences from an inpatient facility or residential treatment center (RTC).

(10)

Custodial care.

(11)

Inpatient stays primarily for domiciliary care purposes.

(12)

Inpatient stays primarily for rest or rest cures.

(13)

Services and supplies provided as a part of, or under, a scientific or medical study, grant, or research program.

(14)

Services and supplies not provided in accordance with accepted professional medical standards or related to experimental or investigational procedures or treatment regimens.

(15)

Services or supplies prescribed or provided by a member of the beneficiary's immediate family, or a person living in the beneficiary's or sponsor's household.

(16)

Services and supplies that are (or are eligible to be) payable under another medical insurance or program, either private or governmental, such as coverage through employment or Medicare.

(17)

Services or supplies subject to preauthorization (see § 17.273) that were obtained without the required preauthorization; and services and supplies that were not provided according to the terms of the preauthorization.

(18)

Inpatient stays primarily to control or detain a runaway child, whether or not admission is to an authorized institution.

(19)

Services and supplies (to include prescription medications) in connection with cosmetic surgery which is performed to primarily improve physical appearance or for psychological purposes or to restore form without correcting or materially improving a bodily function.

(20)

Electrolysis.

(21)

Dental care with the following exceptions—

(i)

Dental care that is medically necessary in the treatment of an otherwise covered medical condition, is an integral part of the treatment of such medical condition, and is essential to the control of the primary medical condition.

(ii)

Dental care required in preparation for, or as a result of, radiation therapy for oral or facial cancer.

(iii)

Gingival Hyperplasia.

(iv)

Loss of jaw substance due to direct trauma to the jaw or due to treatment of neoplasm.

(v)

Intraoral abscess when it extends beyond the dental alveolus.

(vi)

Extraoral abscess.

(vii)

Cellulitis and osteitis which is clearly exacerbating and directly affecting a medical condition currently under treatment.

(viii)

Repair of fracture, dislocation, and other injuries of the jaw, to include removal of teeth and tooth fragments only when such removal is incidental to the repair of the jaw.

(ix)

Treatment for stabilization of myofascial pain dysfunction syndrome, also referred to as temporomandibular joint disorder (TMD). Authorization is limited to initial imaging such as radiographs, Computed Tomography, or Magnetic Resonance Imaging; up to four office visits; and the construction of an occlusal splint.

(x)

Total or complete ankyloglossia.

(xi)

Adjunctive dental and orthodontic support for cleft palate.

(xii)

Prosthetic replacement of jaw due to trauma or cancer.

(22)

Nonsurgical treatment of obesity or morbid obesity for dietary control or weight reduction (with the exception of gastric bypass, gastric stapling, or gastroplasty procedures in connection with morbid obesity when determined to be medically necessary) including prescription medications.

(23)

Services and supplies related to transsexualism or other similar conditions such as gender dysphoria (including, but not limited to, intersex surgery and psychotherapy, except for ambiguous genitalia which was documented to be present at birth).

(24)

Sex therapy, sexual advice, sexual counseling, sex behavior modification, psychotherapy for mental disorders involving sexual deviations (e.g., transvestic fetish), or other similar services, and any supplies provided in connection with therapy for sexual dysfunctions or inadequacies.

(25)

Removal of corns or calluses or trimming of toenails and other routine foot care services, except those required as a result of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes.

(26)

Surgery to reverse voluntary surgical sterilization procedures.

(27)

Services and supplies related to artificial insemination (including semen donors and semen banks), in vitro fertilization, gamete intrafallopian transfer and all other noncoital reproductive technologies.

(28)

Nonprescription contraceptives, except those non-prescription contraceptives used as emergency contraceptives.

(29)

Diagnostic tests to establish paternity of a child; or tests to determine sex of an unborn child.

(30)

Preventive care (such as employment-requested physical examinations and routine screening procedures). The following exceptions apply, including but not limited to:

(i)

Well-child care from birth to age six. Periodic health examinations designed for prevention, early detection, and treatment of disease are covered to include screening procedures, immunizations, and risk counseling. The following services are payable when required as part of a well-child care program and when rendered by the attending pediatrician, family physician, or a pediatric nurse practitioner.

(A)

Newborn examination, heredity and metabolic screening, and newborn circumcision.

(B)

Periodic health supervision visits intended to promote optimal health for infants and children to include the following services:

(1) History and physical examination.

(2) Vision, hearing, and dental screening.

(3) Developmental appraisal to include body measurement.

(4) Immunizations as recommended by the Centers for Disease Control (CDC) and Prevention Advisory Committee on Immunization Practices.

(5) Pediatric blood lead level test.

(6) Tuberculosis screening.

(7) Blood pressure screening.

(8) Measurement of hemoglobin and hematocrit for anemia.

(9) Urinalysis.

(C)

Additional services or visits required because of specific findings or because the particular circumstances of the individual case are covered if medically necessary and otherwise authorized for benefits under CHAMPVA.

(ii)

Rabies vaccine following an animal bite.

(iii)

Tetanus vaccine following an accidental injury.

(iv)

Rh immune globulin.

(v)

Cervical cancer screening.

(vi)

Breast cancer screening.

(vii)

Genetic testing and counseling determined to be medically necessary.

(viii)

Chromosome analysis in cases of habitual abortion or infertility.

(ix)

Gamma globulin.

(x)

School-required physical examinations for beneficiaries through age 17 that are provided on or after October 1, 2001.

(xi)

Colorectal cancer screening.

(xii)

Prostate cancer screening.

(xiii)

Annual physical examination.

(xiv)

Vaccinations/immunizations.

(31)

Chiropractic and naturopathic services.

(32)

Counseling services that are not medically necessary in the treatment of a diagnosed medical condition (such as educational counseling; vocational counseling; and counseling for socioeconomic purposes, stress management, life style modification, etc.).

(33)

Acupuncture, whether used as a therapeutic agent or as an anesthetic.

(34)

Hair transplants, wigs, or hairpieces, except that benefits may be extended for one wig or hairpiece per beneficiary (lifetime maximum) when the attending physician certifies that alopecia has resulted from treatment of malignant disease and the beneficiary certifies that a wig or hairpiece has not been obtained previously through the U.S. Government (including the Department of Veterans Affairs). The wig or hairpiece benefit does not include coverage for the following:

(i)

Maintenance, wig or hairpiece supplies, or replacement of the wig or hairpiece.

(ii)

Hair transplant or any other surgical procedure involving the attachment of hair or a wig or hairpiece to the scalp.

(iii)

Any diagnostic or therapeutic method or supply intended to encourage hair growth.

(35)

Self-help, academic education or vocational training services and supplies.

(36)

Exercise equipment, spas, whirlpools, hot tubs, swimming pools, health club membership or other such charges or items.

(37)

General exercise programs, even if recommended by a physician.

(38)

Eye exercises or visual training (orthoptics).

(39)

Eye and hearing examinations except when rendered in connection with medical or surgical treatment of a covered illness or injury or in connection with well-child care.

(40)

Eyeglasses, spectacles, contact lenses, or other optical devices with the following exceptions—

(i)

When necessary to perform the function of the human lens, lost as a result of intraocular surgery, ocular injury or congenital absence.

(ii)

Pinhole glasses prescribed for use after surgery for detached retina.

(iii)

Lenses prescribed as “treatment” instead of surgery for the following conditions—

(A)

Contact lenses used for treatment of infantile glaucoma.

(B)

Corneal or scleral lenses prescribed in connection with treatment of keratoconus.

(C)

Scleral lenses prescribed to retain moisture when normal tearing is not present or is inadequate.

(D)

Corneal or scleral lenses prescribed to reduce a corneal irregularity other than astigmatism.

(iv)

The specified benefits are limited to one set of lenses related to one qualifying eye condition as set forth in paragraphs (a)(40)(iii)(A) through (D) of this section. If there is a prescription change requiring a new set of lenses, but still related to the qualifying eye condition, benefits may be extended for a second set of lenses, subject to medical review.

(41)

Hearing aids or other auditory sensory enhancing devices.

(42)

Prostheses with the following exceptions—

(i)

Dental prostheses specifically required in connection with otherwise covered orthodontia directly related to the surgical correction of a cleft palate anomaly.

(ii)

Any prostheses, other than dental prostheses, determined to be medically necessary because of significant conditions resulting from trauma, congenital anomalies, or disease, including, but not limited to:

(A)

Artificial limbs.

(B)

Voice prostheses.

(C)

Eyes.

(D)

Items surgically inserted in the body as an integral part of a surgical procedure.

(E)

Ears, noses, and fingers.

(43)

Orthopedic shoes, arch supports, shoe inserts, and other supportive devices for the feet, including special ordered, custom-made built-up shoes, or regular shoes later built up with the following exceptions:

(i)

Shoes that are an integral part of an orthopedic brace, and which cannot be used separately from the brace.

(ii)

Extra-depth shoes with inserts or custom molded shoes with inserts for individuals with diabetes.

(44)

Telephone Services, with the following exceptions—

(i)

Services or advice rendered by telephone (audio only) on or after May 12, 2020, are not excluded when the services are otherwise covered CHAMPVA services provided through this modality and are medically necessary and appropriate.

(ii)

A diagnostic or monitoring procedure which incorporates electronic transmission of data or remote detection and measurement of a condition, activity, or function (biotelemetry) is covered when:

(A)

The procedure, without electronic data transmission, is a covered benefit;

(B)

The addition of electronic data transmission or biotelemetry improves the management of a clinical condition in defined circumstances; and

(C)

The electronic data or biotelemetry device has been classified by the U.S. Food and Drug Administration, either separately or as part of a system, for use consistent with the medical condition and clinical management of such condition.

(45)

Air conditioners, humidifiers, dehumidifiers, and purifiers.

(46)

Elevators.

(47)

Alterations to living spaces or permanent features attached thereto, even when necessary to accommodate installation of covered durable medical equipment or to facilitate entrance or exit.

(48)

Items of clothing, even if required by virtue of an allergy (such as cotton fabric versus synthetic fabric and vegetable-dyed shoes).

(49)

Food, food substitutes, vitamins or other nutritional supplements, including those related to care for a home patient whose condition permits oral feeding, except for prenatal vitamins which are medically necessary as a component of prenatal care and prescribed by a VA provider or an authorized non-VA provider as defined in § 17.270 of this part.

(50)

Enuretic (bed-wetting) conditioning programs.

(51)

Autopsy and post-mortem examinations.

(52)

All camping, even when organized for a specific therapeutic purpose (such as diabetic camp or a camp for emotionally disturbed children), or when offered as a part of an otherwise covered treatment plan.

(53)

Housekeeping, homemaker, or attendant services, including a sitter or companion.

(54)

Personal comfort or convenience items, such as beauty and barber services, radio, television, and telephone.

(55)

Megavitamin psychiatric therapy; orthomolecular psychiatric therapy.

(56)

All transportation except for specialized transportation with life sustaining equipment, when medically required for the treatment of a covered condition.

(57)

Services that are provided to a beneficiary who is referred to a provider of such services by a provider who has an economic interest in the facility to which the patient is referred, unless a waiver is granted.

(58)

Abortions, except when a physician certifies that the life of the mother would be endangered if the fetus were carried to term.

(59)

Aversion therapy.

(60)

Rental or purchase of biofeedback equipment.

(61)

Biofeedback therapy for treatment of ordinary muscle tension states (including tension headaches) or for psychosomatic conditions.

(62)

Immunotherapy for malignant diseases except for treatment of Stage O and Stage A carcinoma of the bladder.

(63)

Services and supplies provided by other than a hospital, such as nonskilled nursing homes, intermediate care facilities, halfway houses, homes for the aged, or other institutions of similar purpose.

(64)

Services performed when the patient is not physically present.

(65)

Medical photography.

(66)

Special tutoring.

(67)

Surgery for psychological reasons.

(68)

Treatment of premenstrual syndrome (PMS).

(69)

Over-the-counter products except for pharmaceutical smoking cessation supplies that are approved by the U.S. Food and Drug Administration, prescribed, and provided through MbM, and insulin and related diabetic testing supplies and syringes.

(70)

Thermography.

(71)

Removal of tattoos.

(72)

Penile implant/testicular prosthesis procedures and related supplies for psychological impotence.

(73)

Dermabrasion of the face except in those cases where coverage has been authorized for reconstructive or plastic surgery required to restore body form following an accidental injury or to revise disfiguring and extensive scars resulting from neoplastic surgery.

(74)

Chemical peeling for facial wrinkles.

(75)

Panniculectomy, body sculpting procedures.

(76)

Medications not approved by the U.S. Food and Drug Administration (FDA), excluding FDA exceptions to the approval requirement.

(77)

Services and supplies related to the treatment of dyslexia.

(78)

Abortion counseling.

(b)

Costs of services and supplies to the extent such amounts are billed over the CHAMPVA determined allowable amount are specifically excluded from coverage.

(1)

The CHAMPVA determined allowable amount is the maximum level of payment by CHAMPVA to an authorized non-VA provider for the provision of CHAMPVA-covered services and supplies to a CHAMPVA beneficiary. The CHAMPVA determined allowable amount is determined before consideration of cost sharing and the application of deductibles or OHI.

(2)

A Medicare-participating hospital must accept the CHAMPVA determined allowable amount for inpatient services provided to a CHAMPVA beneficiary as payment in full. See 42 CFR 489.25.

(3)

An authorized non-VA provider who accepts responsibility for the care of a CHAMPVA beneficiary thereby agrees to accept the CHAMPVA determined allowable amount as full payment for services and supplies rendered to the beneficiary (i.e., accepted assignment). The provider's acceptance of the CHAMPVA determined allowable amount extinguishes the beneficiary's payment liability to the provider. Any attempts to collect any additional amount from the CHAMPVA beneficiary may result in the provider being excluded from Federal benefits programs. See 42 CFR 1003.105.

Notes, amendments, and revision history

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 67 FR 4359, Jan. 30, 2002; 73 FR 65553, Nov. 4, 2008; 87 FR 41600, July 13, 2022; 87 FR 55296, Sept. 9, 2022; 89 FR 34136, Apr. 30, 2024; 90 FR 61328, Dec. 31, 2025]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

§17.273. Preauthorization.

38 C.F.R. § 17.273

Preauthorization or advance approval is required for any of the following, except when the benefit is covered by the CHAMPVA beneficiary's other health insurance (OHI):

(a)

Non-emergent inpatient mental health and substance abuse care including admission of emotionally disturbed children and adolescents to residential treatment centers.

(b)

All admissions to a partial hospitalization program (including alcohol rehabilitation).

(c)

Dental care. For limitations on dental care, see § 17.272(a)(21)(i) through (xii).

(d)

Organ transplants.

(e)

CHAMPVA will perform a retrospective medical necessity review during the coordination of benefits process if:

(1)

It is determined that CHAMPVA is the responsible payer for services and supplies but CHAMPVA preauthorization was not obtained prior to delivery of the services or supplies; and,

(2)

The claim for payment is filed within the appropriate one-year period.

Notes, amendments, and revision history

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 74 FR 31374, July 1, 2009; 87 FR 41601, July 13, 2022; 89 FR 34137, Apr. 30, 2024]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 74 FR 31374, July 1, 2009; 87 FR 41601, July 13, 2022; 89 FR 34137, Apr. 30, 2024]

§17.274. Cost sharing.

38 C.F.R. § 17.274

(a)

Cost sharing generally. CHAMPVA is a cost sharing program in which the cost of covered services is shared with the CHAMPVA beneficiary. CHAMPVA pays the CHAMPVA determined allowable amount less the CHAMPVA deductible, if applicable, and less the CHAMPVA beneficiary cost-share.

(1)

CHAMPVA beneficiary cost-share requirements do not apply to the following—

(i)

Supplies provided through VA MbM.

(ii)

Any medical services and supplies provided to a CHAMPVA beneficiary through CITI.

(iii)

The following services, even if not provided through CITI—

(A)

Colorectal cancer screening.

(B)

Breast cancer screening.

(C)

Cervical cancer screening.

(D)

Prostate cancer screening.

(E)

Annual physical exams.

(F)

Vaccinations/immunizations.

(G)

Well child care from birth to age six, as described in § 17.272(a)(30)(i).

(iv)

Hospice services.

(v)

Or other preventive services as determined by the Secretary of Veterans Affairs.

(2)

[Reserved]

(b)

Deductibles. In addition to the CHAMPVA beneficiary cost-share, an annual (calendar year) outpatient deductible requirement ($50 per beneficiary or $100 per family) must be satisfied prior to VA payment of outpatient benefits. The deductible requirement is waived for:

(1)

CHAMPVA-covered services and supplies provided through VA MbM or through CITI.

(2)

Inpatient services.

(3)

Preventive services listed in paragraph (a)(1)(iii) of this section.

(4)

Hospice services.

(5)

Or other services as determined by the Secretary of Veterans Affairs.

(c)

Cost sharing limitations. To provide financial protection against the impact of a long-term illness or injury, there is a $3,000 calendar year limit or “catastrophic cap” per CHAMPVA eligible family on the CHAMPVA beneficiary's out-of-pocket costs for allowable services and supplies. After a family has paid $3,000 in out-of-pocket costs, to include both cost-share and deductible amounts, in a calendar year, CHAMPVA will pay the full allowable amounts for the remaining CHAMPVA-covered services and supplies through the end of that calendar year. Credits to the annual catastrophic cap are limited to the applied annual deductible(s) and the CHAMPVA beneficiary cost-share amount. Costs above the CHAMPVA determined allowable amount, as well as costs associated with non-covered medical services and supplies, are not credited toward the catastrophic cap calculation.

(d)

Non-payment. If the CHAMPVA benefit payment is under $1.00, payment will not be issued. Catastrophic cap and deductible will, however, be credited.

(e)

Cost-share calculation. The CHAMPVA beneficiary's cost-share amount, if not waived under paragraph (a)(1) of this section, is 25 percent of the CHAMPVA determined allowable amount in excess of the annual calendar year deductible (see § 17.275 for procedures related to the calculation of the allowable amount for CHAMPVA-covered services and supplies), except for the following:

(1)

For inpatient services subject to the CHAMPVA Diagnosis Related Group (DRG) payment system, the cost-share is the lesser of:

(i)

The per diem rate multiplied by the number of inpatient days;

(ii)

25 percent of the hospital's billed amount; or

(iii)

The base CHAMPVA DRG rate.

(2)

For inpatient mental health low volume hospitals and units (less than 25 mental health discharges per federal fiscal year), the cost-share is the lesser of:

(i)

The fixed per diem rate multiplied by the number of inpatient days; or

(ii)

25 percent of the hospital's billed charges.

(f)

Cost sharing and annual deductible requirements under paragraphs (a) and (b) of this section do not apply to:

(1)

Insertion, removal, and replacement of intrauterine systems, contraceptive implants, or similar FDA approved, granted, or cleared contraceptives that require insertion, removal, and replacement by a health care provider;

(2)

Measurement for, and purchase of, contraceptive diaphragms or similar FDA approved, cleared, or granted medical devices, including remeasurement and replacement;

(3)

Administration of injectable contraceptives or similar FDA approved, granted, or cleared contraceptives that require administration by a health care provider;

(4)

Prescription contraceptives, and prescription or nonprescription contraceptives used as emergency contraceptives, approved, granted, or cleared by the FDA;

(5)

Surgical sterilization; and

(6)

Outpatient care or evaluation associated with provision of family planning services listed in paragraphs (f)(1) through (5) of this section.

Notes, amendments, and revision history

Amendments

[67 FR 4359, Jan. 30, 2002, as amended at 67 FR 6875, Feb. 14, 2002; 87 FR 41601, July 13, 2022; 89 FR 34137, Apr. 30, 2024]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[67 FR 4359, Jan. 30, 2002, as amended at 67 FR 6875, Feb. 14, 2002; 87 FR 41601, July 13, 2022; 89 FR 34137, Apr. 30, 2024]

§17.275. CHAMPVA determined allowable amount calculation.

38 C.F.R. § 17.275

CHAMPVA calculates the allowable amount in the following ways, for the following covered services and supplies:

(a)

Inpatient hospital services (non-mental health). Unless exempt or subject to a methodology under paragraph (b) or (c) of this section, inpatient hospital services provided in the 50 states, the District of Columbia, and Puerto Rico are subject to the CHAMPVA Diagnosis Related Group (DRG)-based reimbursement methodology. Under the CHAMPVA DRG-based payment system, hospitals are paid a predetermined amount per discharge for inpatient hospital services, which will not exceed the billed amount. Certain inpatient services will be reimbursed under the CHAMPVA Cost-to-Charge (CTC) reimbursement methodology.

(b)

Inpatient hospital services (mental health). The CHAMPVA inpatient mental health per diem reimbursement methodology is used to calculate reimbursement for inpatient mental health hospital care in specialty psychiatric hospitals and psychiatric units of general acute hospitals that are exempt from the CHAMPVA DRG-based payment system. The per diem rate is calculated by multiplying the daily rate by the number of days (length of stay). The daily rate is updated each fiscal year for both high volume hospitals (25 or more discharges per fiscal year) and low volume hospitals (fewer than 25 discharges per fiscal year).

(c)

Other inpatient hospital services.

(1)

The CHAMPVA CTC reimbursement methodology is used to calculate reimbursement for inpatient care furnished by hospitals or facilities that are exempt from either of the methodologies in paragraph (a) or (b) of this section. Such hospitals or facilities will be paid at the CHAMPVA CTC ratio times the billed charges that are customary and not in excess of rates or fees the hospital or facility charges the general public for similar services in a community.

(2)

The following hospitals and services are subject to the CHAMPVA CTC payment methodology—

(i)

Any hospital that qualifies as a cancer hospital under Medicare standards and has elected to be exempt from the Centers for Medicare & Medicaid Services (CMS) prospective payment system.

(ii)

Christian Science sanatoriums.

(iii)

Critical Access Hospitals.

(iv)

Any hospital outside the 50 states, the District of Columbia, or Puerto Rico.

(v)

Hospitals within hospitals.

(vi)

Long-term care hospitals.

(vii)

Non-Medicare participating hospitals.

(viii)

Non-VA Federal Health Care Facilities (e.g., military treatment facilities, Indian Health Service).

(ix)

Rehabilitation hospitals.

(x)

Hospital or hospital-based services subject to state waiver in any state that has implemented a separate DRG-based payment system or similar payment system in order to control costs.

(xi)

Hospitals and services as determined by the Secretary of Veterans Affairs.

(d)

Outpatient hospital services. The CHAMPVA outpatient prospective payment system (OPPS) is used to calculate the allowable amount for outpatient services provided in hospitals subject to Medicare OPPS. This will include the utilization of TRICARE's reimbursement methodology to include specific coding requirements, ambulatory payment classifications (APCs), nationally established APC amounts, and associated adjustments.

(e)

Outpatient and inpatient non-hospital services. Payments to individual authorized non-VA providers (not hospitals) for CHAMPVA-covered medical services and supplies provided on an outpatient or inpatient basis, including but not limited to, anesthesia services, laboratory services, and other professional fees associated with individual authorized non-VA providers, are reimbursed based on the lesser of:

(1)

The CHAMPVA Maximum Allowable Charge;

(2)

The prevailing amount, which is the amount equal to the maximum reasonable amount allowed providers for a specific procedure in a specific locality; or,

(3)

The billed amount.

(f)

Pharmacy services and supplies. The CHAMPVA pharmacy services and supplies payment methodology is based on specific CHAMPVA pharmacy points of service, which dictate the amounts paid by VA. VA pays:

(1)

For services and supplies obtained from a retail in-network pharmacy, the lesser of the billed amount or the contracted rate; or

(2)

For supplies obtained from a retail out-of-network pharmacy, the lesser of the billed amount plus a dispensing fee or the average wholesale price plus a dispensing fee.

(g)

Skilled Nursing Facility (SNF) care. The CHAMPVA SNF reimbursement methodology is based on the CMS prospective payment system for SNFs under 42 CFR part 413, subpart J.

(h)

Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The CHAMPVA DMEPOS reimbursement methodology is based on the same amounts established under the CMS DMEPOS fee schedule under 42 CFR part 414, subpart D. The CHAMPVA determined allowable amount for DMEPOS is the amount in effect in the specific geographic location at the time CHAMPVA-covered medical services and supplies are provided to a CHAMPVA beneficiary.

(i)

Ambulance services. CHAMPVA adopts Medicare's Ambulance Fee Schedule (AFS) for ambulance services, with the exception of services furnished by a Critical Access Hospital (CAH). Ambulance services are paid based on the lesser of the Medicare AFS or the billed amount. Ambulance services provided by a CAH are paid on the same bases as the CTC method under paragraph (c) of this section.

(j)

Hospice care. CHAMPVA hospice reimbursement methodology uses Medicare per diem hospice rates.

(k)

Home health care (intermittent or part-time). CHAMPVA home health care reimbursement methodology, based on Medicare's home health prospective payment system, uses a fixed case-mix and wage-adjusted episode payment amount to act as payment in full for costs associated with furnishing home health services with exceptions allowing for additional payment to be established.

(l)

Ambulatory surgery. The CHAMPVA reimbursement methodology for facility charges associated with procedures performed in a freestanding ambulatory surgery center is based on a prospectively determined amount, similar to that used by TRICARE. These facility charges do not include physician fees, anesthesiologist fees, or fees of other authorized non-VA providers; such independent professional fees must be submitted separately from facility fees and are calculated under the methodology in paragraph (e) of this section.

(m)

CHAMPVA-covered medical services and supplies provided outside the United States. VA shall determine the appropriate reimbursement method(s) for CHAMPVA-covered medical services and supplies provided by authorized non-VA providers outside the United States.

(n)

Sole Community Hospitals. The CHAMPVA reimbursement methodology for inpatient services provided in a Sole Community Hospital (SCH) will be the greater of: the allowable amount determined by multiplying the billed charges by the SCH's most recently available cost-to-charge ratio from the CMS Inpatient Provider Specific File or the DRG reimbursement rate.

Notes, amendments, and revision history

Amendments

[87 FR 41602, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[87 FR 41602, July 13, 2022]

§17.276. Claim filing deadline.

38 C.F.R. § 17.276

(a)

Unless an exception is granted under paragraph (b) of this section, claims for medical services and supplies must be filed no later than:

(1)

One year after the date of service; or

(2)

In the case of inpatient care, one year after the date of discharge; or

(3)

In the case of retroactive approval for medical services/supplies, 180 days following beneficiary notification of authorization; or

(4)

In the case of retroactive approval of CHAMPVA eligibility, 180 days following notification to the beneficiary of authorization for services occurring on or after the date of first eligibility.

(b)

Requests for an exception to the claim filing deadline must be submitted in writing and include a complete explanation of the circumstances resulting in late filing along with all available supporting documentation. Each request for an exception to the claim filing deadline will be reviewed individually and considered on its own merit. VA may grant exceptions to the requirements in paragraph (a) of this section if it determines that there was good cause for missing the filing deadline. For example, when dual coverage exists, CHAMPVA payment, if any, cannot be determined until after the primary insurance carrier has adjudicated the claim. In such circumstances an exception may be granted provided that the delay on the part of the primary insurance carrier is not attributable to the beneficiary. Delays due to provider billing procedures do not constitute a valid basis for an exception.

(c)

Claims for CHAMPVA-covered services and supplies provided before the date of the event that qualifies an individual under § 17.271 are not reimbursable.

(d)

CHAMPVA is the last payer to OHI, as that term is defined in § 17.270(b). CHAMPVA benefits will generally not be paid until the claim has been filed with the OHI and the OHI has issued a final payment determination or explanation of benefits. CHAMPVA is secondary payer to Medicare per the terms of § 17.271(b).

Notes, amendments, and revision history

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 73 FR 65553, Nov. 4, 2008. Redesignated and amended at 87 FR 41602, 41603, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[63 FR 48102, Sept. 9, 1998, as amended at 73 FR 65553, Nov. 4, 2008. Redesignated and amended at 87 FR 41602, 41603, July 13, 2022]

§17.277. Appeals.

38 C.F.R. § 17.277

(a)

This section applies only to legacy claims.

(b)

Notice of the initial determination regarding payment of CHAMPVA benefits will be provided to the CHAMPVA beneficiary on a CHAMPVA Explanation of Benefits (EOB) form. The EOB form is generated by the CHAMPVA automated payment processing system. If a CHAMPVA beneficiary or provider disagrees with the determination concerning CHAMPVA-covered services and supplies or calculation of benefits, he or she may request reconsideration. Such requests must be submitted to VA in writing within one year of the date of the initial determination. The request must state why the CHAMPVA claimant believes the decision is in error and must include any new and relevant information not previously considered. Any request for reconsideration that does not identify the reason for dispute will be returned to the claimant without further consideration. After reviewing the claim and any relevant supporting documentation, VA will issue a written determination to the claimant that affirms, reverses, or modifies the previous decision. If the claimant is still dissatisfied, within 90 days of the date of the decision he or she may make a written request for review by VA. After reviewing the claim and any relevant supporting documentation, VA will issue a written determination to the claimant that affirms, reverses, or modifies the previous decision. The decision of VA with respect to benefit coverage and computation of benefits is final. When a CHAMPVA beneficiary has other health insurance (OHI), an appeal must first be filed with the OHI, and a determination made, before submitting the appeal to CHAMPVA with limited exceptions such as if the OHI deems the issue non-appealable. Denial of CHAMPVA benefits based on legal eligibility requirements may be appealed to the Board of Veterans' Appeals in accordance with 38 CFR part 20. Medical determinations are not appealable to the Board. 38 CFR 20.101.

Notes, amendments, and revision history

Amendments

[87 FR 41603, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[87 FR 41603, July 13, 2022]

§17.278. Medical care cost recovery.

38 C.F.R. § 17.278

VA will actively pursue medical care cost recovery in accordance with applicable law.

Notes, amendments, and revision history

Amendments

[87 FR 41603, July 13, 2022]

Source

Source: 63 FR 48102, Sept. 9, 1998, unless otherwise noted.

Authority

Amendments

[87 FR 41603, July 13, 2022]