The short answer
CHAMPVA covers medically necessary skilled nursing care and skilled nursing facility (SNF) stays. An SNF stay requires a 3-day inpatient hospital stay first. No preauthorization is needed, but claims are reviewed. CHAMPVA doesn't cover custodial care, meaning help with bathing, dressing, and eating when no skilled care is needed. SNF care has no deductible and a 25% cost share.
What does CHAMPVA cover?
The CHAMPVA Guidebook covers:
- Skilled nursing care: care from licensed professionals like RNs, LPNs, and physical, occupational, or respiratory therapists.
- Skilled nursing facility care: a facility providing skilled nursing or rehab for someone who needs 24-hour care supervised by an RN or physician.
The Guidebook says a service is skilled when it can't be done by a nonmedical person.
What isn't covered?
38 CFR 17.272 excludes:
- custodial care,
- stays mainly for domiciliary (living) purposes,
- housekeeping, homemaker, sitter, or companion services,
- care from non-skilled nursing homes, intermediate care facilities, homes for the aged, or similar places, and
- care from an immediate family member or someone who lives with you.
Custodial care means help with daily activities like bathing, dressing, or eating when skilled care isn't the reason for the stay. Medicare's long-term care page describes it the same way.
So it's not about the building. It's about the level of care the person needs.
Is there a hospital stay requirement?
Yes. The Guidebook says there must be a 3-day inpatient hospital stay before SNF admission. Observation days usually don't count as inpatient, so ask the hospital how the stay was classified.
Medicare has its own version of this rule and some waivers. Don't assume a Medicare waiver changes CHAMPVA's rule. Check with CHAMPVA first.
Does it need preauthorization?
No. The Guidebook says skilled nursing care doesn't need preauthorization, but every claim is subject to medical review. Records should show why skilled care is needed.
What will you pay?
| Situation | Deductible | Your share |
|---|---|---|
| SNF stay, CHAMPVA only | None | 25% of the allowable amount |
| Skilled nursing outside an SNF, CHAMPVA only | $50 / $100 | 25% |
| Other insurance pays first | Usually nothing | |
| Medicare primary, days 1 to 100 | $0 in most cases | |
| Medicare primary, after day 100 | 25% |
Your family's yearly total stops at $3,000. CHAMPVA prices SNF care using Medicare's SNF payment system, under 38 CFR 17.275.
After Medicare's 100 days run out, CHAMPVA doesn't automatically pick up the whole stay. The care still has to be skilled and medically necessary. More here: CHAMPVA and Medicare.
Before an SNF admission
- Ask what skilled services the person needs.
- Confirm the 3-day inpatient stay and keep the dates.
- Ask the facility what records will show medical necessity.
- Identify who pays first.
- Ask if the facility accepts CHAMPVA assignment.
- Keep records and EOBs.
If a claim is denied
Check the reason: missing records, care judged custodial, the 3-day stay, or other insurance. Send records if that's what's missing. If you disagree with the decision, use the review steps in the letter.
For end-of-life care, see CHAMPVA hospice care. For care at home, see CHAMPVA home health care.