TRICARE and VA Health Care:
Impact of the Patient Protection and
Affordable Care Act (ACA)
Sidath Viranga Panangala
Specialist in Veterans Policy
Don J. Jansen
Analyst in Defense Health Care Policy
April 22, 2013
Congressional Research Service
7-5700
www.crs.gov
R41198
CRS Report for Congress
Pr
epared for Members and Committees of Congress
TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act
Summary
The 111th Congress passed, and the President signed into law, the Patient Protection and
Affordable Care Act (P.L. 111-148; ACA), which was later amended by the Health Care and
Education Reconciliation Act of 2010 (P.L. 111-152; HCERA), and is hereafter referred to as
ACA. In general, ACA did not make any significant changes to the Department of Defense
(DOD) TRICARE program or to the Department of Veterans Affairs (VA) health care system.
However, many have sought clarification as to whether certain provisions in ACA, such as a
mandate for most individuals to have health insurance, or extending dependent coverage up to
age 26, would apply to TRICARE and VA health care beneficiaries.
To address some of these concerns, Congress has introduced and/or enacted legislation. The
TRICARE Affirmation Act (P.L. 111-159), signed into law on April 26, 2010, affirms that
TRICARE satisfies the minimum acceptable coverage requirement in ACA. Similarly, P.L. 111-
173, signed into law on May 27, 2010, clarifies that the Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA), Spina Bifida Health Care Program, and the
Children of Women Vietnam Veterans Health Care Program meet the “minimum essential
coverage” requirement under ACA. TRICARE coverage of children was extended to age 26 by
the Ike Skelton National Defense Authorization Act for Fiscal Year 2011 (P.L. 111-383).
ACA requires that if a health insurance plan provides for dependent coverage of children, the plan
must continue to make such coverage available for an adult child until age 26. This requirement
relating to coverage of adult children took effect for the plan years beginning on or after
September 23, 2010. Under ACA, both married and unmarried children qualify for this coverage.
The authorizing statute for CHAMPVA currently does not conform to this ACA requirement.
Furthermore, although the TRICARE authorizing statute has been amended to provide for
coverage of children until age 26, the coverage provided by the new legislation differs from that
required by ACA in some important ways. To address CHAMPVA’s nonconformance with ACA’s
requirements, the CHAMPVA Children’s Protection Act (H.R. 288) and a similar measure (S.
325) have been introduced in the 113th Congress.
This report addresses key questions concerning how ACA affects TRICARE and VA health care.
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TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act
Contents
Introduction ...................................................................................................................................... 1
Background ...................................................................................................................................... 2
TRICARE .................................................................................................................................. 2
The VA Health Care System and Eligibility for Care ................................................................ 2
Civilian Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA).................................................................................................................... 3
Questions and Answers .................................................................................................................... 4
How Does ACA Affect TRICARE? .......................................................................................... 4
How Does ACA Affect VA Health Care? .................................................................................. 5
Do TRICARE and VA Health Care Meet “Minimum Essential Coverage”
Requirements? ........................................................................................................................ 5
Will CHAMPVA, and VA Coverage of Children with Spina Bifida and Certain Birth
Defects Meet the “Minimum Essential Coverage” Requirement? ......................................... 6
Does ACA Require TRICARE to Provide Coverage to Dependent Children Up to Age
26? .......................................................................................................................................... 6
Will ACA Extend Coverage to Dependent Children Under CHAMPVA Up to Age 26? .......... 7
Will ACA Affect the Cost of Prescription Drugs and Medical Devices Provided to
Veterans? ................................................................................................................................ 9
Contacts
Author Contact Information............................................................................................................. 9
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TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act
Introduction
On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (P.L.
111-148, ACA). On March 30, 2010, ACA was amended by P.L. 111-152, the Health Care and
Education Reconciliation Act of 2010 (HCERA). Throughout this report, this amended version is
referred to as ACA. This health reform legislation touched on many aspects of the nation’s health
care delivery and financing systems. However, in general, ACA did not make any significant
changes to the Department of Defense (DOD) TRICARE program or to the Department of
Veterans Affairs (VA) health care system.
Among its numerous provisions, ACA (when fully implemented in 2014) will require most
individuals, large employers, and health plans to meet certain coverage requirements. Beginning
in 2014, ACA includes a mandate for most individuals to have health insurance,1 or potentially
pay a penalty for noncompliance.2 Individuals will be required to maintain minimum essential
coverage for themselves and their dependents. Those who do not meet the mandate will be
required to pay a penalty for each month of noncompliance. Under ACA, private health insurance
provisions that take effect prior to 2014 (including some this year) include the following: ending
lifetime and “unreasonable” annual limits on benefits, prohibiting rescissions of health insurance
policies, requiring coverage of preventive services and immunizations, extending dependent
coverage up to age 26, capping insurance companies’ nonmedical administrative expenditures,
guaranteeing coverage for preexisting health conditions for enrollees under age 19, and providing
assistance for those who are uninsured because of a preexisting condition. Furthermore, ACA
raises revenues to pay for expanded health insurance coverage by imposing excise taxes and fees
on industries in the health care sector, limiting tax-advantaged health accounts, and increasing the
Medicare payroll tax on upper-income households and adding an additional tax on net investment
income on upper-income households.3
Since the enactment of ACA, concerns have been raised by veterans and Veterans Service
Organizations (VSOs) on how the new law would affect TRICARE beneficiaries, as well as
veterans and certain dependents receiving care through the VA health care system.4 Moreover,
many have sought clarification as to whether certain provisions in ACA, such as a mandate for
most individuals to have health insurance, or extending dependent coverage up to age 26, would
apply to TRICARE and VA health care beneficiaries.5 Although the Obama Administration issued
statements assuring that the two health care systems would not be negatively affected, some
veterans groups have requested statutory clarification.6 To address some of these concerns,
1 §1501(b) as amended by §10106 (b) of P.L. 111-148 and by §1002 of P.L. 111-152.
2 §1501 of P.L. 111-148 includes congressional findings that address the constitutionality of an individual mandate to
obtain health insurance. For more information on this issue, see CRS Report R42698, NFIB v. Sebelius:
Constitutionality of the Individual Mandate, by Erika K. Lunder and Jennifer Staman.
3 For further details on provisions in PPACA, see Congressional Research Service, Issues in Focus, Health, Affordable
Care Act and Health Policy available at http://www.crs.gov/pages/subissue.aspx?cliid=3746&parentid=13&preview=
False (accessed April 17, 2013).
4 Michael Posner, “Veterans Push For Fixes To New Law,” Congress Daily, April 6, 2010.
5 Jane Norman, “Military Families Left Out of Expanded Health Coverage for Adult Children,” CQ HealthBeat CQ
Today, September 27, 2010.
6 Ibid. Also see Department of Veterans Affairs, “Statement from VA Secretary Eric K. Shinseki,” press release, March
21, 2010, http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1871(acessed April 17, 2013) ; Department of Defense,
“Tricare Meets Health Care Bill’s Standards, Gates Says,” press release, March 22, 2010, http://www.defense.gov//
(continued...)
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Congress has introduced and/or enacted legislation. This report, one of a series of CRS products
on ACA, addresses key questions concerning the impact of enactment of the ACA on the
TRICARE and VA health care programs. To provide some context to this discussion, the report
begins with a brief overview of the two health care systems and eligibility for care under each
system.
Background
TRICARE7
The Department of Defense (DOD) administers health care services through a program known as
TRICARE to over 9 million eligible beneficiaries that include active duty uniformed personnel
and their dependents, eligible members of the Reserve Component and their dependents, and
uniformed services retirees and their dependents and survivors. TRICARE provides health care
services through both military and nonmilitary hospitals, clinics, and other providers. TRICARE
is administered on a regional basis by the TRICARE Management Activity, which uses a regional
managed care support contractor to develop networks of civilian providers and process
beneficiary claims in each of its North, South, and West regions. TRICARE has three basic
options for non-Medicare eligible beneficiaries: TRICARE Prime, which is a managed care
option that relies primarily upon military providers and treatment facilities; a fee-for-service
option known as TRICARE Standard; and a preferred-provider option known as TRICARE Extra.
Individuals who are eligible for Medicare and otherwise eligible for TRICARE may enroll in
Medicare Part B and receive “wrap-around” TRICARE coverage through the TRICARE for Life
Program, which covers costs not paid by Medicare that would otherwise be incurred by the
beneficiary.
The VA Health Care System and Eligibility for Care8
The Department of Veterans Affairs (VA), through the Veterans Health Administration (VHA),
operates the nation’s largest integrated direct health care delivery system.9 While Medicare,
Medicaid, and the Children’s Health Insurance Program (CHIP) are also publicly funded
programs, most health care services under these programs are delivered by private providers in
private facilities. In contrast, the VA health care system could be categorized as a veteran-specific
(...continued)
News/NewsArticle.aspx?ID=58412 (accessed April 17, 2013); and Letter from Kathleen Sebelius, Secretary of Health
and Human Services, to Honorable Max Baucus, Chairman, Senate Committee on Finance, March 24, 2010 (copy
available from the authors)http://www.tricare.mil/downloads/Baucus PPACA.PDF.
7 For more detailed information on the TRICARE program, see CRS Report RL33537, Military Medical Care:
Questions and Answers, by Don J. Jansen and Katherine Blakeley.
8 For a complete discussion of eligibility for VA health care, priority groups, and enrollment, see CRS Report R42747,
Health Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin Bagalman.
9 U.S. Department of Veterans Affairs, FY 2008 Performance and Accountability Report, Washington, DC, November
17, 2008, p. 10. Established on January 3, 1946, as the Department of Medicine and Surgery by P.L. 79-293, succeeded
in 1989 by the Veterans Health Services and Research Administration, renamed the Veterans Health Administration in
1991.
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national health care system in the sense that the federal government owns the medical facilities
and employs the health care providers.10
In general, eligibility for VA health care is based on veteran status,11 presence of service-
connected disabilities12 or exposures,13 income,14 and/or other factors, such as status as a former
prisoner of war or receipt of a Purple Heart.
The VHA also pays for care provided to veterans by private-sector providers on a fee basis under
certain circumstances. Inpatient and outpatient care are also provided in the private sector to
eligible dependents of veterans under the Civilian Health and Medical Program of the Department
of Veterans Affairs (CHAMPVA; see discussion below). All enrolled veterans are offered a
standard medical benefits package.15
Veterans do not pay premiums or enrollment fees. However, under current law most veterans are
required to pay copayments for the treatment of nonservice-connected conditions.16 It should be
noted that those veterans who are rated 50% or more service-connected disabled and enrolled in
the VA health care system do not pay copayments even for nonservice-connected care. Moreover,
VA is required to collect reasonable charges for medical care or services (including prescription
drugs) from a third-party insurer to the extent that the veteran or the provider of the care or
services would be eligible to receive payment from a third-party insurer for a nonservice-
connected disability for which the veteran is entitled to care (or the payment of expenses of care)
under a health insurance plan.17
Civilian Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA)18
Unlike TRICARE, VA health care covers only a select group of dependents. In 1973, Congress
established the Civilian Health and Medical Program of the Department of Veterans Affairs
10 Adam Oliver, “The Veterans Health Administration: An American Success Story?” The Milbank Quarterly, vol. 85,
no. 1 (March 2007), pp. 5-35.
11 Veteran’s status is established by active-duty status in the U.S. Armed Forces and an honorable discharge or release
from active military service. Generally, persons enlisting in one of the armed forces after September 7, 1980, and
officers commissioned after October 16, 1981, must have completed two years of active duty or the full period of their
initial service obligation to be eligible for VA health care benefits. Service members discharged at any time because of
service-connected disabilities are not held to this requirement.
12 A service-connected disability is a disability that was incurred or aggravated in the line of duty in the U.S. Armed
Forces (38 U.S.C. §101 (16)). 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% (38 C.F.R. §§4.1-4.31).
13 For example, veterans who may have been exposed to Agent Orange during the Vietnam War or veterans who may
have diseases potentially related to service in the Gulf War may be eligible to receive care.
14 Veterans with no service-connected conditions and who are Medicaid eligible, or who have an income below a
certain VA means-test threshold and below a median income threshold for the geographic area in which they live, are
also eligible to enroll in the VA health care system.
15 A detailed listing of VHA’s standardized medical benefits package is available at 38 C.F.R. §17.38 (2010).
16 38 U.S.C. §1729.
17 38 U.S.C. §1729(a)(2)(D); 38 C.F.R. §17.101(a)(1)(i) (2010).
18 For more information, see CRS Report RS22483, Health Care for Dependents and Survivors of Veterans, by Sidath
Viranga Panangala.
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(CHAMPVA) as a means of providing health care services to dependents and survivors of certain
veterans.19 CHAMPVA primarily is a fee-for-service program that provides reimbursement for
most medical care for certain eligible dependents and survivors of veterans rated permanently and
totally disabled from a service-connected condition. Eligibility for CHAMPVA requires inclusion
in one of the following categories:20
• 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 VA-
rated service-connected disability; or
• 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.21
Questions and Answers
How Does ACA Affect TRICARE?
In general, ACA does not affect TRICARE administration, health care benefits, eligibility, or cost
to beneficiaries.
ACA does open a special Medicare Part B enrollment window to enable certain individuals to
gain coverage under the TRICARE for Life program.22 TRICARE was extended to Medicare-
eligible military retirees, their Medicare-eligible spouses and dependent children, and Medicare-
eligible widow/widowers by the Floyd D. Spence National Defense Authorization Act of 2001
(P.L. 106-398). This law established the TRICARE for Life (TFL) program, which acts as a
secondary payer to Medicare and provides supplemental coverage to TRICARE-eligible
beneficiaries who are entitled to Medicare Part A based on age, disability, or end-stage renal
disease (ESRD). In order to participate in TFL, these TRICARE-eligible beneficiaries must enroll
in and pay premiums for Medicare Part B. TRICARE-eligible beneficiaries who are entitled to
Medicare Part A based on age, disability, or ESRD, but decline Part B, lose eligibility for
TRICARE benefits.23 In addition, individuals who choose not to enroll in Medicare Part B upon
becoming eligible may elect to do so later during an annual enrollment period; however, the
Medicare Part B late enrollment penalty would apply. ACA also waives the Medicare Part B late
19 Veterans Health Care Expansion Act of 1973 (P.L. 93-82).
20 38 U.S.C. §1781; 38 C.F.R. §17.270-17.278; 38 C.F.R. §71.25.
21 Primary Family Caregiver means an individual who meets the requirements specified in 38 C.F.R. §71.25.
22 §3110 of PPACA.
23 10 U.S.C. §1086(d).
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enrollment penalty during the 12-month special enrollment period (SEP) for military retirees,
their spouses (including widows/widowers), and dependent children who are otherwise eligible
for TRICARE and are entitled to Medicare Part A based on disability or ESRD, but have declined
Part B. The Secretary of Defense is required to identify and notify individuals of their eligibility
for the SEP; the Secretary of Health and Human Services (HHS) and the Commissioner for Social
Security must support these efforts. This section was amended by the Medicare and Medicaid
Extenders Act of 201024 to clarify that Section 3110 applies to Medicare Part B elections made on
or after the date of enactment of ACA. This is the only provision in ACA that has an effect on
beneficiary eligibility under the TRICARE program.
A 2011 Government Accountability Office report indicates that, overall, DOD expects to incur
minimal costs to implement applicable ACA and HCERA provisions with which department
officials have determined it is required to comply.25
How Does ACA Affect VA Health Care?
In general, ACA does not appear to affect current VA health care benefits, eligibility, or cost to
beneficiaries.
However, ACA does contain several provisions related to the VA. Specifically, it includes a
provision (§9011) that requires the VA to report to Congress on the effect to VA health care
regarding the annual fee imposed by ACA on certain manufacturers and importers of branded
prescription drugs, as well as the new excise tax imposed on the sale of medical devices by
manufacturers, producers, or importers (see question on medical devices later in this report).
Furthermore, it requires VA to participate in the Interagency Working Group on Health Care
Quality (§3012), exempts the VA from a fee on all health insurers based on their market share
(§4377), and provides VA access to the National Practitioner Data Bank without a charge (§6403).
Do TRICARE and VA Health Care Meet “Minimum Essential
Coverage” Requirements?
It appears that TRICARE beneficiaries and veterans enrolled in the VA health care system would
meet the minimum essential coverage requirements of ACA.
ACA requires certain individuals to maintain minimal essential health care coverage and provides
a penalty for failure to maintain such coverage beginning in 2014. “Minimum essential coverage”
is explicitly defined as coverage under VA Health Care; Medicare Part A; Medicaid; CHIP; the
TRICARE for Life program; the Peace Corps program; an eligible employer-sponsored plan (as
defined by ACA); a governmental plan (local, state, federal) including the Federal Employees
Health Benefits Program (FEHBP) and any plan established by an Indian tribal government; any
plan offered in the individual, small group, or large group market; a grandfathered health plan;
and any other health benefits coverage, such as a state health benefits risk pool, as recognized by
the HHS Secretary in coordination with the Treasury Secretary. The relevant definition26 of
24 §201, P.L. 111-309.
25 U.S. Government Accountability Office, Impact of Health Care Reform Legislation on the Department of Defense,
GAO-11-837R, September 26, 2011, p. 2, http://www.gao.gov/new.items/d11837r.pdf.
26 See 42 U.S.C. 300gg-91(d)(8).
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“government plan” includes the TRICARE program beyond the TRICARE for Life program.
However, because TRICARE is not explicitly listed as minimum essential coverage, some
concern had been expressed by beneficiary groups that regular TRICARE coverage may not meet
the requirement. The TRICARE Affirmation Act (H.R. 4887; P.L. 111-159), signed into law on
April 26, 2010, amends the Internal Revenue Code to provide that TRICARE coverage satisfies
the minimum essential coverage requirements as required by ACA. Likewise, P.L. 111-173,
signed into law on May 27, 2010, clarifies that those enrolled in the VA health care system meet
the minimum essential coverage requirement.
Will CHAMPVA, and VA Coverage of Children with Spina Bifida
and Certain Birth Defects Meet the “Minimum Essential Coverage”
Requirement?
It was initially unclear whether the Spina Bifida Health Care Program (SBHCP) and the Children
of Women Vietnam Veterans Health Care Program (CWVV) met the “minimum essential
coverage” requirement under ACA. However, P.L. 111-173, signed into law on May 27, 2010,
clarifies that CHAMPVA, SBHCP, and CWVV meet the minimum essential coverage
requirement.
VA administers the Spina Bifida Health Care Program (SBHCP) for those biological children
diagnosed with spina bifida of veterans who served in Vietnam, and of veterans who served in
Korea during the period September 1, 1967, through August 31, 1971.27 The program provides
reimbursement for comprehensive medical care for those beneficiaries diagnosed with spina
bifida except for conditions associated with spina bifida occulta. Similarly, VA administers the
Children of Women Vietnam Veterans Health Care Program (CWVV). Under this program, VA
reimburses for care of certain birth defects identified by the VA as resulting in permanent physical
or mental disability of the biological child of a woman veteran who served in Vietnam between
February 28, 1961, and May 7, 1975.28
Does ACA Require TRICARE to Provide Coverage to Dependent
Children Up to Age 26?
The ACA provision extending health insurance coverage to dependent children until age 26 did
not extend to TRICARE beneficiaries.
Subsequent to the passage of the ACA, however, the Ike Skelton National Defense Authorization
Act for Fiscal Year 2010 (P.L. 111-383) authorized a new TRICARE option now known as the
TRICARE Young Adult Program,29 that allows children up to age 26 who lose coverage under a
parent’s TRICARE policy, and who are not otherwise eligible to enroll in an employer-sponsored
plan, to purchase TRICARE coverage for themselves.
27 38 U.S.C. §§1803; 1821.
28 38 U.S.C. §§1811; 1812; 1813.
29 http://www.tricare.mil/Welcome/Plans/TYA.aspx (accessed April 22, 2013).
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In general, eligibility for TRICARE under a parent’s policy is lost when either a dependent child
turns 23 (if enrolled in an accredited school as a full-time student) or 21 if not enrolled. Section
1001 of ACA amends Part A of Title XXVII of the Public Health Service Act (PHSA) to add a
new Section 2714 specifying that a group health plan and a health insurance issuer offering group
or individual health insurance coverage that provides dependent coverage of children shall
continue to make such coverage available until the dependent child turns 26 years of age.
However, the provisions of title XXVII of the PHSA do not appear to apply to TRICARE.30
Coverage under the TRICARE program is governed by Chapter 55 of Title 10, United States
Code. Under 10 U.S.C. §1072(2)(D), the term “dependent” only includes a child who has not
attained the age of 21 or has not attained the age of 23 and is enrolled in a full-time course of
study at an institution of higher learning.
Section 702 of the Ike Skelton National Defense Authorization Act for Fiscal Year 2010 (P.L. 111-
383)31 amended title 10, to add a new Section 1110b extending coverage to children up to age 26
who are not otherwise eligible to enroll in an employer-sponsored plan to purchase TRICARE
coverage. The premium would be equal to the cost of the coverage as determined by the Secretary
of Defense on an appropriate actuarial basis. The program is effective retroactively, not later than
January 1, 2011. The program is known as the “TRICARE Young Adult Program. For calendar
year 2013 the monthly premium for a TRICARE Young Adult (TYA) Prime enrollment is $176
and $152 for a TYA Standard enrollment.32 As of June, 2012, there were approximately 11,171
beneficiaries enrolled in TYA Standard and 6,407 in TYA Prime.
The premium feature does make the TRICARE program dissimilar from the coverage mandated
by ACA. The ACA provision amended the Public Health Service Act to include a Section 2714
that provides:
A group health plan and a health insurance issuer offering group or individual health
insurance coverage that provides dependent coverage of children shall continue to make such
coverage available for an adult child (who is not married) until the child turns 26 years of
age.
Department of Health and Human Services regulations have interpreted this to extend dependent
coverage, not create a new policy for which a separate premium would be charged.33
Will ACA Extend Coverage to Dependent Children Under
CHAMPVA Up to Age 26?
The provision extending health insurance coverage to dependent children until age 26 in ACA
does not appear to extend to CHAMPVA beneficiaries.
30 See 42 U.S.C. §300gg-21(b), as amended by PPACA (containing limitations on the applicability of the Public Health
Services Act provisions).
31 H.R. 6523 was signed into law on January 7, 2011.
32 http://www.tricare.mil/Welcome/Plans/TYA.aspx (accessed April 22, 2013).
33 Department of the Internal Revenue Service, Department of the Treasury; Employee Benefits Security
Administration, Department of Labor; Department of Health and Human Services , “Interim Final Rules for Group
Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient
Protection and Affordable Care Act,” 75 Federal Register 27122-27140, May 13, 2010.
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In general, eligibility for CHAMPVA is lost when either a child (other than a helpless child)34
turns 18, unless the child is enrolled in an accredited school as a full-time student; a child, who
has been a full-time student, turns 23 or loses full-time student status; a child marries; or a
stepchild who no longer lives in the household of the sponsor.
Section 1001 of ACA amends Part A of Title XXVII of the PHSA to add a new Section 2714
specifying that a group health plan and a health insurance issuer offering group or individual
health insurance coverage that provides dependent coverage of children shall continue to make
such coverage available for an adult child until the child turns 26 years of age. This requirement
relating to coverage of adult children took effect for the plan years beginning on or after
September 23, 2010.35 However, the provisions of Title XXVII of the PHSA do not appear to
apply to CHAMPVA.36 During the 111th Congress, the House-passed version of the National
Defense Authorization Act (NDAA) for FY2011 (H.R. 5136, H.Rept. 111-491) included a
provision that would have extended dependent coverage under CHAMPVA until age 26.
However, the final version of the FY2011 NDAA (H.R. 6523; P.L. 111-383) did not include any
provision to extend CHAMPVA coverage to eligible dependent children up to age 26.37
In the 113th Congress, the CHAMPVA Children’s Protection Act of 2013 (H.R. 288) and a similar
measure (S. 325) have been introduced. These measures, if enacted, would extend eligibility for
coverage of children under CHAMPVA until they reach age 26, so that eligibility for coverage of
children under CHAMPVA will be consistent with provisions in the ACA. In the 112th Congress,
the Senate Veterans’ Affairs Committee held a hearing on S. 490 (a measure similar to S.
325[113th]). At this hearing the Administration provided its views on S. 490:
VA supports S. 490, which would amend 38 U.S.C. § 1781(c) to extend eligibility for
coverage of children under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) until they reach age 26 so that eligibility for coverage of
children under CHAMPVA will be consistent with private sector coverage under the
Affordable Care Act. S. 490 would extend eligibility for coverage of children under
CHAMPVA regardless of age, marital status, and school enrollment status up to the age of
26; and the bill would ensure that CHAMPVA eligibility would not be limited for
individuals described in § 101 (4)(A)(ii) (individuals who, before attaining age 18, became
permanently incapable of self-support). The amendments made by S. 490 would apply with
respect to medical care provided on or after the date of enactment of the bill. The extension
of eligibility to age 26 would not be limited to children who are currently enrolled in or even
those who are currently eligible for CHAMPVA. This is because we read this bill to provide
that a “child who is eligible for benefits” under § 1781(a) will still be considered an eligible
“child” until his or her 26th birthday, notwithstanding the age limits in 38 U.S.C. § 101(4).
We offer for the Committee’s information that S. 490 would not extend eligibility for
children who, before January 1, 2014, are eligible to enroll in an eligible employer-sponsored
health plan (as defined in I.R.C. § 5000A(f)(2)). This means that the age, school status, and
marital status requirements in 38 U.S.C. § 101(4) will, before 2014, apply to children who
are eligible to enroll in an eligible employer-sponsored health plan and would not extend
34 A helpless child is established after a fact-based analysis completed by a VA Regional Office determines the child to
be permanently incapable of self-support by the age of 18. See 38 C.F.R. §3.356 and http://www.va.gov/hac/
forbeneficiaries/champva/handbook/chandbook.pdf.
35 45 CFR 147.120.
36 See 42 U.S.C. 300gg-91(b)(1).
37 During the 111th Congress, four stand-alone measures were introduced to extend CHAMPVA coverage to eligible
dependent children up to age 26: H.R. 5185, H.R. 5206, S. 3356, and S. 3801.
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eligibility for coverage of those individuals. This provision in the bill is thus in accordance
with the discretion provided to grandfathered health plans that are group health plans in the
private sector under the Affordable Care Act. VA estimates the cost of implementing S. 490
to be $64.6 million in fiscal year 2012, $390.5 million over five years, and $1.022 billion
over ten years.”38
Will ACA Affect the Cost of Prescription Drugs and Medical
Devices Provided to Veterans?
It is unclear at this time whether ACA will affect the cost of prescription drugs and medical
devices provided to veterans.
Under current law, there are excise taxes on sales by manufacturers of certain products. Certain
sales are exempt from this tax.39 ACA imposes an annual fee on certain manufacturers and
importers of branded prescription drugs (including biological products and excluding orphan
drugs). The fee structure is based on annual sales and is set to reach a certain revenue target each
year.40 In addition, under ACA a new excise tax of 2.3% is imposed on the sale of medical devices
by manufacturers, producers, or importers.41 This provision exempts eyeglasses, contact lenses,
hearing aids, and any device of a type that is generally purchased by the public at retail for
individual use. The tax applies to sales of devices made after December 31, 2012.42 Section 9011
of ACA required the Secretary of Veterans Affairs to conduct a study on the effect of provisions in
Title IX of ACA—in particular the new fees on drug and device manufacturers—on the cost of
medical care provided to veterans, and veterans’ access to medical devices and branded
prescription drugs. The Secretary was required to report the results of such a study to the House
Committee on Ways and Means and the Senate Committee on Finance.
Author Contact Information
Sidath Viranga Panangala
Don J. Jansen
Specialist in Veterans Policy
Analyst in Defense Health Care Policy
spanangala@crs.loc.gov, 7-0623
djansen@crs.loc.gov, 7-4769
38 U.S. Congress, Senate Committee on Veterans’ Affairs, Pending Legislation, 112th Cong., 1st sess., June 8, 2011
(Washington: GPO, 2011), pp. 22-23.
39 See Internal Revenue Code Chapter 32.
40 For more detailed information see, CRS Report R42971, Medical Device Excise Tax Regulations, by Andrew Nolan.
41 Ibid.
42 For more detailed information see, CRS Report R41128, Health-Related Revenue Provisions in the Patient
Protection and Affordable Care Act (ACA), by Janemarie Mulvey; and CRS Report R42971, Medical Device Excise
Tax Regulations, by Andrew Nolan.
Congressional Research Service
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