Confusing insurance.

I have Tricare For Life but only because I am disabled. Husband is active duty so it is treated like Standard. Does anyone here have this? I just want to know what all the cover.

After my sleep study and appointment with the sleep Dr., I was sent to a sleep lab (not where I had my study) and a man handed me a bag with the machine in it, telling me my insurance would cover a new mask every 6 months as well as a new filter. I assumed he meant the gray foam filter. I failed to ask him about the white allergen filters. I have since bought some of them online since it appears I need to replace them anywhere between weekly to every 15 days.

I assumed I had to pay nothing because I have already paid my $1,000 catastrophic cap for the year. Daughter and I are the only ones on this plan but we've both been sick solid since Sept. and have seen a variety of Dr., sometimes several times a week. She also had a broken arm just after the start of our year which is Oct.

Now I get this confusing letter stating they will pay so much for 3 months, then so much for 9 months then so much for 1 month for two different items. I assume these items are the humidifier and CPAP machine but it doesn't say. It also lists my portion that I would have to pay.

The letter then goes on to say that they strongly urge me to buy the equipment.

I will call them tomorrow, even though I hate doing that. Seems I always have to make numerous calls because nobody knows what is going on. I have looked online and found some forum where a person had the Tricare Prime and they said Tricare paid 80%.

Bump.

Just thought I would bump this back to the top of the page since you haven't been getting a response. If we don't have anyone here who can answer your questions, it might not be pertinent but there is a long running thread at apneasupport .com regarding CPAP, the military, benefits, VA and CPAP benefits, etc. I think that thread has "military families" in it but won't swear on that as it is not a thread I've paid any attention to since it doesn't pertain to me and my family.

Good luck!

Okay I got an answer. A confusing answer, but an answer. Basically I/they are renting the machine because I/they do not know that this is the machine I am going to stick with. The rental goes for 13 months with the largest amount being paid for the first three months, then slightly smaller for 9 months and a really small final payment on the 13th month.

Since I have paid my $1,000 castasrophic cap, I am paid up through Oct. and don't pay a dime. The year starts again in Oct. In case you were wondering why my cap is $1,000 it is because my husband is active duty. Apparently the cap is normally $3,000. Eek! Anyway...

When Oct. comes around, I will have to pay the first $150 out of pocket for myself. That money does not come just from the CPAP equipment but also Drs. and I see a lot of them. I then have to pay the remaining 20% until it is paid off, which will be March of 2010. So it looks like the maximum amount I will have to pay (in the future) is about $221, but this won't come all at once. It will be paid over 6 months.

Now if I change machines, things start all over again and alas, I will pay more out of pocket because there is less of this year left. And next year I will not have met my catastrophic cap for awhile. Normally I don't meet it till about August, but daughter broke her arm and she and I have been really sick. Lots of Dr. visits, tests and meds.

I also asked him what would happen if I moved? Husband has been transferred to CA for three years then he can retire. Daughter and I do not want to move back there (we lived there before) for a variety of reasons. One being that we own our house here and with the bad market it will likely not sell. We can not afford to pay the house payment here and pay for all of us to live there! Plus I don't think this place would rent, and we wouldn't have anyone to look over it and all that jazz. Bottom line, it just seems to make more sense for us to stay here at least for now. But if we *do* have to move, that presents a whole new set of problems and he didn't know what would happen. He told me I would have to call my supplier if that happened. *crosses fingers that it won't*

I have Tricare Standard with a supplemental insurance plan. Tricare for Life is the secondary to Medicare when you reach Medicare age. I was unsure if Tricare would pay for a new machine as my old machine was paid for by another insurance plan I had when I was working. I took a chance as my old one was broken(had to have one anyway) and ordered from cpap.com and sent in the insurance claim to Tricare and they did cover it. Your best bet would be to call Tricare if they are your primary and clarify with them what and how much they will cover.

terry123 wrote:I have Tricare Standard with a supplemental insurance plan. Tricare for Life is the secondary to Medicare when you reach Medicare age. I was unsure if Tricare would pay for a new machine as my old machine was paid for by another insurance plan I had when I was working. I took a chance as my old one was broken(had to have one anyway) and ordered from cpap.com and sent in the insurance claim to Tricare and they did cover it. Your best bet would be to call Tricare if they are your primary and clarify with them what and how much they will cover.

That's odd. I ordered supplies from cpap.com and it says on their website that they don't take Tricare.

cpap.com is a cash/plastic money up front place

some insurance companies will reimburse for purchases made there; some won't

Well, that's weird. I just went back there and looked. I see that they don't personally take *any* insurance but that you can send the bill in yourself and it is your responsibility to see if your insurance will cover whatever it is, but... I don't see the disclaimer about Tricare. I am pretty sure this is where I ordered my cleaner and filters, but maybe it was somewhere else. At any rate, I was pretty sure they wouldn't be covered by insurance. I was told I could get a new gray filter every six months, but I wanted more white ones.

Having been on Champus then Tricare Standard and now Tricare for Life, I believe I can answer some of your questions. If you buy something to benefit your health that is part of an Rx, then you can download the form needed from the Tricare website, complete it, mail it in and get re-imbursed for that item. If you are trying to buy something yourself that you have an Rx for, 99% of the time Tricare will cover it because of the Rx, but always check first. Again, many suppliers will NOT accept your insurance(Tricare), so you will have to submit your receipts for payment. As far as the rental, it is less expensive for you, if you purchase your equipment and then submit the bill. 20% of $500 is $100 and that would be your portion of the cost to buy your machine. With Medicare you have no choice, but with Tricare as your primary, you do have a choice. Do not take the word of a clerk on the phone, but go to the local base medical dept and talk to the Tricare co-ordinator. Been there done that.

Cpap.com will not file the insurance with Tricare, but they will supply a form with purchases and proper coding so you can file your insurance yourself. They will not file any insurance. They supplied me with the proper form with coding which I sent in with my Tricare form that I filled out and Tricare reimbursed me. Sorry I gave the impression that Cpap.com filed the Tricare. One of the reasons they can sell the products at a lower cost is that they do not file the claims - that's up to the buyer.

I could be wrong, or the person I spoke to could be wrong, but I was told they would only pay for the machine if it were spread apart into 13 payments. If they were to pay it all right now, it would cost me nothing at all because my catastrophic cap has been met for the year.

It is not true that I would only pay 20%. I have a family plan and there is a $300 deductible ($150 per person) per year. I factored that into my total, but that's assuming I have no other medical expenses during that time period. And that's not likely.

Why do you have Tricare for Life? I always understood that if your spouse was active duty you qualified for Tricare Prime. Is it just not available in your area?

I have Tricare Prime so I'm not sure how the Tricare for Life works. I'm retired military and the Tricare is better than any insurance offered from the company I work for now. I

No way would I take Prime! Why would I want to have to wait for a referral every time my daughter or I need to see a specialist? And we see a lot of specialists! This is why I took Standard. Alas, because I am disabled and forced by law to take Medicare for hospitalization, I am also forced to take Tricare For Life. Daughter is still on Standard.

Since I live in the DC area I am close to the military clinic for my PCP. I have no problem getting referrals and all my sleep studies were done in civilian facilities at the cost of only $12 per visit. I don't have to mess with meeting the deductable that comes with the standard or Tricare for life. Getting a referral has never been a problem. I don't have to meet a deductable and all meds cost me nothing. If I fill them at a civilian pharmacy they are only $3 per prescription. I did have to pay 20% for the cost of my machine that they bought outright and didn't rent. Getting supplies has never been a problem. The Tricare Prime has been great and works for my situation.

Are you too far from a military facility? I've done the standard and it just didn't cover as well.

I don't *want* a referral. I want to call the Dr. of my choice and make an appointment. This is why I want the Standard. There are no military Drs. in the area where I live that see dependants. Also no military pharmacies. And I don't care about the money. For me it's all about the convenience.