ADP changes to CPAP in Ontario

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
ironhands
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Re: ADP changes to CPAP in Ontario

Post by ironhands » Fri Apr 11, 2014 7:23 am

glad things went well for you. You were lucky in getting the APAP rx, there aren't as many option with an APAP, so the s9 auto's one of the most common, I think there are only 3-4 machines on the ADP list, so there's not much wiggle room. When it's a straight CPAP, they might try try weasel you into a non-data machine. I was quoted like $100 less on an APAP versus a data capable CPAP, even though by ADP pricing, the APAP is suppose to be ~$45 more

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SleepWrangler
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Re: ADP changes to CPAP in Ontario

Post by SleepWrangler » Fri Apr 25, 2014 1:12 pm

The great DME negotiation is over. I really like the technician that guided me through the trial process. She was helpful and pleasant. She was very well trained in the DME sales process. No worse than a used car salesman (but no better either). Being armed with the information from this thread allowed me to get the best machine possible as specified by my prescription with minimal fuss and out-of-pocket cost.

The negotiations started with "Which package are you going to choose?" Option 1, option 2, or option 3. I choose none. None? Yes, none. Sorry, but I don't need any of those options. Thanks. I felt a little selfish because of the generous trial period of nearly two months, but given the choice I would have simply purchased a machine after the titration study, and not participated in the forced pre-sales ritual. I didn't feign any interest in the options because none of them are worth considering. Had I been less certain there would have been a "discussion". There was none.

Next was to write up the invoice for a ResMed Elite CPAP /w Humidifier, mask, and hose (my prescription is for CPAP). With ADP funding the total should be exactly $215.00. My invoice was for $445.00. Why is my invoice for $445.00? Because of the new ADP funding rules. What? Look at invoice and see a mask for $230 dollars ... I didn't know they made a gold plated version. No. I only want the ADP funded package and nothing more please.

She offered to supply the basic hose from my trial plus a new heated hose. I didn't want an unusable mask anyway. By offer I really mean she stuffed the heated hose and trial hose in my carrying case then asked me to sign the acceptance form. Hmmmmmm. Do I want to stick to my guns and go for a "basic mask" too. No. I was happy getting a heated hose instead of an unusable mask. Proposal accepted.

Without being armed with information from this thread I would have spent an extra $400, possibly more, on "upgrades" not funded by the ADP. The only bit I would have found useful is a good fitting mask but that can be had for about $100. I purchased one two weeks ago from this forums' host. People lucky enough to have generous health insurance package may not care and just go for the Cadillac $650 in "upgrades". Some people may genuinely need the hand extra holding. Anyone reading this forum is not likely to be one of those people. I'm just not in a position to humor the DME and reward them with lots of insurance supplied cash. I am pleased with the outcome.

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ShelaghDB
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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Sat Jul 12, 2014 8:47 pm

Includes basic crummy mask/headgear too.

What do you mean by crummy mask/headgear too?

I was given a Quattro Air FF mask. The hubby was given a nasal mask, Mirage FX Nasal although I absconded with it.

Do those both qualify as what are referred to as crummy masks?

If so please give me the name of some much better quality masks so i may look them up and know for next time to ask for them..

TIA

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Re: ADP changes to CPAP in Ontario

Post by Julie » Sun Jul 13, 2014 4:00 am

Those masks are good, but not everyone has the same dealer experience, especially depending on where they live (T.O. vs the boonies).

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SleepWrangler
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Re: ADP changes to CPAP in Ontario

Post by SleepWrangler » Mon Jul 14, 2014 8:30 pm

ShelaghDB wrote:What do you mean by crummy mask/headgear too?
I was given a Quattro Air FF mask. The hubby was given a nasal mask, Mirage FX Nasal although I absconded with it.
Do those both qualify as what are referred to as crummy masks?
I was loaned a Mirage FX nasal mask for trial but when purchasing the ADP funded Resmed Elite CPAP package the vendor wanted to charge $230 for that very same mask. This caused the total out of pocket invoice to exceed $450 instead of $215 as defined by the ADP. Some speculate that if you refuse to pay more than the mandated $215 the vendor will supply a crummy mask and headgear. My vendor didn't want to give me any mask at all saying "we don't have any basic masks in stock" and instead threw in an extra heated hose and data card.

It seems that standard operating procedure is to charge excessive upgrade fees when supplying good masks with ADP funded package. The ADP specifically has a clause that allows this behavior. The ADP rules protect the tax payer but rely on the patient having good insurance with low co-pay for upgrades (or being well read in these forums and immune to the games being played by the vendor).

The consensus is that without generous insurance it's best to purchase the ADP package and then get any upgrades on-line (this forums' host is a good choice although they may not be allowed to ship some items cross-border).

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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Mon Jul 14, 2014 9:51 pm

Hosehead
You cannot buy a better cpap from Resmed than their Elite model
No, the S9 AutoSet is superior to the Elite model
The Elite model is only superior to the brick, the Escape model

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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Mon Jul 14, 2014 10:01 pm

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


For Some reason I have to keep repeating this over and over.

Here in Toronto, there is now a respirologist I think he is, selling S9 AUTOSETS on Kijijij for $650 or best offer. It comes with a heated hose, an SD card, a carry bag and your choice of one of two different nasal masks. I got the Swift FX Nasal, all brand new not yet opened.

In my case i did not bother to barter and just paid the $650. I am sure some people could get away with $600
I didn't want to take a chance and lose out but realized afterwards he had plenty more of I would have said Id pay $600
but maybe if you didnt want the mask you could go lower?

He charges $450 or Best offer for the lesser one.......whats its name again........the ELITE


I still have his phone number if anyone needs it or can't find his ad on Kijii.
I had to go pick it up at his place in Mississauga which was right beside the big shopping centre there, Square One.

Just 5 weeks ago and i still see him advertising......he brings in shipments of them

the vendor wanted to charge $230 for that very same mask
wow, i had no idea they were that much


In my case I was given both this Mirage Nasal mask, the FF Quattro Air...........and then when I bought the S9 Autoset for $650 on Kijijij here a few weeks ago I also got with that the Swift FX Nasal Mask brand new and a few different sizes of the mask with it but i have yet to open it


my doctor refused to give me the Auto Set and only gave me the Escape but I sold it for $200 and threw that against the S9 auto set I bought for $650

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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Mon Jul 14, 2014 10:14 pm

What I am curious about then, here in Ontario.

I am now on the S9 Autoset which I purchased.

WHAT IF i cannot get this to work in the long run?
i have read that if you cannot do so, they will move you to the S9 Bipap I believe it is called?

So how does one come into the Bipap?
What must be wrong with his sleep apnea that sends hi from using an S9 AutoSet to a Bipap machine and if the doctor does move you to one, who pays for that and how much does it usually go for, please?


TIA

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Re: ADP changes to CPAP in Ontario

Post by SleepWrangler » Tue Jul 15, 2014 8:31 am

No, the S9 AutoSet is superior to the Elite model
The Elite model is only superior to the brick, the Escape model
I have both the Elite (as primary) and the AutoSet (as backup). The AutoSet is more capable but not superior unless the extra features are actually required. Jury is still out if the AutoSet was worth the effort and added expense because I just don't have enough soak time comparing CPAP mode to APAP mode for my needs. Respected forum members like Den make their experiences clear and say that CPAP is sometimes a better treatment. This may be true for me as well. Time will tell.

For American consumers the argument is a bit different because AutoSet, Elite, and Escape fall under the same medicare code and therefore the patient is probably being shortchanged by the DME if an AutoSet is not supplied. Ontario ADP has maximum set prices for each class of machine with a really well defined set of standards for each. I let the medicare purchasing "philosophy" override my frugal nature and bought an AutoSet. This may not have been necessary.

I wanted to have a backup machine which ADP will not fund. The extra expense of a backup machine seems worth it to guarantee that I have a machine that allows me to breathe properly at night. Buying an AutoSet for backup seemed appropriate so in the end I may have overspent for the backup machine but only by $150 or so. No buyers remorse to be found here.
ShelaghDB wrote:He charges $450 or Best offer for the lesser one.......whats its name again........the ELITE
The ADP funded model is $215.
ShelaghDB wrote:What I am curious about then, here in Ontario.
WHAT IF i cannot get this to work in the long run?
i have read that if you cannot do so, they will move you to the S9 Bipap I believe it is called?
There are standards for each class of machine. If you become eligible for a different machine your doctor will submit new ADP paperwork. No biggie.

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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Tue Jul 15, 2014 8:59 am

The ADP funded model is $215.

He's selling these hand over fist although the Auto Set is the more desired model and he sells many more than the Elite.
I gather a lot of buyers are people that have more than one home, or travel and need a backup machine
Or those that cannot be prescribed the Elite.
My doctor it turns out rarely prescribed them and only the Escape.
He told me that the Escape was as good as the AutoSet and Elite, at which point i knew him to be a liar

There are standards for each class of machine. If you become eligible for a different machine your doctor will submit new ADP paperwork. No biggie.
You are right. I didnt ask the right question.
Rephrased, what is it that causes these people to switch from an S9 to a BiPap machine?
What is it that is happening or they are being discovered with, etc that has taken them from one machine to the other?


TIA

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Re: ADP changes to CPAP in Ontario

Post by Pugsy » Tue Jul 15, 2014 10:33 am

ShelaghDB wrote:Rephrased, what is it that causes these people to switch from an S9 to a BiPap machine?
What is it that is happening or they are being discovered with, etc that has taken them from one machine to the other?
Sometimes people need higher pressures than cpap/apap can provide as they only go to 20 cm.
Bilevel machines (BiPap is Respironics model term and VPAP is ResMed model term) can go to 25 cm.

Sometimes people have issues with pressures and the ability to have the 2 levels (inhale and exhale set differently) allow for simply more comfort. The EPR feature on the S9 Elite/Autoset offer up to 3 cm differential between inhale and exhale but sometimes 4 or 5 or 6 cm is needed for comfortable breathing. Bilevel machines offer greater than 3 cm differential.

Sometimes people have an issue with centrals and that's a whole other discussion. There are "plain" bilevel machines that are really nothing more than glorified cpap/apap machines used when centrals aren't an issue.
When centrals are an issue (complex sleep apnea or central sleep apnea) then there is another higher end bilevel machine model for those issues and that's where the ASV type of bilevel machines comes into play.

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Re: ADP changes to CPAP in Ontario

Post by ChrisC » Wed Jul 30, 2014 8:26 pm

Trying to get a replacement machine under the 'new' funding model.. and it's a bit silly. Have a vendor that's trying to tell me that there are "basic" and "upgrade" machines under the CPAP umbrella. If I want to go "basic" with what ADP offers, I can only select from crappy machines like the S9 Escape. If I want an S9 elite or REMstar system one series 60, that's an "upgraded" machine worth an additional $200 out of pocket.

The ADP FAQ clearly states the following:

Q9 Can the vendor charge the client more than the ADP
approved price?
A9 The ADP approved price is for a complete PAP system. The vendor cannot charge more
than the ADP approved price for any ADP approved PAP system, unless the vendor has
provided an upgrade mask and headgear, or one of the services listed in A7.

I specifically asked what the price was for just the machine: no 'service package' or add-ons.. just the machine. She told me that $860 would be sent to ADP, then I'd have to cover the 25% plus a $200 "upgrade fee".

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Re: ADP changes to CPAP in Ontario

Post by SleepWrangler » Wed Jul 30, 2014 9:31 pm

ChrisC wrote:I specifically asked what the price was for just the machine: no 'service package' or add-ons.. just the machine. She told me that $860 would be sent to ADP, then I'd have to cover the 25% plus a $200 "upgrade fee".
That doesn't sound like an ADP approved package. There's no such thing as an "upgraded" machine. For CPAP your out-of-pocket is $215. Period.

It doesn't surprise me that your vendor is outright lying to you. If your vendor was like mine, their sales process is still very heavyweight and the Ontario government basically slashed prices to on-line levels with a small premium for service. To compensate the vendors have added optional service packages and mask upgrades. The service packages include a lot hand holding that some may need but I didn't.

So far nobody has reported a problem getting an ADP approved Elite CPAP machine but none have reported success getting a basic mask included in their package. I accepted an extra heated hose instead of a mask.

You may have to call the ADP to see how far you can push an uncooperative vendor, or choose another.

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Re: ADP changes to CPAP in Ontario

Post by ShelaghDB » Fri Aug 01, 2014 11:20 pm

I have a very close girlfriend that was a reporter here in Toronto for a well known media outlet but has since had a succession of 3 brain tumours and although she survived each one, has now developed a disease as well. The name slips my mind at the moment but because of it she developed a Moon shaped face and gained an extraordinary amount of weight.
Not that she had been given enough to deal with, she then developed Sleep Apnea.

This would have been just before the S9 came out as she was given an S8 machine, most likely I would guess, the Brick for with her illnesses she has had to resort to ODSP which is a disability pay for she won't ever be able to work again. Everything is going into fighting one problem after another.
A sweeter person you could not meet

Am trying to get her back on it and for her to sign in here and find out whatever it is she was doing wrong that caused her to walk away from it.


In any event, she never got the hang of CPAP and I have been trying to get her back on it but I want to know a couple of things first if anyone happens to have the answer please?

As she is on ODSP, how well would she be covered when she needs a new machine?
I believe at the time she didn't qualify for she received a large pay out but that has now been a few years and its more or less gone.

Today she relies 100% on her monthly disability cheque.

Under these new changes to Toronto, can anyone tell me how often someone on this disability, ODSP can have a sleep study and how often? Is it every 5 years?
For some reason that number sits in my head
Perhaps in her case they might make an allowance as she has had so many medical issues on the past couple of years but if i knew the regular time period between sleep tests i might be able to get her into another one very soon.

Secondly, on ODSP would she be able to get masks hoses, etc; covered or would there by a cost involved?
Last but not least, would she have to pay for a machine or would that be covered?

Due to her brain tumours in the past, I would assume she is working with the best doctor already as she is someone that has a great support team and due to a lot of good things she has done for Toronto, she's received a lot of accolades, celebrated on TV for her work and the doctors know her due to something she worked on, and are usually eager to help her or work with her so i have no doubt she would not have just used any old sleep doctor.

She won't really talk about it but has started to show interest again only because I now have it and so I can believe I can get her back on it but would really like to know what I am dealing with first. As in are there any huge bricks in front of her that i am not aware of, fiscally perhaps, that is preventing her from following through....
Am hoping there might be someone from Ontario on ODSP or familiar with how it works pertaining to CPAP that can tell me what exactly will be covered and how often.

Ive managed to set up situations where I arranged that her daughter would be given a brand new bike not once twice and other things along this line so I just want to know where she stands on this with ODSP first, before considering going to various companies and trying to set up merchandise in exchange for an interview with her, etc as its a lot of work for me to undertake but i will do it again if need be.........but hoping this time around ODSP will be all she needs?

thanks

TIA

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Re: ADP changes to CPAP in Ontario

Post by SleepWrangler » Sat Aug 02, 2014 11:09 am

ShelaghDB wrote:Under these new changes to Toronto, can anyone tell me how often someone on this disability, ODSP can have a sleep study and how often? Is it every 5 years?
At a follow-up with my sleep doctor she noted that I had lost weight and thus gave me an open invitation to have another sleep study. After thinking a bit she said to contact her office no earlier than NOV14 to schedule a new study given that my previous study was done JAN14. Anecdotal evidence is not the best but that's all I have at the moment.