California Kaiser CPAP coverage?

Hello everyone.

I have Kaiser Platinum 90 HMO individual plan in Southern California.

I have been diagnosed with sleep apnea and my doctor has prescribed a CPAP machine.

However, according to Kaiser, CPAP is not covered under my platinum plan. There is no way I can add this coverage because it's not covered in California. This sounds absurd.

I've called member services and sales both and I cannot get simple, straight answers from anyone. Each call produces a rambling rep who carries on about what I already know and produces an "I don't know" response.

Is there anyone in So Cal Kaiser who can help me with the facts and what to do next?

Thanks,

Neal

Neal, the member Janknitz is an expert about Kaiser. Send her a mail.

Back in the 70's and 80's when my wife and I had Kaiser it was considered the gold standard and we liked it quite a lot. Guess things have changed because not having CPAP coverage is absurd.

Call the state department of insurance.
Something smells fishy.

I have coverage with Kaiser Southern California using the Fontana facility. I have 100% coverage of the doctor appointments ($20.00 copay) and 100% coverage of CPAP Machine and all supplies (No copay). A lot of people lump of all Kaiser coverage into one while there are many different plans available. I for one am very happy with the Kaiser experience and particularly with the Sleep center.

I have known of a handful of forum members who had Kaiser but their Kaiser plan didn't cover cpap supplies.
It all depends on the plan they have chosen.

I found this about the Platinum 90 plan. Page 31 is where it talks about Durable Medical Equipment and absent is any mention of cpap supplies of any kind. I didn't read the entire document to see if sleep apnea is mentioned anywhere. All it says on page 31 is to call member services to see if what you are needing is covered.
http://info.kaiserpermanente.org/health ... MO_ADA.pdf

Thank you for the replies.

Kaiser keeps mentioning their "formulary." However, I cannot find the "durable medical equipment formulary guidelines" anywhere.

This is very frustrating. I'm shocked that a top shelf plan would not cover this item. Of all things.

Neal

I got a rejection letter last night, so this is what started my search.

I just found this:

"Durable Medical Equipment. If your provider prescribes durable medical equipment such as a
wheelchair, he or she will submit a written referral. If your coverage includes the item and it is listed
on our durable medical equipment formulary for your condition, it will be approved. If the
equipment requested doesn't appear to meet our formulary guidelines, it will be submitted to a UM
physician decision-maker for review."

https://healthy.kaiserpermanente.org/st ... =kp.org/UM

However, I don't know if my request as been submitted to a "UM physician" or not. I don't know what that even means or how long it takes. I don't know what to expect.

This lack of direction and transparency is what has me upset.

I just want to start treating my condition.

Utilization Management I see.

I guess they've denied me too perhaps? I don't know if this is an automatic appeal or what.

No idea what to do.

Neal have you tried to send a PM (private message) to JENKNITZ?
Check these:

viewtopic/t113896/viewtopic.php?f=1&t=1 ... r#p1098112

viewtopic/t113896/memberlist.php?mode=v ... le&u=48201

It's not JENKNITZ
It's Janknitz
memberlist.php?mode=viewprofile&u=48201

She lives in California and has Kaiser and is fairly well acquainted with the different Kaiser plans and/or what is needed to be done if there is a problem with coverage.

Even before Covered California, many Kaiser individual plans (including mine when I was self-employed and had an individual KP plan) did not cover CPAP supplies/equipment. Sounds like their individual plans still don't.

You should be able to call Member Services, give them your Kaiser member (medical record) number, and be told specifically if your plan does or does not include CPAP supplies/equipment.

I'm confident this is the case. It's one thing that's not covered despite the fact this is a platinum plan.

If this isn't covered in the platinum plan, then what plan is it covered under?

Why don't they cover what is a fairly common item?

And what should be my next step? Can I get coverage? Do I just need to go to the street and buy my own equipment? Is there a market someplace where I can get it?

I have visions of a seedy alley where people sell CPAPs to unsuspecting newbies out of the trunks of dilapidated cars... LOL

This is a little overwhelming and Kaiser is failing.

I have a Kaiser silver plan now and I don't think that it's covered under my plan either. We're paying more than our house payment every month for NOTHING.

Here's what you have to do: Call member services (good luck with that, better to go in. I've spent hours on hold with member services, only to be told when the phone is finally answered that "voicemail is full. Please call back another time.")

At any rate, you need to request the EVIDENCE OF COVERAGE. That is the actual contract between you and Kaiser even though you've never seen it and didn't know of its existence until this moment. In there it will state what your DME coverage is. Here's what mine says:

Durable Medical Equipment for Home
Use
Inside your Home Region Service Area, we cover the
durable medical equipment specified in this "Durable
Medical Equipment for Home Use" section for use in
your home (or another location used as your home) in
accord with our durable medical equipment formulary
guidelines. Durable medical equipment for home use is
an item that is intended for repeated use, primarily and
customarily used to serve a medical purpose, generally
not useful to a person who is not ill or injured, and
appropriate for use in the home. Coverage is limited to the standard item of equipment
that adequately meets your medical needs. We decide
whether to rent or purchase the equipment, and we select
the vendor. You must return the equipment to us or pay
us the fair market price of the equipment when we are no
longer covering it.
Durable medical equipment items that are
essential health benefits
Inside your Home Region Service Area, we cover the
following durable medical equipment (including repair
or replacement of covered equipment) at 20°/o
Coinsurance (not subject to the Plan Deductible):
• Blood glucose monitors for diabetes blood testing and
their supplies (such as blood glucose monitor test
strips, lancets, and lancet devices)
• Bone stimulator
• Canes (standard curved handle or quad) and
replacement supplies
• Cervical traction (over door)
• Crutches (standard or forearm) and replacement
supplies
• Dry pressure pad for a mattress
• Enteral pump and supplies
• Infusion pumps (such as insulin pumps) and supplies
to operate the pump
• IV pole
• Nebulizer and supplies
• Peak flow meters
• Phototherapy blankets for treatment of jaundice in
newborns
• Tracheostomy tube and supplies

Durable medical equipment items that are not
essential health benefits
Durable medical equipment that are not essential health
benefits are not covered.

(Excuse the misspellings, this was from a PDF and it sees some letters incorrectly)

No CPAP equipment or supplies on there. I'm guessing your Evidence of Coverage document says the same thing (but it's ALWAYS worth checking). But, whoopee, they cover a "peak flow meter"--$25 item. That Kaiser, it really has your back!

Now, I think I could make a very good argument that CPAP is "intended for repeated use, primarily and customarily used to serve a medical purpose, generally not useful to a person who is not ill or injured, and appropriate for use in the home." and it " adequately meets your medical needs." But the sleep lab people have already told me that there's NO coverage on the ACA plans.

If you're willing to take up a legal challenge and carry it through, there are some good arguments to make, But your chances of winning are pretty low, unless you can find an agency or organization willing to foot the legal bill for you. Kaiser has things pretty well sewn up.

One thing is that if you are willing to work with Crapria, you get Kaiser's contracted price for stuff. It's definitely less expensive than anywhere else, including online suppliers. But Kaiser ain't gonna pay for it, and you have to take what Kaiser orders, not necessarily what you want.

Speaking for Kaiser through California Choice insurance (Covered CA is likely very similar): Kaiser has two different DME Formulary Lists, one is the Basic and the other is the Extended. Unfortunately all of their Individual and Small Group Plans use the Basic list, even if you have a platinum plan. The Extended list is used for Large Group plans. All CPAP equipment and supplies are listed under Extended (in 2015 when I checked). I tried to petition them to get CPAP equipment on the basic list but they wouldn't budge. My solution was to get the F off a Kaiser plan. Their doctors don't know anything about sleep apnea so I wouldn't use them anyway. My PCP refused to give me a sleep study twice because I wasn't an elderly obese person; had to pay for one out-of-pocket and bill them after (with 3 denials before going through).