CHAMPVA Hospice Care: Coverage, Costs, and Provider Billing

Quick answer

Yes. CHAMPVA covers hospice care for terminally ill beneficiaries with a life expectancy of six months or less. VA describes hospice as comfort-focused care that emphasizes supportive services such as pain control, home care, and patient comfort.

For covered hospice services, CHAMPVA waives both the deductible and the beneficiary cost share. When CHAMPVA is the primary payer, the current CHAMPVA Guidebook says the patient pays no deductible and no cost share, while CHAMPVA pays up to 100% of the allowable amount. The cost-sharing waiver is also stated in 38 CFR § 17.274.

Hospice is not the same as ordinary home health care, custodial care, or a skilled nursing facility stay. It has its own coverage and reimbursement rules.

When CHAMPVA hospice coverage applies

The CHAMPVA Guidebook describes hospice coverage for a terminally ill patient whose life expectancy is six months or less.

That does not mean every service delivered during a terminal illness is automatically payable as hospice. CHAMPVA generally pays for covered, medically necessary services furnished by an authorized provider, and VA cautions that listing a service as a covered benefit does not by itself guarantee payment because benefit-specific coverage guidelines can apply.

The practical question is therefore not only whether the beneficiary has CHAMPVA, but whether the care is being furnished and billed under the CHAMPVA hospice benefit and meets the applicable hospice coverage rules.

The four CHAMPVA hospice levels

VA identifies four levels on which hospice reimbursement is based:

1. Routine Home Care. This is the routine hospice level when the patient is not receiving continuous home care.
2. Continuous Home Care. VA describes this level as a minimum of 8 hours of care during a 24-hour period.
3. Inpatient Respite Care. VA limits this level to a maximum of 5 days, counting the admission day but not the discharge day.
4. General Inpatient Care. This level applies when general inpatient hospice care is provided and is reimbursed at the inpatient hospice rate.

These are reimbursement levels, not four separate insurance plans. The appropriate level depends on the hospice care being furnished.

What does a CHAMPVA beneficiary pay for hospice?

For covered hospice services, CHAMPVA has no deductible and no beneficiary cost share.

That rule applies to hospice generally and to hospice inpatient services. The Guidebook states that when CHAMPVA is primary, CHAMPVA pays up to 100% of the allowable amount.

If the beneficiary has other health insurance, CHAMPVA is normally secondary. VA's current CHAMPVA care guidance says the other health plan should generally be billed first. The Guidebook says hospice patients with CHAMPVA as a secondary or tertiary payer pay nothing in most cases, with CHAMPVA payment determined after the other insurance payment.

A zero CHAMPVA deductible and cost share does not mean that every charge from every provider is automatically a covered CHAMPVA charge. Coverage rules, other insurance, the CHAMPVA allowable amount, and whether the provider accepts assignment can still affect the bill.

For a broader explanation of services that CHAMPVA exempts from cost sharing, see CHAMPVA Services With No Deductible or Cost Share.

What hospice services are included?

VA's public Guidebook describes the hospice benefit as care and comfort for a terminally ill patient, emphasizing pain control, home care, and patient comfort. It then organizes reimbursement around the four hospice levels above.

The Guidebook does not present a complete public line-item list of every service that can be included in a hospice episode. Instead, it directs readers to the CHAMPVA Policy Manual, Chapter 2, Section 16.4, for full hospice benefit information.

That distinction matters when a family receives separate bills. Ask the hospice to identify:

• which services are part of the hospice plan and are being billed under the hospice benefit;
• which hospice level applies to the dates of service;
• whether any service is being billed separately from the hospice benefit; and
• whether another health plan must be billed before CHAMPVA.

What is not automatically covered just because someone is in hospice?

CHAMPVA's general exclusions still matter when a service is not payable as part of the hospice benefit.

For example, 38 CFR § 17.272 generally excludes stand-alone housekeeping, homemaker, attendant, sitter, or companion services; personal comfort or convenience items; and services from certain non-skilled residential institutions. The regulation also excludes amounts billed above the CHAMPVA-determined allowable amount from CHAMPVA coverage.

These general exclusions should not be confused with the hospice benefit itself. A hospice may furnish covered services in the home under the hospice plan. The important billing question is whether the item or service is a covered part of the hospice episode or a separately billed non-covered service.

How CHAMPVA pays hospice providers

Under 38 CFR § 17.275(j), CHAMPVA uses Medicare per-diem hospice rates to determine hospice reimbursement.

This means the provider's submitted charge is not necessarily the amount CHAMPVA recognizes for payment. CHAMPVA applies its hospice reimbursement methodology to determine the allowable amount.

For a deeper explanation of that distinction, see What Is the CHAMPVA Allowable Amount?.

What hospice billing staff should do

VA's current CHAMPVA provider guidance says providers can submit CHAMPVA claims electronically or by mail and should use the current VA family-member-care claim instructions.

For hospice claims, a practical workflow is to:

1. Verify CHAMPVA eligibility for the dates of care.
2. Identify other health insurance. When another health plan is primary, bill it first and include its adjudication information with the CHAMPVA claim as required.
3. Bill the correct hospice level and dates of service. CHAMPVA's hospice reimbursement is based on Medicare per-diem hospice rates.
4. Use the current CHAMPVA provider claim process. VA maintains current electronic and paper filing instructions on its provider page.
5. Confirm payment setup. VA states that providers in family-member-care programs must be enrolled in Electronic Funds Transfer to receive payment.
6. Review the CHAMPVA EOB before rebilling or collecting from the patient. A denial, a request for documentation, an other-insurance issue, and an allowable-amount adjustment are different problems and should not be handled as if they were the same.

Assignment and unexpected hospice bills

CHAMPVA does not have a closed provider network. VA recommends asking a provider whether the provider accepts CHAMPVA assignment.

An assigning provider agrees to accept the CHAMPVA allowable amount for covered services under the applicable assignment rules. Because covered hospice services have no CHAMPVA deductible or cost share, an unexpected patient bill should be compared with the CHAMPVA EOB before payment.

VA's current beneficiary guidance also warns that when a provider does not accept assignment, CHAMPVA may pay only its allowable amount and the beneficiary can be responsible for charges above that amount.

See CHAMPVA Assignment and Balance Billing: What Providers Can Charge for the broader assignment rules.

A checklist before hospice care starts

Before relying on CHAMPVA for a hospice episode:

1. Confirm that the beneficiary's CHAMPVA eligibility is active.
2. Make sure the hospice understands that the patient has CHAMPVA and any other health insurance.
3. Ask the hospice which of the four hospice levels is expected to apply.
4. Ask whether the hospice accepts CHAMPVA assignment.
5. Ask the hospice to distinguish hospice-covered services from any separately billed items or services.
6. If another health plan is primary, confirm that it will be billed before CHAMPVA.
7. Keep the hospice paperwork, provider bills, other-insurance EOBs, and CHAMPVA EOBs together.

In most cases, the provider should file the CHAMPVA claim. If the provider does not file and the beneficiary pays out of pocket, see Who Files a CHAMPVA Claim: Provider or Beneficiary?.

Hospice is different from skilled nursing care

Hospice is an end-of-life comfort benefit. Skilled nursing and skilled nursing facility care are separate CHAMPVA benefits with different medical-necessity, payment, and beneficiary cost rules.

Do not assume that a nursing-facility stay becomes hospice simply because a person is terminally ill, or that ordinary custodial care becomes covered because hospice is involved.

For the extended-care distinction, see CHAMPVA Skilled Nursing and SNF Coverage: Extended Care Rules.

If a hospice claim is denied or the bill looks wrong

Start with the CHAMPVA EOB and identify the reason for the payment or denial before resubmitting anything.

Check whether the issue involves:

• eligibility on the dates of service;
• other health insurance that should have paid first;
• whether the care was billed under the appropriate hospice benefit and level;
• missing clinical or claim documentation;
• the CHAMPVA allowable amount; or
• assignment and an amount the provider is attempting to collect from the patient.

If the EOB asks for documentation, supply the requested material rather than filing duplicate claims. If the dispute is about the CHAMPVA decision itself, use the applicable CHAMPVA decision-review process.

Primary authorities

This guide is based on VA's current CHAMPVA Guidebook, 38 CFR § 17.272, 38 CFR § 17.274, 38 CFR § 17.275, VA's current CHAMPVA care page, and VA's current CHAMPVA provider page.