Health Care for Dependents and Survivors of Veterans Sidath Viranga Panangala Specialist in Veterans Policy April 4, 2013 Congressional Research Service 7-5700 www.crs.gov RS22483 CRS Report for Congress Prepared for Members and Committees of Congress Health Care for Dependents and Survivors of Veterans Summary The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) was established by the Veterans Health Care Expansion Act of 1973 (P.L. 93-82). CHAMPVA is primarily a health insurance program where certain eligible dependents and survivors of veterans receive care from private sector health care providers. Eligibility To be eligible for CHAMPVA benefits, the beneficiary must be the spouse or child of a veteran who has a total and permanent service-connected disability, or the widowed spouse or child of a veteran who (1) died as a result of a service-connected disability; or (2) had a total, permanent disability resulting from a service-connected condition at the time of death; or (3) died while on active duty status and in the line of duty; and does not qualify for health care under the Department of Defense (DOD) TRICARE program. The Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163) expanded CHAMPVA benefits for primary caregivers of certain seriously injured veterans if they do not have any other form of health insurance. Under current law a child (other than a helpless child) loses eligibility when (1) the child turns 18, unless enrolled in an accredited school as a full-time student; or (2) the child, who has been a full-time student, turns 23 or loses full-time student status; or (3) the child marries. Benefits The CHAMPVA program covers most health care services and supplies that are determined to be medically necessary, including inpatient and outpatient care, prescription drugs, mental health services, and skilled nursing care. Certain types of care require advance approval, commonly known as preauthorization. Currently, preauthorization is required for durable medical equipment, hospice services, mental health/substance abuse services, organ and bone marrow transplants, and dental procedures that are directly related to covered medical conditions. Payments CHAMPVA beneficiaries usually pay 25% of the cost of medical care up to an annual catastrophic cap of $3,000 plus an annual outpatient deductible of $50 per individual or $100 per family. CHAMPVA pays the remaining 75% of the cost of the beneficiaries’ medical care. CHAMPVA is generally a secondary payer to other health insurance coverage and Medicare. CHAMPVA is the primary payer for Medicaid, Indian Health Service, and State Victims of Crime Compensation Programs. Congressional Research Service Health Care for Dependents and Survivors of Veterans Contents Overview.......................................................................................................................................... 1 Questions and Answers .................................................................................................................... 4 Eligibility ......................................................................................................................................... 4 Who Is Eligible to Receive CHAMPVA Benefits?.................................................................... 4 What Happens If a CHAMPVA-Eligible Spouse Divorces or Remarries? ............................... 5 When Does a Child Lose Eligibility? ........................................................................................ 5 Benefits ............................................................................................................................................ 6 Which Medical Benefits Are Available to Eligible Beneficiaries? ............................................ 6 What Is the CHAMPVA Policy on Abortion? ........................................................................... 6 Payments .......................................................................................................................................... 7 What Is the CHAMPVA Payment Structure? ............................................................................ 7 What Happens If the Beneficiary Has Other Health Insurance? ............................................... 7 How Are CHAMPVA Claims Processed? ................................................................................. 7 Other Programs ................................................................................................................................ 8 What Is the Difference Between CHAMPVA and TRICARE? ................................................. 8 What Is the Relationship Between CHAMPVA and Medicare? ................................................ 8 What Is the CHAMPVA In-House Treatment Initiative (CITI)? ............................................... 9 Figures Figure 1. CHAMPVA-Enrolled Beneficiaries, FY2001-FY2012 .................................................... 2 Figure 2. CHAMPVA Unique Users, FY2001-FY2012 .................................................................. 3 Figure 3. CHAMPVA Expenditures, FY2001-FY2012 ................................................................... 4 Tables Table A-1. Major Legislation Affecting the CHAMPVA Program ................................................ 10 Table B-1. CHAMPVA-Enrolled Beneficiaries and Unique Users by State, FY2012 .................. 11 Appendixes Appendix A. CHAMPVA Legislative History ............................................................................... 10 Appendix B. CHAMPVA Enrollment and Unique Users, by State ............................................... 11 Contacts Author Contact Information........................................................................................................... 12 Acknowledgments ......................................................................................................................... 13 Congressional Research Service Health Care for Dependents and Survivors of Veterans Overview The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) provides health care services to veterans who meet certain eligibility requirements.1 The VHA is primarily a direct service provider of primary care, specialized care, and related medical and social support services to veterans though an integrated health care system. In 1973, Congress enacted the Veteran Health Care Expansion Act of 1973 (P.L. 93-82), which, among other things, established effective September 1, 1973, the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) as a means of providing health care services to dependents and survivors of certain veterans. As stated in the House report accompanying P.L. 93-82: The nation has long recognized that the widow and children of a veteran who dies of serviceconnected disease or injury or of a veteran who has a service-connected total disability are in a special category and deserving of substantial compensation and assistance in return for the sacrifice the family has made. This recognition has been shown in title 38 programs which provide for death compensation benefits, home loans, and educational assistance benefits for wives, widows, and war orphans. Failure to provide for the medical care of such individuals is an oversight which should be corrected.2 CHAMPVA is fundamentally a health insurance program where certain eligible dependents and survivors of veterans (veterans rated permanently and totally disabled from a service-connected condition) obtain medical care from private health care providers.3 Beneficiaries usually pay 25% of the cost of medical care up to an annual catastrophic cap of $3,000 plus an annual outpatient deductible of $50 per individual or $100 per family. CHAMPVA pays the remaining 75% of the cost of the beneficiaries’ medical care.4 CHAMPVA was designed to provide medical care in a manner similar to the care provided to certain eligible beneficiaries under the Department of Defense (DOD) TRICARE program (described later in this report).5 The number of beneficiaries enrolled in CHAMPVA has grown over the years. From FY2001 through FY2012, enrollment grew by 290%—from 96,500 in FY2001 to 375,900 beneficiaries in FY2012 (see Figure 1). The 2001 expansion of CHAMPVA eligibility to certain individuals aged 65 years and older has contributed to the increase in enrollment.6 Moreover, there has been an increase in enrollment of dependents and spouses of certain Vietnam-era veterans with serviceconnected disabilities. This increase in Vietnam-era CHAMPVA sponsorship has occurred as 1 For more information on eligibility for VA healthcare, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin Bagalman. 2 U.S. Congress, Committee on Veterans’ Affairs, Veterans Health Care Expansion Act of 1973, report to accompany H.R. 9048, 93rd Congress, first session, H.Rept. 93-368 (Washington: GPO, 1973). 3 The term “service-connected” means, with respect to disability, that such disability was incurred or aggravated in the line of duty in the active military, naval, or air service. VA determines whether veterans have service-connected disabilities, and for those with such disabilities, assigns ratings from 0 to 100% based on the severity of the disability. Percentages are assigned in increments of 10%. 4 Department of Veterans Affairs, Office of Inspector General, Audit of the Civilian Health and Medical Program of the Department of Veterans Affairs, Report No. 06-03541-219, September 28, 2007, p. 1; and 38 C.F.R. §17.274. 5 P.L. 93-82 authorized VA to furnish medical care similar to that provided to dependents and survivors of retired members of the armed forces in the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). CHAMPUS was later renamed TRICARE Standard in 1995. 6 Department of Veterans Affairs, Office of Inspector General, Audit of the Civilian Health and Medical Program of the Department of Veterans Affairs, Report No. 06-03541-219, September 28, 2007, p. 1. Congressional Research Service 1 Health Care for Dependents and Survivors of Veterans aging Vietnam-era veterans with service-connected disabilities experience a worsening of symptoms and a change in disability status. Once a veteran becomes VA-rated permanently and totally disabled for a service-connected disability, the veteran’s spouse and dependents are then eligible to enroll in CHAMPVA. More recently, with the passage of the Caregivers and Veterans Omnibus Health Services Act of 2010 (P.L. 111-163), Congress has expanded CHAMPVA eligibility to include additional categories of non-veterans, such as caregivers of certain seriously injured veterans. Table A-1 provides a summary of major legislative changes that have affected the CHAMPVA program since 1973 (see Appendix A). Figure 1. CHAMPVA-Enrolled Beneficiaries, FY2001-FY2012 400.0 375.9 350.0 Enrollment (In Thousands) 305.0 317.0 325.2 339.6 355.9 300.0 285.0 250.0 248.6 224.3 200.0 186.5 150.0 126.3 100.0 96.5 50.0 0.0 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 Fiscal Year Source: Chart prepared by Congressional Research Service (CRS), based on data from U.S. Department of Veterans Affairs, Chief Business Office, Health Administration Center. The number of unique CHAMPVA users has also grown by 363% from 61,900 in FY2001 to 286,700 in FY2012 (see Figure 2). Unique users are enrollees who utilize health care at least once in a fiscal year. Appendix B provides a state-by-state breakdown of the number of CHAMPVA enrollees and unique users for FY2012. Congressional Research Service 2 Health Care for Dependents and Survivors of Veterans Figure 2. CHAMPVA Unique Users, FY2001-FY2012 350 300 Unique Users (In Thousands) 272.5 286.7 250.6 250 233.5 202.8 200 170.4 217.8 187.8 149.4 150 115.5 100 61.9 81.4 50 0 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 Fiscal Year Source: Chart prepared by Congressional Research Service (CRS), based on data from the U.S. Department of Veterans Affairs, Chief Business Office, Health Administration Center. Funding for CHAMPVA is provided through the VHA’s Medical Services account.7 As shown in Figure 3, spending for CHAMPVA (excluding administrative costs) has increased by 716.7% between FY2001 and FY2012. The average cost per patient has also increased from approximately $2,342 per patient in FY2001 to an estimated $4,141 per patient in FY2012. A demographic shift in CHAMPVA enrollees from less expensive younger beneficiaries to more expensive aging beneficiaries, “extension of CHAMPVA benefits to beneficiaries over the age of 65,”8 and the general inflation of medical costs are potential reasons for this increase in CHAMPVA expenditures. 7 For detailed information on VHA appropriations, see CRS Report R42518, Veterans’ Medical Care: FY2013 Appropriations, by Sidath Viranga Panangala. 8 Department of Veterans Affairs, Office of Inspector General, Audit of the Civilian Health and Medical Program of the Department of Veterans Affairs, Report No. 06-03541-219, September 28, 2007, p. 1. Congressional Research Service 3 Health Care for Dependents and Survivors of Veterans Figure 3. CHAMPVA Expenditures, FY2001-FY2012 $1,400 $1,200 Millions $1,000 $800 $600 $400 $200 $0 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 Expenditures 145.4 157.0 289.6 420.5 528.6 615.3 712.2 794.0 884.9 989.9 1,098.0 1,187.4 Source: Chart prepared by Congressional Research Service (CRS), based on data from U.S. Department of Veterans Affairs, Chief Business Office, Health Administration Center. The next section provides answers to frequently asked questions about the program. The questions are presented according to the following topics: eligibility, benefits, payments, and other relevant programs. Questions and Answers9 Eligibility Who Is Eligible to Receive CHAMPVA Benefits? Eligibility for CHAMPVA requires inclusion in one of the following categories:10 • the individual is the spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability; or • the individual is the surviving spouse or child of a veteran who died from a VArated service-connected disability; or 9 This part was drawn from: Department of Veterans Affairs Health Administration Center, CHAMPVA Handbook, at http://www.va.gov/hac/forbeneficiaries/champva/handbook/chandbook.pdf and http://www4.va.gov/hac/ forbeneficiaries/champva/champva.asp (accessed on March 27, 2013). 10 38 U.S.C. §1781; 38 C.F.R. §17.270-17.278; 38 C.F.R. §71.25. Congressional Research Service 4 Health Care for Dependents and Survivors of Veterans • the individual is the surviving spouse or child of a veteran who was at the time of death rated permanently and totally disabled from a service-connected disability; or • the individual is the surviving spouse or child of a military member who died on active duty, not due to misconduct (in most cases, these family members are eligible under TRICARE, not CHAMPVA); or • the individual is designated as a “primary family caregiver” of a seriously injured veteran and does not have any other form of health insurance.11 What Happens If a CHAMPVA-Eligible Spouse Divorces or Remarries? CHAMPVA eligibility is terminated by divorce or annulment of marriage to the qualifying veteran. CHAMPVA has specific eligibility rules for widows. When a CHAMPVA-eligible widow remarries, eligibility is terminated if the marriage occurs before the age of 55. As of February 4, 2003, a CHAMPVA-eligible widow who remarries at age 55 or older remains eligible for CHAMPVA. If a CHAMPVA-eligible widow under the age of 55 remarries, and the remarriage is later terminated, the widow is again eligible for CHAMPVA. When Does a Child Lose Eligibility? A child’s eligibility, excluding that of a helpless child,12 for CHAMPVA is terminated under the following conditions: • if the child is not enrolled in an accredited school as a full-time student, the child loses eligibility at age 18; or • if the child is enrolled in an accredited school as a full-time student, the child loses eligibility at age 2313 or upon losing full-time student status; or • if the child marries; or • if the child is a stepchild, the stepchild loses eligibility upon no longer living in the household of the sponsor. 11 Primary Family Caregiver means an individual who meets the requirements specified in 38 C.F.R. §71.25. A child who, before the age of 18, became permanently incapable of self-support and was rated as a helpless child by the VA, is eligible for CHAMPVA with no age limitation. For more information see Department of Veterans Affairs, Health Administration Center, CHAMPVA Handbook, May 2009, p. 10, http://www.va.gov/hac/forbeneficiaries/ champva/handbook/chandbook.pdf (accessed on April 1, 2013). 13 The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) required that a group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children to continue to make such coverage available for a dependent child until 26 years of age. This ACA requirement did not apply to CHAMPVA benefits. Congress may need to amend 38 U.S.C. §1781(c) if a policy choice is made to extend eligibility for coverage of children under CHAMPVA until they reach age 26 so that eligibility for coverage of children under CHAMPVA would be consistent with private sector coverage under the ACA. For more information see, CRS Report R41198, TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act (ACA), by Sidath Viranga Panangala and Don J. Jansen. 12 Congressional Research Service 5 Health Care for Dependents and Survivors of Veterans Benefits Which Medical Benefits Are Available to Eligible Beneficiaries? The CHAMPVA program covers most health care services and supplies that are determined to be medically necessary, including inpatient and outpatient care, prescription drugs, mental health services, and skilled nursing care. By law, CHAMPVA is required to provide health care benefits that are similar to the DOD’s TRICARE program. Chiropractic services, routine eye examinations, hearing aids, and most dental benefits are excluded from both the federal CHAMPVA and TRICARE programs.14 In late 2008, benefits were expanded to include any nondental prostheses and remove the exclusion from coverage of enuretic (bed-wetting) devices.15 Certain types of care require advance approval, commonly known as preauthorization. Generally, a CHAMPVA beneficiary determines if a provider will accept a CHAMPVA beneficiary; this is known as “accepting assignment.” This means that the provider will bill the VA directly for covered services, items, and supplies and will be paid the “allowable charge.” Doctors or providers who agree to accept assignment cannot try to collect more than the CHAMPVA deductible and cost share amounts from the beneficiary. If the provider does not accept assignment, the CHAMPVA beneficiary is responsible for paying the annual deductible, the cost share amount (copay), and any provider-billed amount that exceeds the total allowable amount. For care that is not covered by CHAMPVA, the beneficiary has to pay the full bill.16 For example, with very few exceptions, dental care is not a covered benefit. Currently, preauthorization is required for • durable medical equipment, • hospice services, • mental health/substance abuse services, • organ and bone marrow transplants, and • dental procedures that are directly related to covered medical conditions. What Is the CHAMPVA Policy on Abortion? The CHAMPVA program does not cover the cost of abortion counseling or abortion procedures unless a physician certifies that the life of the mother would be endangered should the fetus be carried to term.17 CHAMPVA does not cover the cost of abortion in cases of incest or rape. 14 38 C.F.R. §17.272. Department of Veterans Affairs, “Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): Expansion of Benefit Coverage for Prostheses and Enuretic Devices; Miscellaneous Provisions,” 73 Federal Register 65552, November 4, 2008. 16 Department of Veterans Affairs Health Administration Center. Fact Sheet 01-16 for Outpatient Providers and Office Managers. p. 1, available at http://www.va.gov/hac/factsheets/champva/FactSheet01-16.pdf (accessed March 27, 2013April 5, 2013). 17 TRICARE covers the cost of abortion when there is a threat to the life of the mother, or in cases of rape or incest as directed by 10 U.S.C. §1093. 15 Congressional Research Service 6 Health Care for Dependents and Survivors of Veterans Payments What Is the CHAMPVA Payment Structure? CHAMPVA is a cost-sharing program that reimburses at rates comparable to the Medicare and TRICARE programs. CHAMPVA has an outpatient deductible of $50 per person and $100 per family per calendar year. After the deductible is reached, CHAMPVA pays 75% of the allowable amount, and the beneficiary pays 25% of the total amount.18 The patient typically pays the cost share at the time the service is provided, unless the beneficiary has another health insurance plan. In cases where a beneficiary has another form of health insurance, CHAMPVA is the secondary payer (with the exception of the circumstances outlined in the question “What Happens If the Beneficiary Has Other Health Insurance?”), and pays the lesser of either 75% of the allowable amount after the deductible or the rest of the billed charges. There is a $3,000 cap on cost sharing per CHAMPVA-eligible family. There is also an exception to the payment scheme outlined here for instances in which medical services are rendered through VA facilities participating in the CHAMPVA In-house Treatment Initiative (CITI).19 What Happens If the Beneficiary Has Other Health Insurance? By law, CHAMPVA is generally the secondary payer for beneficiaries having any other form of health insurance. The primary health insurance company is billed first, and then beneficiaries submit an explanation of benefits (EOB) for additional reimbursement by CHAMPVA. Exceptions exist for beneficiaries with Medicaid, beneficiaries receiving care under the State Victims of Crime Compensation Program, beneficiaries receiving care from the Indian Health Service, or beneficiaries with a CHAMPVA supplementary insurance policy. In those cases, CHAMPVA is the first payer.20 How Are CHAMPVA Claims Processed? All CHAMPVA claims are processed through the VA Health Administration Center (HAC) in Denver, CO. Claims can be submitted by either the provider or the beneficiary, with each case requiring a different set of forms. All claims must be filed within one year after the date of service. For inpatient care, the claim must be filed within one year of the discharge date, and all payments will be made to the hospital regardless of which party submits the billing. Claims submitted after the one-year deadline will be denied. As of 2009, the reimbursement ceiling on durable medical equipment (DME) was raised to $2,000 to facilitate the administrative claims process and to accurately reflect the current costs of medical equipment.21 18 An allowable amount is the maximum payment that is authorized by the VA for a covered medial service or supply. 38 C.F.R. §17.274. 20 38 C.F.R. §17.275. 21 Department of Veterans Affairs, “(CHAMPVA): Preauthorization of Durable Medical Equipment,” 74 Federal Register 31373, July 1, 2009. 19 Congressional Research Service 7 Health Care for Dependents and Survivors of Veterans Other Programs What Is the Difference Between CHAMPVA and TRICARE? TRICARE is a health care program run by the DOD for families of active duty military service members, families of service members who died while on active duty, and retired military service men, women, and their families, regardless of their disability status. CHAMPVA is a comprehensive program run by the VA for eligible family members of veterans rated permanently and totally disabled for a service-connected disability or the family members of veterans who died from a VA-rated service-connected disability, whereas TRICARE has no disability criteria required for eligibility.22 The sponsoring veteran does not receive services through CHAMPVA, as he or she is eligible to receive services through the VA. Dependents of military retirees23 are not eligible for CHAMPVA, and must apply for benefits through TRICARE. What Is the Relationship Between CHAMPVA and Medicare? CHAMPVA is the secondary payer for beneficiaries with Medicare coverage. Under Section 3 of the Veterans’ Survivors Benefits Improvement Act of 2001 (P.L. 107-14), referred to as CHAMPVA for Life, CHAMPVA benefits were expanded to those over the age of 65 in the following circumstances. • If a beneficiary turns 65 before June 5, 2001, and only receives Medicare Part A, the beneficiary is eligible for CHAMPVA without having to purchase Medicare Part B coverage. • If a beneficiary turns 65 before June 5, 2001, and receives both Medicare Part A and Part B, the beneficiary must retain both parts to be eligible for continued CHAMPVA as secondary coverage. • If a beneficiary turns 65 on or after June 5, 2001, the beneficiary must be enrolled in Medicare Parts A and B to be eligible for CHAMPVA. • Enrollment in Medicare Part D is not required to become or remain eligible for CHAMPVA. • Individuals aged 65 or older who are not entitled to Medicare Part A retain CHAMPVA eligibility. 22 For further information on TRICARE, see CRS Report RL33537, Military Medical Care: Questions and Answers, by Don J. Jansen and Katherine Blakeley; also see http://www.TRICARE.osd.mil; relevant regulations are at 32 C.F.R. §199. 23 It should be noted that there is a distinction between a veteran and a military retiree. Title 38 of the United States Code defines a “veteran” as a person who has been discharged under conditions other than dishonorable from active military, naval, or air service, (38 U.S.C. §101). All military retirees, by definition, are veterans. However, to be considered a “military retiree,” an individual generally must have spent at least 20 years on active duty in the armed services. Congressional Research Service 8 Health Care for Dependents and Survivors of Veterans What Is the CHAMPVA In-House Treatment Initiative (CITI)? The CITI is a voluntary program for CHAMPVA beneficiaries that provides medical care through local VA facilities on a space-available basis. Beneficiaries receiving care at the VA through the CITI program are not required to pay a deductible or participate in cost sharing. No extra enrollment is necessary to participate in the CITI program; the beneficiary simply has to determine if the local VA is a participating facility. The majority of VA facilities are CITI participants. It is important to emphasize that care is delivered based on the availability of space. Beneficiaries on Medicare or who have an HMO plan as their primary insurance are not eligible for the CITI program. Congressional Research Service 9 Health Care for Dependents and Survivors of Veterans Appendix A. CHAMPVA Legislative History Table A-1. Major Legislation Affecting the CHAMPVA Program Year Summary Public Law 1973 The CHAMPVA program was established. P.L. 93-82 1976 Expanded the criteria under which surviving spouses and children would receive benefits following the death of the veteran. P.L. 94-581 1979 Authorized CHAMPVA coverage for dependents in the case of death of active duty service member when not covered by TRICARE. Authorized CHAMPVA coverage for unmarried children until the age of 23 if enrolled in a full-time course of education. P.L. 96-151 1982 Authorized CHAMPVA beneficiaries who lose their CHAMPVA health care eligibility by virtue of becoming eligible for Medicare benefits to regain their CHAMPVA eligibility once any of their Medicare benefits have been exhausted. P.L. 97-251 2001 Authorized the extension of CHAMPVA benefits to beneficiaries over the age of 65. Prior to 2001, beneficiaries over the age of 65 were not eligible for CHAMPVA because they were eligible for Medicare. P.L. 107-14 2002 Authorized a CHAMPVA-eligible widow who remarries at age 55 or older to remain eligible for CHAMPVA benefits. P.L. 107-330 2010 Authorized primary family caregivers of seriously injured veterans to enroll in CHAMPVA. P.L. 111-163 Source: Table prepared by the Congressional Research Service. Congressional Research Service 10 Health Care for Dependents and Survivors of Veterans Appendix B. CHAMPVA Enrollment and Unique Users, by State Table B-1. CHAMPVA-Enrolled Beneficiaries and Unique Users by State, FY2012 State Enrolled Unique Users 608 423 Alabama 8,802 6,860 Arkansas 8,617 7,206 Arizona 8,637 6,570 California 24,188 16,112 Colorado 5,633 4,204 Connecticut 1,888 1,431 District of Columbia 192 99 Delaware 780 589 Florida 30,518 23,656 Georgia 12,555 9,716 Hawaii 1,443 901 Iowa 3,109 2,444 Idaho 2,277 1,826 Illinois 7,539 5,496 Indiana 5,904 4,677 Kansas 2,874 2,321 Kentucky 8,563 7,277 Louisiana 6,704 5,165 Massachusetts 5,264 3,882 Maryland 3,255 2,279 Maine 4,157 3,382 Michigan 10,039 7,315 Minnesota 8,026 6,226 Missouri 8,397 6,818 Mississippi 4,558 3,755 Montana 2,320 1,817 North Carolina 16,969 13,800 North Dakota 914 703 Nebraska 3,505 2,870 New Hampshire 1,732 1,379 New Jersey 5,677 4,035 Alaska Congressional Research Service 11 Health Care for Dependents and Survivors of Veterans State Enrolled Unique Users New Mexico 5,533 4,056 Nevada 3,118 2,309 New York 12,377 8,336 Ohio 11,009 8,549 Oklahoma 12,614 10,129 Oregon 7,998 6,258 Pennsylvania 11,234 8,274 Rhode Island 1,191 882 South Carolina 8,892 7,214 South Dakota 1,536 1,235 Tennessee 10,395 8,525 Texas 33,586 25,751 Utah 1,899 1,503 Virginia 8,595 6,846 756 596 Washington 8,273 6,238 Wisconsin 7,979 6,171 West Virginia 6,485 5,281 Wyoming 698 553 American Samoa 108 42 Guam 318 158 Puerto Rico 4,785 2,120 Virgin Islands 30 10 Overseasa 876 148 Vermont Source: Table prepared by Congressional Research Service (CRS), based on data from U.S. Department of Veterans Affairs, Chief Business Office, Health Administration Center. a. CHAMPVA beneficiary lives in a foreign country. Author Contact Information Sidath Viranga Panangala Specialist in Veterans Policy spanangala@crs.loc.gov, 7-0623 Congressional Research Service 12 Health Care for Dependents and Survivors of Veterans Acknowledgments Michael Taylor, an intern in the Domestic Social Policy Division, provided research assistance for this report. Congressional Research Service 13