Insurance Question.....

Im 33 and never had insurance. I am in the process of finally getting insurance. How do insurance companies typically pay for the products? Do they get billed directly? Do they reimburse you? If they reimburse.... thats pretty messed up not everyone has the type of money for a new/updated machine laying around to dish out wether getting paid back or not.

My insurance just paid directly, it didn't go through me at all. It was interesting, though, to look at the statements from the insurance company, at how much the DME billed and how much the insurance company paid them. Now I'm on Medicare, and they also pay directly to the DME. And there's another guy in the loop, Medicare Supplement insurance, and they also are billed directly. They pay what Medicare doesn't, assuming that Medicare accepts the expense as billable. Very intricate, that Medicare thing.

Anyways, I'm guessing that your DME will deal directly with the insurance company. You'll be able to see how much was billed by the DME, and how much your insurance paid. I don't know if your insurance has a deductible, but if it does you'll have to pay that each year before your insurance company will start paying during that year. That's life around here, I guess.

ElvishKnight wrote:Im 33 and never had insurance. I am in the process of finally getting insurance. How do insurance companies typically pay for the products? Do they get billed directly? Do they reimburse you? If they reimburse.... thats pretty messed up not everyone has the type of money for a new/updated machine laying around to dish out wether getting paid back or not.

Most insurance companies will have a list of in network providers. They will be billed and pay their portion, and you will be billed for you portion.

That said, there are different ways of purchasing the equipment. Some will do an outright purchase. Mine did a 2 month rental during compliance, and once I passed compliance, then they converted it to a full purchase. My insurance paid 85%, and I was billed for the rest. I had no bills before the compliance check. Some companies do a capped rental. Usually for 13 months, so you get hit with 2 deductibles. You pay your portion of a monthly rental fee and after the 13 months, it is paid off. You will need to make sure you know what you have before you pick up equipment, and you will need to compare prices as it might be cheaper to buy out of pocket than use insurance, depending one what you need.

A couple more things. DMEs (durable medical equipment providers) like to sell you the cheapest possible machine because they get paid the same regardless of which model it is. So, it is up to YOU to make sure you get a good machine with full data. If you get your machine through a DME, you need to do your homework here first so that you know when they are lying to you. They are worse to deal with than the stereotypical used car salesman.

Compliance. Most insurance companies require compliance before they pay fully as many people quit quickly, and they don't want to buy an expensive machine that will sit in a closet. So, the typical requirement is 4 hours in each 24 hour period for 70% of nights. Usually in a 30 day consecutive period. So, if you fail in the first month, you keep trying. Most insurance companies have the first compliance check during the second month. I had mine at 6 weeks, passed, and never had to do it again. If you are struggling, they will usually extend the time, but you need to be in contact with the DME and doctor so that they can back up your claim for needing more time.

This is a question you should ask your insurer: " what DME coverage does this plan offer? How does it cover. CPAP equipment and supplies?"

If you are shopping for insurance, this is an important question to ask. Very different from the days where we just accepted what an employer gave us or went without (unles you are only able to get insurance via the medicaid/medi-cal expansion which has no choice).