The short answer
CHAMPVA uses a handful of insurance terms that sound alike but mean different things. The three people mix up most are authorized provider (who can treat you), assignment (how they bill), and preauthorization (approval before certain care). Knowing the difference prevents most billing surprises.
The three terms people mix up most
These three sound similar, but each one answers a different question.
Authorized provider answers "Is this provider allowed to treat me under CHAMPVA?" Under 38 CFR 17.270, that generally means the provider is licensed or certified by the state for the care, or, where the state doesn't license that kind of provider, certified by a national professional organization. It does not mean "in network." CHAMPVA doesn't have a network.
Assignment answers "How will this provider bill me?" A provider who accepts assignment bills CHAMPVA for you and accepts CHAMPVA's allowable amount as full payment. You owe only your deductible and cost share. A provider can be authorized but not accept assignment. In that case, you may have to pay up front, file the claim yourself, and pay anything above the allowable amount.
Preauthorization answers "Does CHAMPVA need to approve this before I get it?" Most care doesn't. A few services do, like certain inpatient mental health and substance use treatment, some dental care, and organ transplants. More here: Which CHAMPVA services require preauthorization?
A good question to ask any office: "Do you accept CHAMPVA assignment and bill CHAMPVA directly?" It's much clearer than "Do you take CHAMPVA?"
The money terms
Allowable amount. The most CHAMPVA will count for a covered service, no matter what the provider charges. VA says it's usually based on what Medicare or TRICARE would pay. It's often lower than the provider's bill. More here: What is the CHAMPVA allowable amount?
Deductible. What you pay each calendar year before CHAMPVA starts paying for most outpatient care: $50 per person or $100 per family. It doesn't apply to everything. Inpatient care, CITI, and Meds by Mail don't have one. You don't send CHAMPVA a payment for it; it's applied as your claims are processed.
Cost share. Your part of the allowable amount on a covered claim. For most outpatient care when CHAMPVA is your only coverage, that's 25% after the deductible, and CHAMPVA pays 75%. Some services have no cost share. More here: CHAMPVA cost share.
Catastrophic cap. The most your family pays out of pocket for covered care in a calendar year: $3,000. After that, CHAMPVA pays its full allowable amount for the rest of the year. More here: CHAMPVA catastrophic cap.
Here's how the money terms fit together. Say a therapist accepts assignment, charges $180, and CHAMPVA's allowable amount is $120. Your deductible is already met. You pay 25% of $120, which is $30. CHAMPVA pays $90. The other $60 the therapist charged is written off, and you don't owe it.
Insurance and billing terms
Beneficiary. The person enrolled in CHAMPVA and getting care. On a bill, that's the patient, not the Veteran.
OHI (other health insurance). Any other plan that can pay for your care, like an employer plan, Medicare, or a Marketplace plan. If you have OHI, it usually pays before CHAMPVA. You have to tell CHAMPVA about it, or claims can be held up. More here: How CHAMPVA works with other health insurance.
Payer, primary and secondary. The payer is whoever pays the claim. The primary payer pays first. The secondary payer looks at the claim after that. When you have OHI, CHAMPVA is usually secondary. There are a few exceptions where CHAMPVA pays first, including Medicaid, the Indian Health Service, state victims-of-crime programs, and CHAMPVA supplemental policies.
EOB (Explanation of Benefits). The statement CHAMPVA sends after it processes a claim. It shows what was billed, what CHAMPVA allowed and paid, and what you owe. It isn't a bill. More here: How to read a CHAMPVA EOB.
Payer ID. The number a provider's billing office uses to send electronic claims. CHAMPVA's medical payer ID is 84146.
Common mix-ups to avoid
- "Authorized" doesn't mean "in network." CHAMPVA has no network.
- "They take CHAMPVA" doesn't mean "they accept assignment." Ask about assignment specifically.
- The bill isn't the allowable amount. A provider can charge more than CHAMPVA allows.
- Deductible and cost share aren't the same thing. One is a yearly amount; the other is your part of each claim.
- Preauthorization isn't about the provider. It's approval for a specific service.
- Accepting assignment doesn't guarantee payment. The service still has to be covered, and any required preauthorization still has to be in place.