The USBA CHAMPVA Supplement Plan will pay your cost share for both
covered inpatient and outpatient medical expenses after you satisfy the calendar
year plan deductible of $250 per person, $500 family maximum. Take a moment to read
the details below. Then enroll today to give your family the additional protection
of the USBA CHAMPVA Supplement Plan that complements your CHAMPVA benefits.
Eligibility - Eligible Spouse: “Spouse” means your
spouse who is under age 65 and a CHAMPVA benefits recipient, but not a spouse from
whom you are legally separated or divorced. “Spouse” also means widow(er)
if he or she is a member of the Participating Organization.
Spouses over age 65 are also eligible if documentation from the Social Security
Administration certifying their non-entitlement to Medicare Part A benefits is submitted
with their enrollment form. Eligible dependents and unmarried children under 18
(23 if a full-time college student) may also enroll.
Effective Date - Coverage for dependents becomes effective on the
first day of the month following receipt of your Enrollment Form and first premium
Covered Dependent Effective Date - Subject to the Deferred Effective
Date provision, an Eligible Dependent will become covered by the Policy on the Certificate
Effective Date that first shows coverage for him or her. Your coverage is shown
on your Schedule of Insurance.
Deferred Effective Date - If on the date that an Eligible Dependent
is to become covered under the Policy he or she is confined in a Hospital, coverage
of such person will be deferred until the first day after he or she is discharged.
Renewability - Your coverage is renewable to age 65. As long as
premiums are paid on time and the Master Policy remains in effect, no one can be
individually canceled. So even if you or a covered dependent develops a serious
health condition in the future, the coverage will not terminate, provided these
conditions are met.
Change of Policy Premiums - We have the right on each Premium Due
Date to change the rate at which premiums will be calculated. This includes the
right to change premium rates for a benefit that applies to all individuals of the
same class, age, plan and effective date. Rates may be changed based on claims experience
of the Policy. We will give the Policyholder or Organization notice of any change
at least 45 days before the Premium Due Date on which it is to become effective.
Termination - A Covered Person’s coverage under the Policy
will cease on the first to occur of: (1) the date the Policy terminates, or the
date USBA ceases to be a Participating Organization of the Policyholder; (2) the
date the required premium is not paid, subject to the Grace Period provisions; (3)
the date you or your widow(er) terminates membership in the Participating Organization;
(4) the first premium due date on or next following the date a dependent ceases
to be an Eligible Spouse or an Eligible Child; (5) the date we or the group cancel
coverage for a class of Eligible Person to which he or she belongs; (6) the first
premium due date on or next following the date he or she ceases to be covered by
CHAMPVA; (7) the date he or she becomes eligible for Medicare unless the covered
person resides in an area where Medicare is not available, in which case coverage
will not terminate until the covered person returns to residency in an area where
Medicare is available; (8) if a child, the date he or she attains age 18, or 23
if enrolled full-time in a school of higher learning; (9) if a spouse, the date
he or she attains age 65. Termination of insurance will not prejudice any claim
which occurred before the effective date of termination. Limitations and exclusions
may vary by state. Please see Certificate for details.
Exclusions - The Policy does not cover - (1) injury or sickness
resulting from war or act of war, whether war is declared or undeclared; (2) treatment
or confinement not ordered by a Physician or necessary for medical care; (3) intentionally
self-inflicted injury; (4) suicide or attempted suicide, whether sane or insane
(in Colorado and Missouri while sane); (5) routine physical exams and immunizations,
except when considered Well Baby Care covered by CHAMPVA; (6) domiciliary or custodial
care, care received in a retirement home, rest home or halfway house; (7) rest cures;
(8) eye refractions and routine eye exams except when considered Well Baby Care
covered by CHAMPVA; (9) eyeglasses and contact lenses; (10) cosmetic procedures,
except those resulting from Sickness or Injury while a Covered Person; (11) hearing
aids or hearing exams except when considered Well Baby Care covered by CHAMPVA;
(12) orthopedic footwear; (13) care for the mentally incapacitated or physically
handicapped if the care is required because of the mental incapacitation or physical
handicap; (14) drugs which do not require a prescription, except insulin and other
diabetic supplies; (15) any confinement, service, or supply that is not covered
under CHAMPVA; (16) expenses in excess of the CHAMPVA Cap; (17) expenses in excess
of the CHAMPVA Allowed Amount; (18) expenses which are paid in full by CHAMPVA;
(19) any expenses or portion thereof applied to the CHAMPVA Deductible; (20) any
part of a covered expense which the Covered Person is not legally obligated to pay;
(21) care received as part of a grant, study or research program; (22) care considered
experimental or investigational.
Limitations - The coverage provided under the Inpatient Benefit
of the CHAMPVA Supplement Plan for nervous, mental and emotional disorders, including
alcoholism and drug addictions, is limited to: (a) 30 Inpatient treatment days for
a Covered Person age 19 or older; or (b) 45 Inpatient treatment days for a Covered
Person under age 19; or (c) 150 Inpatient treatment days in a CHAMPVA authorized
Residential Treatment Center for a Covered Person under age 21 per Calendar Year.
This Inpatient limit is based on the number of days CHAMPVA normally provides each
Calendar Year for such confinements. In rare instances, CHAMPVA extends these daily
limits. If this occurs, we will limit the number of days that we provide for such
confinement to the lesser of: (a) the number of days CHAMPVA pays for such Inpatient
treatment during the Calendar Year; or (b) 90 Inpatient days per Calendar Year.
The coverage provided under the Outpatient Benefit of the CHAMPVA Supplement Plan
for: (a) nervous, mental, and emotional disorders; and (b) alcoholism and drug addition;
is limited to $500 during any Calendar Year for all such disorders.
Coverage provided under the CHAMPVA Supplement Plan for: (1) routine newborn and
Well Baby Care; (2) hospital nursery charges for a well newborn; (3) dental care;
(4) treatment for the prevention or cure of alcoholism or drug addition; (5) and
prosthetic devices; will be limited to those expenses covered by CHAMPVA for such
care or service.
*Pre-Existing Condition Limitations - Any injury or sickness, whether
diagnosed or undiagnosed, for which a covered person received medical care or treatment
within the 6 month period preceding the effective date of his or her insurance will
not be covered until the coverage has been in effect for 6 months. However, new
conditions will be covered immediately.
Waiver for Conditions Prior to Effective Date of Coverage: Under the following conditions,
the period of time required to satisfy the Pre-Existing Condition exclusion will
be reduced or waived as stated:
If you retire from Active Duty and become eligible for TRICARE Retiree Supplement
coverage as provided under â€śPlan Conversionsâ€ť and Requests such coverage within
63 days of the date you first becomes eligible for coverage, we will credit you
with continuity of coverage from your prior effective date under the CHAMPVA Supplement
This site explains the general purpose of the insurance described, but in no way
changes or affects the policy as actually issued. In the event of any discrepancy
between this site and the contract, the terms of the contract will apply. Complete
details are found in the certificate of insurance issued to each insured individual.
This program may not be available to residents of all states. You will be notified
by the Administrator if you are ineligible for coverage.