38 CFR § 17.274 - Cost sharing.
(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.