The short answer
For most covered outpatient care, you pay 25% of CHAMPVA's allowable amount after your deductible, and CHAMPVA pays 75%. The 25% is figured from what CHAMPVA allows, not what the provider bills. It can be lower or zero if you have other insurance, if the service has no cost share, or once your family hits the $3,000 yearly cap.
What does the 25% cost share mean?
Under 38 CFR 17.274, when CHAMPVA is your only coverage, your usual share is 25% of CHAMPVA's allowable amount after any deductible. CHAMPVA pays the other 75%.
The allowable amount is what CHAMPVA recognizes as the price of a covered service. It's often lower than what the provider bills. More here: What is the CHAMPVA allowable amount?
Example: deductible already met
The provider bills $300. CHAMPVA's allowable amount is $200.
- Your 25%: $50
- CHAMPVA's 75%: $150
The $300 doesn't enter the math. Whether the provider can bill you the other $100 depends on whether they accept CHAMPVA's payment as payment in full. More here: Assignment and balance billing.
Example: deductible not met yet
Same $200 allowable amount, but you still owe your $50 deductible.
- Deductible: $50
- 25% of the remaining $150: $37.50
- You pay: $87.50
- CHAMPVA pays: $112.50
When isn't it 25%?
Some services have no cost share
The regulation waives the cost share for:
- Meds by Mail,
- care at a VA facility through CITI,
- listed preventive care, like cancer screenings, yearly physicals, vaccines, and well-child care through age 6,
- hospice, and
- certain birth control and family planning services.
More here: CHAMPVA services with no deductible or cost share.
Hospital stays use a different formula
Inpatient care has no deductible, but your share is figured differently, often as the lowest of a daily rate times the number of days, 25% of the hospital's bill, or CHAMPVA's set rate for that kind of stay. More here: CHAMPVA inpatient costs.
Other insurance usually pays first
If you have other coverage, it pays first and CHAMPVA pays after. VA says you may not owe any CHAMPVA cost share at all. More here: CHAMPVA and other health insurance.
The catastrophic cap
Once your family's deductibles and cost shares reach $3,000 in a calendar year, CHAMPVA pays the full allowable amount for covered care for the rest of the year. More here: CHAMPVA catastrophic cap.
Your bill looks like more than 25%
Compare it with your CHAMPVA explanation of benefits (EOB). The EOB shows the allowable amount, what CHAMPVA paid, and what it says you owe. Common reasons a bill is higher:
- The provider billed above the allowable amount and doesn't accept assignment.
- Part of the bill went to your deductible.
- The service isn't covered.
More here: How to read a CHAMPVA EOB.
Estimating before planned care
Ask these in order:
- Is it covered?
- Is CHAMPVA paying first or second?
- Does it have a cost-share waiver or a special rule?
- How much deductible is left?
- Does the provider accept assignment?
- Has the family reached the $3,000 cap?
Treat any estimate as rough until the claim is processed.