Just Over to Medicare- Many Questions

CPAP patient since 2/2014 with a ResMed S9Elite and virtually 100% nights using P10 nasal pillows. Previous DME is not a Medicare provider and it appears the nearest one that my sleep doc uses is about 60 miles away. Set up an account with them, gave them my Medicare A and B and supplemental insurance #. They then required the original sleep study report and notes from a recent "face to face" update with the sleep doc stating that therapy was being used and was helpful. All that is done.

From what one rep from the new DME said, I could get a new CPAP machine (I would likely upgrade to AirSense 10 Auto). What are the other Medicare guidelines in terms of new nasal pillows, straps, Climateline hoses etc?

I should mention that I have quite a collection of unopened hoses, water reservoirs sent to me over the past three years by the old DME.

But what are the Medicare equipment guidelines? I have done a search, and there is info scattered all over this board, but a concise practical summary would be greatly appreciated. Thanks.

Medicare replacement guidelines for the replacement parts. See image below.

About the machine ....you might want to call Medicare and ask because last I heard even though Medicare didn't pay for the current machine they still are going more by the "won't replace unless broken and not fixable" rule.
I know people report that they got a new machine when they went on Medicare but I don't know if their DME simply maybe said the old machine was broken or not. Medicare doesn't require proof other than the DME saying it isn't working. In other words...maybe the DME stretched things a bit. I don't know....all I know is Medicare is moving towards the "won't replace unless broken and not fixable" despite their official replacement thing still showing 5 years.
It's not just Medicare...more and more insurance companies are going with "don't replace unless broken" rule in an attempt to save money.

Medicare doesn't allow automatic shipment of any replacement parts....you have to specifically ask for it and by asking for it you are implying that the old whatever isn't working well or has broken or something.
The new DME shouldn't be sending you stuff to accumulate that you don't use up very fast...like hoses or water chambers.
If you get the new AirSense 10...get a spare of everything when allowed then don't ask for stuff that doesn't wear out often
Like I have one S9 ClimateLine heated hose that has been through 3 different S9 machines...soo well over 10,000 hours on that hose and it still works just fine and looks like new.

RobertS975 wrote:CPAP patient since 2/2014 with a ResMed S9Elite and virtually 100% nights using P10 nasal pillows. Previous DME is not a Medicare provider and it appears the nearest one that my sleep doc uses is about 60 miles away. Set up an account with them, gave them my Medicare A and B and supplemental insurance #. They then required the original sleep study report and notes from a recent "face to face" update with the sleep doc stating that therapy was being used and was helpful. All that is done.

From what one rep from the new DME said, I could get a new CPAP machine (I would likely upgrade to AirSense 10 Auto). What are the other Medicare guidelines in terms of new nasal pillows, straps, Climateline hoses etc?

I should mention that I have quite a collection of unopened hoses, water reservoirs sent to me over the past three years by the old DME.

But what are the Medicare equipment guidelines? I have done a search, and there is info scattered all over this board, but a concise practical summary would be greatly appreciated. Thanks.

I'm curious....If you obviously didn't need them, why did you let your DME send them to you? Now some of the supplies are useless to you.

RobertS975 wrote:But what are the Medicare equipment guidelines? I have done a search, and there is info scattered all over this board, but a concise practical summary would be greatly appreciated. Thanks.

Be sure to add medicare dot gov and/or cms dot gov to your search criteria. That is unless you have a Medicare "Advantage" plan then you would have to search their site to get their info.

Oh...just in case...make sure if you get the new AirSense 10 model that they give you either the Elite like you had or preferably the Autoset.
Those are both full data machines.

Don't let them give you the AirSense 10 CPAP model (and CPAP is the model name not just the mode) because that model has extremely limited data.
It does have data but only summary AHI and summary 95% leak numbers. Nothing else...no event category breakdown and no detailed graphs or anything else.

Pugsy wrote:Don't let them give you the AirSense 10 CPAP model (and CPAP is the model name not just the mode) because that model has extremely limited data.
It does have data but only summary AHI and summary 95% leak numbers. Nothing else...no event category breakdown and no detailed graphs or anything else.

To be sure you get what you want I would ask the doc to specify the exact make & model (with do not substitute) in the equipment order. Also call the DME before hand to ask if they can provide you with that model - if not call another provider until you get what you want. Hopefully, most of the supplies you have on hand will work with you new machine.

Do NOT settle for less to make easy for the DME. If they won't do this for you they will do even less when it comes to your supplies. Believe me, been there.

LSAT wrote:

RobertS975 wrote:CPAP patient since 2/2014 with a ResMed S9Elite and virtually 100% nights using P10 nasal pillows. Previous DME is not a Medicare provider and it appears the nearest one that my sleep doc uses is about 60 miles away. Set up an account with them, gave them my Medicare A and B and supplemental insurance #. They then required the original sleep study report and notes from a recent "face to face" update with the sleep doc stating that therapy was being used and was helpful. All that is done.

From what one rep from the new DME said, I could get a new CPAP machine (I would likely upgrade to AirSense 10 Auto). What are the other Medicare guidelines in terms of new nasal pillows, straps, Climateline hoses etc?

I should mention that I have quite a collection of unopened hoses, water reservoirs sent to me over the past three years by the old DME.

But what are the Medicare equipment guidelines? I have done a search, and there is info scattered all over this board, but a concise practical summary would be greatly appreciated. Thanks.

I'm curious....If you obviously didn't need them, why did you let your DME send them to you? Now some of the supplies are useless to you.

LSAT, much of it came unrequested along side the stuff I did request!

Pugsy wrote: About the machine ....you might want to call Medicare and ask because last I heard even though Medicare didn't pay for the current machine they still are going more by the "won't replace unless broken and not fixable" rule.
I know people report that they got a new machine when they went on Medicare but I don't know if their DME simply maybe said the old machine was broken or not. Medicare doesn't require proof other than the DME saying it isn't working. In other words...maybe the DME stretched things a bit. I don't know....all I know is Medicare is moving towards the "won't replace unless broken and not fixable" despite their official replacement thing still showing 5 years.
It's not just Medicare...more and more insurance companies are going with "don't replace unless broken" rule in an attempt to save ]

Don't know what the current Medicare policy is - BUT

As late as Feb 2013 (that I can verify), Medicare did in fact give people a new machine when they 1st went on Medicare regardless of the age of their previous machine.
If "Medicare" had not previously paid for a machine for you, they basically just treated you as though you had never purchased a machine - even if that machine was paid for by a private insurance plan.
And even then, it was Medicare's policy to not replace a machine (even if it was over 5 years old) unless it was broken & not repairable. But, that referred to machines "Medicare" had purchased.
It was the fact that Medicare had never purchased a machine for you that ruled.

Of course, Medicare only paid 80% - so you were still out 20% unless that was covered by something else.

I have even seen Medicare pay the 80% as the primary insurer and most of the 20% was paid by the secondary insurer even when that secondary insurer used to be the primary private insurance plan and the machine purchased by that primary private insurance plan was only 2 years old.
That happened when that primary private insurance plan (now the secondary plan) had a stated $ amount they paid for CPAP and some of that $ amount was now available again after 2 years.

StuUnderPressure wrote: Don't know what the current Medicare policy is - BUT

As late as Feb 2013 (that I can verify), Medicare did in fact give people a new machine when they 1st went on Medicare regardless of the age of their previous machine.

Just reporting what I have read and heard for the past couple of years about Medicare and people just turning 65.
And a few recently here on the forum have confirmed it (one member claims to work for Medicare in some sort of capacity confirmed it but I forget his name)...and again we don't know what the DME may have used as a reason either for those that did get one upon signing up for Medicare without any apparent hassle.
That's why I said to contact Medicare and find out exactly what the current policy is...don't rely on what a DME might say because we all know that it isn't always 100% truthful.

Last couple of years it seems like more and more insurance companies are going to the "don't replace unless not fixable" and it's just best to contact whatever insurance is involved directly to find out exactly how they do things.

My own DME...knows I bought my machine privately and when I asked last year about finally using my Medicare for getting a machine told me that they would have to state that my current machine wasn't fulfilling my needs either because it was broken or my medical needs changed and I needed a different type of machine.
Now would they lie and say my machine wasn't working....dunno...didn't push it because I usually get my machines for less than my 20% copay anyway and I didn't want the monthly rent to own hassle thing with compliance and all that crap.

xxyzx wrote: they seem to only want to talk to sleep lab or doctor not us

While that is true....

xxyzx wrote:the problem i run into is that none of them answer their phones
and many dont return calls if you leave a message

It is good to find out now how they do behave, isn't it?

That is part of the reason to call around and not stop at the first DME that answers the phone or makes you a promise. Get your paperwork to them all then make a choice. In the long run it saves time. Don't be shy about telling them what you want either.

I remember when I told my sleep doc the DME lied to me - she leaned over and whispered in my ear "They ALL lie". No truer words were ever spoken.

And that is why it helps to use your notebook when you call around, introduce yourself, write down their name, date, time, and any promises made, etc. Write down their phone, hours, what they need to get started, and be sure to ask about their mask exchange policy, and how they handle after hours, weekends, holidays, etc.

You will find you are on your own unless you are also on O2 and that is the problem. CPAP is not considered life support. Keep your other cpap for a backup.

RobertS975 wrote: I should mention that I have quite a collection of unopened hoses, water reservoirs sent to me over the past three years by the old DME.

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