Medicare changes--can't get mask--Youre next

[andorra3]

In NY Medicare recently declared New York state a competitive bidding area for all sleep apnea products. They are slowly are expanding this across the country. When this happens you can access apnea supplies only from their designated suppliers.
What is happening in NY is that now that you are locked up with certain suppliers, Medicare has allowed the suppliers to severely restrict the type of masks they will supply. This month my supplier decided no more Resmed. Or at least now they are announcing it. Three month ago they told me I could not get my mirage swift and got me to agree to a substitution which did not fit and was useless. There are no companies within the NYC area that show my mask on the Medicare site. Apparently I will have to change to a distant company but only if I can get my current provider to send the volumes of information Medicare requires to the new company and if the company wants to accept me. When I called yesterday they were not enthusiastic about a new customer. I am at this point obtaining a prescription from my doctor and will have to order and pay myself while the red tape is straightened out. We should be writing to our congressmen and preventing this lack of access to reasonable life saving medical equipment from expanding.

[chunkyfrog]

If your doctor can write a letter of medical necessity that ONLY that mask will fit well enough for you to be treated,
then you should be able to get it, either from the approved supplier or another.
More paperwork, because the initial "no" is there to save money, but the appeals are there to save your life.
If we flood them with paperwork, the providers will start to complain to Medicare, and they will be listened to.
Edit: It just occurred to me that Resmed has a considerable stake in this, and you should speak to them.

[Sir NoddinOff]

.
That's not a good thing to hear about MediCare.

I know my insurance company has recently started clamping down on Rx meds of all sorts... they just say it's no longer in their formulary, sorry about that . You can get your doctor to fill out the reams of paperwork to get an exception, presumably a medical necessity, but good luck with that.

[KarenK]

I am in western New York and I have a Medicare Advantage plan, so I don't have to go to someone on *the list.* I use a Pilairo nasal cushion mask. My main place told me a few months ago that they would no longer carry the "old" Pilairo, so I bought a new one at a DME nearer my home. I went back to the original place yesterday to get a new hose and they had both the Pilairo and new Pilairo. BUT he said they are not supplying as many F&P masks as they used to.

[CapnLoki]

... There are no companies within the NYC area that show my mask on the Medicare site. Apparently I will have to change to a distant company but only if I can get my current provider to send the volumes of information Medicare requires to the new company and if the company wants to accept me. When I called yesterday they were not enthusiastic about a new customer. ...

So I did a quick check and found a number of suppliers for your area, but most are actually out of state. There were several within the city that seemed to carry most brands, including your mask, but that doesn't mean they actually stock everything. What I don't understand is how they can refuse a customer. I thought part of the competitive bidding system was that they had to accept everyone within the area.

[Catnapper]

I have experienced this in KY where I live. How can they fit a mask long distance?

Another change that really irritates me is the generic for my blood pressure medicine which cost $3 last year has become a Tire 4 drug and now costs $80 for a month's supply. Not only that, but it requires a medical exception. I said that if I have to pay the same for the generic as the name brand I should get the name brand. They replied that the insurance would not go for that because then they would have to pay a higher amount for their part.

Nice.

Catnapper-Joanie

[Janknitz]

Joanie, I can't speak to the mask situation because I don't know how that will all shake out, but as for meds, you learned a hard lesson.

EVERY YEAR during open enrollment time you MUST check out your meds with Part D providers to make certain how they will be covered in the coming year. These plans change every year. It's not Medicare, but your Part D provider"s formulary which changed. If you don't check the plan each year, you get complacent thinking the coverage will be the same, and then get stuck in the new year. You can call your local SHIP or HICAP for help evaluating plans or 1-800-medicare or medicare.gov. They will help you find a plan that best covers your meds Unfortunately, you're stuck this year, since open enrollment ended. But next year, Medicare.gov has a calculator you can use to evalute part D plans in your area with your med list.

[sleeplessinaz]

Which mask are you looking for? Many of us have storage boxes loaded with masks and mask parts so you may find one on here!
Let us know!
Carrie

[Wulfman...]

In NY Medicare recently declared New York state a competitive bidding area for all sleep apnea products. They are slowly are expanding this across the country. When this happens you can access apnea supplies only from their designated suppliers.
What is happening in NY is that now that you are locked up with certain suppliers, Medicare has allowed the suppliers to severely restrict the type of masks they will supply. This month my supplier decided no more Resmed. Or at least now they are announcing it. Three month ago they told me I could not get my mirage swift and got me to agree to a substitution which did not fit and was useless. There are no companies within the NYC area that show my mask on the Medicare site. Apparently I will have to change to a distant company but only if I can get my current provider to send the volumes of information Medicare requires to the new company and if the company wants to accept me. When I called yesterday they were not enthusiastic about a new customer. I am at this point obtaining a prescription from my doctor and will have to order and pay myself while the red tape is straightened out. We should be writing to our congressmen and preventing this lack of access to reasonable life saving medical equipment from expanding.

Got a copy of your prescription?
If you want/need one bad enough, you can order one from an online seller like CPAP-dot-COM, out-of-pocket.

I stocked up on everything BEFORE I got on Medicare. (and, paid for it all out-of-pocket)


Den

.

[wardmiller]

Medicare has allowed the suppliers to severely restrict the type of masks they will supply.

Can you cite a reference in a Medicare publication or their web site? I'm in NY and have not encountered that restriction. A lot of unwarranted blame is placed on Medicare's doorstep, often generated by DME's. I'd lean on the DME and ask management to cite the Medicate source of that action.

Getting a DME you trust and can work with can be worth the effort to change, in my experience.

[andorra3]

I just got a prescription and paid for a mask on line. I use the mirage swift2. My problem is that I pay for medicare and have supplementary through my pre-retirement employer and should have been able to get my prescription filled by them. The private insurer said I could use any medicare provider not just in network because the medicare approved providers now that they have been approved have been steadily cutting down on which equipment they will supply to maximize profits. I will attempt to switch to a more distant provider that lists my mask but that requires that my present provider forward to them all the information that medicare requires to issue a mask. This could be a lengthy process. So I bought one. There is no appeal as medicare approves of my mask, it is the provider whom has decided to cut down and not supply it.

Those of you who are on medicare or whom soon will be there should be concerned as this new policy hits your state.

[library lady]

KarenK, I also have a Medicare Advantage Plan (UCare Minnesota), and the way I understand it, UCare and other Advantage Plans accept the Medicare and DME assignment, and Medicare pays the Advantage Plans directly for its share of the bill, not the DME. I don't know how things will pan out for Medicare Advantage plans in terms of apnea supplies, but since my DME bills UCare, I suspect that I may have limited options too, when this gets to the Midwest states.

[Janknitz]

There is no appeal as medicare approves of my mask, it is the provider whom has decided to cut down and not supply it.

If people who have experiences like you don't FILE COMPLAINTS with Medicare, then nothing will be done. ResMed is probably the major mask manufacturer, and if a Medicare certified competitive bid winner is refusing to carry any ResMed masks on their formulary, then that IS something to complain about. If enough people complain, Medicare will step in. But if you just curse the darkness, people with fewer resources, who can't get on the internet to whine or afford their own masks, are going to be stuck.

And I second the suggestion to contact ResMed. They have a big stake in this--if other bid winners follow suit they will lose their shirt in the US. They should be stepping to the plate for all the people who have become dependent on their products over many, many years.

Finally, it never hurts to call "up the ladder" for your DME and ask what Wulfman suggests--"Show me where it says you don't have to carry an entire line of popular masks". It may be true--perhaps the Medicare regs don't require DME's to carry all of the popular brands as long as the lines they offer carry some FF masks, some nasal masks, some nasal pillow masks, and some hybrids. But if people who can't get the masks that work for them don't complain, the noose will get tighter and tighter.

Kaiser is my insurer--not Medicare yet--and they have a limited mask formulary. So I get that DME's and insurers can do that. But Kaiser's formulary is still pretty broad and does at least carry SOME masks from all of the major manufacturers--ResMed, Philips Respironics, and Fisher & Paykel.

[Sir NoddinOff]

Medicare has allowed the suppliers to severely restrict the type of masks they will supply.

Can you cite a reference in a Medicare publication or their web site? I'm in NY and have not encountered that restriction. A lot of unwarranted blame is placed on Medicare's doorstep, often generated by DME's. I'd lean on the DME and ask management to cite the Medicate source of that action. Getting a DME you trust and can work with can be worth the effort to change, in my experience.

I'm starting to get the feeling that some DMEs will use the ruse of "Medicare sez" or "Your insurance company sez" as a tool to steer their hapless clients into whatever product line, whether PR or ResMed, that tends to yield the most profit. With Obamacare thrown into the mix, the system is in a crazy flux pattern anyway... that opens the door to profit grabbing, just like when there's a natural disaster and local stores ream out the victims for weeks afterwards. Maybe I'm too cynical???.

[library lady]

Janknitz, you are so right... we do need to complain, but I haven't encountered the problem yet, and until I have facts to substantiate my complaints, I won't make any. If I find some facts before I need a new mask, I'll certainly do that. The more people who complain, the better.... starting with our DMEs.