Costs with medicare

Can anybody point me to the costs of cpap with medicare? Or give me a break down. Was told my cost on the machine should be around $169. I understand they charge for the humidifier separate and that is paying for it. Just want to see if I'm going to be over charged or not. Was told with a new mask it would be around $130 on delivery and then around $15 a month for 12 months so not sure if this is too much. The place I'm looking at ordered a machine 2 weeks ago and told me it would only take a week to get so I'm about to take my business somewhere else. Just want to see what the cost should be so if I stay with these guys or go somewhere else I will know how bad I'm getting screwed. The first machine I got thru a local company charged me about double what I'm seeing right now so I'd like to do better this time around if I can

Costs sound about right....rent for 12-13 months then you own it. $12-15 mo sounds right. With medicare, you pay 80% of the negotiated costs. Ask for a breakdown of the up front costs. Should be the humidifier plus 1 months rental.

Actually that sounds about right.

Medicare "allows" different amounts for this equipment depending on where you live. It isn't the same allowable amount over the entire US.
Your copay is based on whatever the allowable amount might be for your particular area.
To figure out what is allowable in your area you need to go to the website where they have all the HCPCS codes listed for your area and look up each item because they are all paid separately.
Your DME is under contract with Medicare to be happy with whatever Medicare says they have to be happy with and your co pay (after any deductible) is based on that allowable amount.

It takes some digging. I did it a few years ago for my area.

You have to start here and go digging
https://www.cms.gov/medicare/medicare-f ... edule.html

and you have to know the HCPCS codes which you can find here
page 4
https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf

Allowable amounts typically change from year to year and sometimes within a year...and then there is competitive bidding areas if you happen to be in one of those. So...there's no way for me to point you to exactly what Medicare will pay in your area but you can find out with some digging.
But based on past experience when I have done the digging...the amounts quoted are sounding about right and remember that Medicare should send you an EOMB after the billing and it will clearly show the allowable amount (don't confuse that with the pie in the sky billing amount) and clearly show your portion and if they don't match with what you paid you can call up Medicare and tell on them.

Most DMEs will toe the line when Medicare is involved because a good chunk of there business is from Medicare patients.
They don't want to lose the ability to cash in on Medicare patients...they know if Medicare says they have been bad and won't pay for business with them that they will lose the business because there's always some DME around the corner who will accept Medicare.

Well at the end of 13 months I will have paid $310 and was thinking somebody told me total out of pocket should only be around the $169 price. But I know that was without the mask. Seems like at this rate I'm paying for the mask in full in the end. I will do some digging and see if I can find anything for sure.
Trouble is I get the summery from medicare about 2-3 months after I've signed the paper work. Got some papers from medicare about my doc billing me for something I never had. Called medicare and they really didn't care

Well if you really want to know for sure you have to do the digging.
The numbers are there but it takes a lot of work to get them.
Plus even in the numbers there are slight variations....like I think it is so much for first months and then a little less thereafter....just talking about the blower.

The mask is always a one time fee (but it is always broken down into each component even if it's all in one bag)...as is the hose, water chamber, filters, mask cushions, etc.

Humidifier is usually a one time fee but there may be times when it is "rent to own" like the blower.

Blower with Medicare is usually rent to own for 13 months...and amounts allowed can vary within the "rental period".

The DME should be able to give you an itemized bill with all charges broken down ahead of time. They already know what Medicare is going to allow for anything they dispense to you. They get a brand new copy of the fee schedule from Medicare every time Medicare changes it. Now will they be willing to do that...dunno...but they could do it but it would involved a little bit of work on their part. Sometimes they don't want to do the work and they tell you they don't know what Medicare will do...but that's not true. They get a notice from Medicare anytime the fees change.

Assuming that this is original Medicare, the costs for the machine seem about right. I'm confused about the mask charges though. I paid ONE TIME for the mask (straight 20%). Same for cushions and other supplies - straight 20%. So, I'm puzzled why they have a drag-out pricing schedule for that. I'll let others chime in here, but I could understand that the mask is higher if it is the deductible, but can't fathom where they are getting this monthly charge.

I agree with Pugsy though - they should give you an itemized billing so that you can see exactly what you are being charged for.

Do you have a supplemental medigap policy? We have one through United Health Care and our out of pocket costs for CPAP machines, supplies and masks has been zero - 12 years for me and 3 years for my wife. The supplemental policy picks up the 20% Medicare does not pay.
The humidifier has to be sold as separate item per Medicare rules but was still paid for by Medicare and the supplemental policy.

ClayL wrote:Do you have a supplemental medigap policy? We have one through United Health Care and our out of pocket costs for CPAP machines, supplies and masks has been zero - 12 years for me and 3 years for my wife. The supplemental policy picks up the 20% Medicare does not pay.
The humidifier has to be sold as separate item per Medicare rules but was still paid for by Medicare and the supplemental policy.

Bmanley, with all the options on Medicare, it would be difficult for someone else to say what yours would pay. You could have Original Medicare with a supplement and there is a variety of supplements all paying different amounts or you could have an Advantage Plan. The only way to know would be to look at your plan.

The last time I got a machine thru medicare was June, 2014. My complete S9 Autoset (blower and humidifier)package (without mask) was $169 on a 12 month rental.

LSAT wrote:The last time I got a machine thru medicare was June, 2014. My complete S9 Autoset (blower and humidifier)package (without mask) was $169 on a 12 month rental.

Was that the amount allowed by Medicare and did you have a co pay of 20% of that amount.
Also remember...you have a Medicare Advantage plan and while they go by most of Medicare's rules...they don't always follow them exactly. They don't have to.

There are different DME situations.
See the provider link in my sig., and enter your zip code to find who is approved by original Medicare.
The green M indicates contracted providers, who are restricted to accept the Medicare price as full payment.
Medicare pays 80% of that and you, or your supplement, pay 20%.
Non-green M providers may add an upcharge, which is on you, but limited by law.
Any provider not on the list: locals will scalp you, but online is usually better, especially cpap.com.

You have found out there is a 13 month rental but also during this period compliance is critical. If you do not meet compliance you could end up responsible for the cost of the equipment. While compliance is not hard you should be aware of it and if you do not plan to use it then just turn it back in.

There is also a thing called ABN that if you sign it you are responsible for payment if Medicare doesn't pay for any reason. The reason could be non-compliance or that the DME did not submit the required info to get paid (for whatever reason). And the reason can be as simple as the DME will collect more if the go after you for payment.

So pay attention to your EOB statements - if Medicare denied payment you need to call to find out why.

That brings us full circle to who is your DME? Cuz Apria has been known to try this method to get more money even tho the patient was 100% compliant - so BEWARE.

Upon completion of this 13 month rental period you should receive a letter officially transferring ownership to you.

chunkyfrog wrote:There are different DME situations.
See the provider link in my sig., and enter your zip code to find who is approved by original Medicare.
The green M indicates contracted providers, who are restricted to accept the Medicare price as full payment.
Medicare pays 80% of that and you, or your supplement, pay 20%.
Non-green M providers may add an upcharge, which is on you, but limited by law.
Any provider not on the list: locals will scalp you, but online is usually better, especially cpap.com.

Thank you for the part about the Green M. The first place I used doesn't have that and the place I'm talking to now doesn't. Guess this is why I had extra charges the first time. There is one other place in the area which I didn't see before and not sure why unless they just got on the list, which is hard to believe since it is a local hospital that has been around for 75 years. But they do have the Green M

And yes I understand the need to use it to get it paid for. No problem there as I use my machine every night and have since I got it over 5 years ago. Only nights I didn't was when I was in the hospital. Didn't know about paying if they didn't get the bill covered by medicare. Doesn't make since if this is their fault and not mine. They have contacted medicare and say it is covered.

Pugsy wrote:

LSAT wrote:The last time I got a machine thru medicare was June, 2014. My complete S9 Autoset (blower and humidifier)package (without mask) was $169 on a 12 month rental.

Was that the amount allowed by Medicare and did you have a co pay of 20% of that amount.
Also remember...you have a Medicare Advantage plan and while they go by most of Medicare's rules...they don't always follow them exactly. They don't have to.

Pugsy...That was my total co-pay for the year...including the humidifier, hose, filters etc.

LSAT wrote:Pugsy...That was my total co-pay for the year...including the humidifier, hose, filters etc.

That's a pretty good deal. If I remember correctly you have the same Medicare Advantage plan that I have.
It doesn't mean that is what someone on regular Medicare would have the same copays though. Medicare Advantage plans are their own little unique animals...they don't always match traditional Medicare in terms of what copays will end up being.
Goes a long way for those that say that the Advantage plans are crap though. It all depends on the plan.