ADP changes to CPAP in Ontario

[SleepWrangler]

Several have said they can upgrade to an APAP for a few hundred over the cost, averaging about 400-500$ out of pocket instead of the $215 for a CPAP.

ALL, with the exception of one, have told me that they will not sell me the S9 Elite for the approved price, they are only allowed to sell it for $215 out of the patients pocket, but most have quoted much higher, $350-400 on average, some forced a package deal of $500 with my choice of mask (which they cannot force, and at least a basic mask is to be included).

In terms of the overall process you're a month ahead of me. So one DME at least superficially agreed to sell an ResMed S9 Elite™ w/H5i™ Humidifier for the approved price? OK. Personally I'm inclined to favor an ADP funded ResMed S9 Elite if it comes w/H5i™ Humidifier and a backup mask and hose. If even that requires upgrades then there's no point in making this investment. Otherwise, $400 - $500 for a new AutoSet is a good deal.

[paradoiley]

You cannot get an AutoSet for $500 out of pocket.

In order to get ADP funding, the DME has to complete this form:

http://www.forms.ssb.gov.on.ca/mbs/ssb/ ... 93-67E.pdf

The requirements for getting an APAP are specific. If you don't meet the requirements, you have to select a machine from the CPAP list. In case you haven't found it yet, here it is http://www.health.gov.on.ca/en/pro/prog ... manual.pdf.

There is no provision in the rules for applying CPAP funding towards an APAP machine and paying the difference.

If you want APAP and you don't qualify, you or your insurance will have to pay for the whole thing yourself. Obviously the DME is not going to sell you an AutoSet for $500.

If you really want APAP, you need to talk to your insurance to find out what they will pay for. You need to find out if it is a requirement that you receive ADP funding before they cover the rest.

I think it's stupid, but this is what I ended up doing. Fortunately, my insurance did pay 90% of the full cost, so I wasn't out that much. They did require a note from the DME stating that ADP would not cover an APAP. I did also get an Rx from the doc for APAP though.

[ironhands]

Several have said they can upgrade to an APAP for a few hundred over the cost, averaging about 400-500$ out of pocket instead of the $215 for a CPAP.

ALL, with the exception of one, have told me that they will not sell me the S9 Elite for the approved price, they are only allowed to sell it for $215 out of the patients pocket, but most have quoted much higher, $350-400 on average, some forced a package deal of $500 with my choice of mask (which they cannot force, and at least a basic mask is to be included).

In terms of the overall process you're a month ahead of me. So one DME at least superficially agreed to sell an ResMed S9 Elite™ w/H5i™ Humidifier for the approved price? OK. Personally I'm inclined to favor an ADP funded ResMed S9 Elite if it comes w/H5i™ Humidifier and a backup mask and hose. If even that requires upgrades then there's no point in making this investment. Otherwise, $400 - $500 for a new AutoSet is a good deal.

As someone pointed out, the ADP has strict guidelines for an apap, and has nothing setup to allow a person to upgrade, BUT, some do anyway.

They may offer you an elite, but most likely they'll opt to provide you with the cheapest or most abundant unit they have in stock, so you may have to push a bit for a specific unit, but they are obligated to give you the unit best suited for you on the approved list, for $215 out of pocket. This *must* include a hose, humidifier, case, adapter. Its supposed to also include a basic mask, but I don't think anyone really knows what a basic mask is. I'd recommend just getting the mask from an online supplier, they're almost always cheaper.

Again I'll point out they CANNOT force you into an upgraded package. They are required to provide what I've listed above for $960 of which the ADP kicks in 75%. If they tell you any different they are violating the ADP policies and risk their license.
Nothing has changed with the ADP policies other than the costs. Some DMEs had 2 sets of prices, one for cash/insurance, and a more expensive ADP price, basically they were making extra profit from ADP sales and OHIP finally had enough. The S9 elite has been on their list for at least a year, and now they're obligated to sell it at a new low price, like most other CPAP machines. I'd recommend getting email quotes on your upcoming purchase. If they're not following the policies, I can give you an email address to have someone call them, officially.

[ironhands]

Oh, yeah. I got my elite today. 215$, full kit, no mask, but I already had a wisp I got for $100. Told the doc about my DME experiences and he said he'd call them if they wouldn't sell at the required price.

[SleepWrangler]

Oh, yeah. I got my elite today. 215$, full kit, no mask, but I already had a wisp I got for $100. Told the doc about my DME experiences and he said he'd call them if they wouldn't sell at the required price.

So I started talking to my Ontario based DME about prices. They provided a trial machine for 6 weeks (finish two weeks from now) for a flat $30 fee. Their brochure says the ADP provides partial funding for the CPAP device, heated humidifier (with starter water chamber), carrying case, standard tube, one filter, power cord, and user manual. This implies they do not supply a mask.

Of course this description fails to meet the ADP program criteria because they must also supply a basic mask and system configuration. It is an omission that implies they expect to always sell an upgraded mask. In addition they sell a series of optional kits starting at $150, $250, and $400. The brochure suggests one these kits are "required" to ensure good therapy. Wording is misleading. It is not required by the ADP.

Thing is I already purchased an S9 AutoSet and mask from the U.S to be picked-up in a couple of weeks. This particular DME will be supplying my backup unit so I'm only interested in ADP (75%) funded equipment and supplies. Also, I will offer to purchase the mask I used for the trial but only at near on-line pricing.

[thefabulousmrsk]

This thread has been so helpful! I go to purchase my machine this Thursday. I have actually met the criteria and been prescribed apap. So I'm planning on getting the resmed s9 autopap. Questions about what a "basic mask" is though. I'm currently using the Fisher and Paykel simplus and actually am quite comfortable with it.

[chunkyfrog]

Make sure it is not an Escape Auto, but an Autoset!

[SleepWrangler]

Questions about what a "basic mask" is though. I'm currently using the Fisher and Paykel simplus and actually am quite comfortable with it.

That's a good question. My guess is the cheapest the DME can supply, or nothing at all, but I'm a pessimist. Maybe report back what you find out.

The way the ADP rules are written I see no advantage to paying for an upgraded mask at the same time as purchasing the ADP funded package because you just lose the "basic mask" entirely and instead pay DME price for an upgrade. The word "upgrade" is confusing. More like a substitution. My DME mentioned an outrageous price for a ResMed Mirage FX ... something like $220. No way that's going to happen.

I suspect the DME premium service and corresponding prices are for fully insured clients. That is not my situation so getting them to provide value options will probably require some tough negotiating.

[ironhands]

I don't think anyone knows what a basic mask is, but yes, I would assume it's the cheapest.

But.

If what the DME says a basic mask is, and it doesn't suit your needs, you're stuck buying an upgraded one. That's the problem with the current ADP system, while they do a great job of keeping track of the machines, the masks don't really fall under much regulation. My advice, get the machine under the ADP with whatever they give you, and just buy the mask online after they give you a trial fitting. If you've done the CPAP trial at home for a while, you'll likely already know what mask works well and can order it. Just make up some excuse to not buy the mask at the DME while you're there.

[thefabulousmrsk]

I'm going in with the approved pricing list in hand. I actually work for the government of Ontario.. I plan on using that clout when I go in to purchase, in a nice way of course.

I can pay for the mask I suppose because I do get work coverage. I just don't like the idea of being overcharged or gouged for no reason. I'm going to call ADP today and see if there's any pricing paramaters around "basic mask". I'm assuming I won't get a clear answer but I want to be as informed as possible

[ironhands]

I'm going in with the approved pricing list in hand. I actually work for the government of Ontario.. I plan on using that clout when I go in to purchase, in a nice way of course.

I can pay for the mask I suppose because I do get work coverage. I just don't like the idea of being overcharged or gouged for no reason. I'm going to call ADP today and see if there's any pricing paramaters around "basic mask". I'm assuming I won't get a clear answer but I want to be as informed as possible

you won't. Last time I spoke to someone on the phone they couldn't even tell me if the pricing change would save me money or not (despite the FAQ clearly stating it would). All they'll likely tell you is that it's supposed to include a mask, but the DME will likely say that their "basic mask" doesn't suit your needs. I wouldn't pull out the ADP price sheet right away when you're there. Ask them about pricing and such first and see how far they try and gouge you, then watch them go pale when you pull out the sheet and mention you're a government employee

[thefabulousmrsk]

ADP was so helpful! The agent told me that the machine should have a mask within the box. (this is the first I've heard of this??) It will more than likely be hard plastic mask. He told me it probably makes more sense to take the basic mask and shop around for a better mask, because he said he's heard from people paying $300 for a mask. I guess I'll see what they are charging and I will go in with quotes from other places as to what I can get it for. If they are gouging I won't purchase. I would prefer to stay with what I like but I won't overpay for it.

[ironhands]

ADP was so helpful! The agent told me that the machine should have a mask within the box. (this is the first I've heard of this??) It will more than likely be hard plastic mask. He told me it probably makes more sense to take the basic mask and shop around for a better mask, because he said he's heard from people paying $300 for a mask. I guess I'll see what they are charging and I will go in with quotes from other places as to what I can get it for. If they are gouging I won't purchase. I would prefer to stay with what I like but I won't overpay for it.

I've never seen one in the box, but yeah, they're supposed to provide at least something for free.

I was going to PM you, but I see you're not registered. Where are you in Ontario?

[Guest]

Yeah I registered now. Lol, took me a while to figure out how. I'm in Toronto.

[thefabulousmrsk]

LOL, I registered but didn't sign in. I slept well last night so I can't even use that as an excuse.