Does blue Cross Blue Shield allow/pay 100% for S9 AutoSetsB

Does Blue Cross Blue Shield (BC/BS) normally allow/pay 100% for an S9 AutoSet for an in network provider?

Are there any things I need to do to get a DME to prescribe an S9 AutoSet other than to ask for it specifically?

What is the usual and customary price for an S9 AutoSet (preferably in the Boston area)?

If the DME will not prescribe one or if BC/BS will not pay in full, what will BC/BS pay if purchased by an out of network provider, such as CPAP.com?

Not mine; but contracts vary by individual employers/groups.
Check with BCBS on the phone--they need your ID to find YOUR benefits.

With in-network DMEs, the price they can charge is usually the same no matter what CPAP or APAP they dispense. That's why so many will do anything they can to sell you a cheap machine. They don't have to give you a more expensive machine, but they probably can't charge extra.

Be careful that a DME doesn't give you an Escape Auto instead of an AutoSet. Look next to the power button for the name. Remember there is no "S9 Auto" machine.

As for reimbursement, you have to check your own policy.

Almost no one gets 100% on anything these day, but 80% is common.

It's quite common for insurance to pay nothing for online purchases, not even the "out of network" rate. And they have separate deductibles.

Find out who the in network CPAP DMEs are for your area. Be ready to shop around and let them know you're shopping around.

See if you can get your doctor to prescribe a pressure range rather than a single pressure. It can be a small range, such as 10-14. That way, they have to dispense an Auto machine.

Get your prescription on paper, don't let the doctor choose the DME.

There are as many BC/BS plans out there as there are employers who use them. It also depends on if the plan is a PPO or an HMO. I have BC/BS of FL HMO, and they wouldn't approve ANY type of auto or data capable machine. HMO's have the power to override a doctor's Rx, and unless you are willing to wait many months while you TRY to fight that, be aware they will probably prevail in the end, anyway. A PPO is quite different, and you just need to call them and ask for a copy of the detailed coverage your plan has. Ask what their practice is in terms of cpap equipment; what is their normal replacement schedule for machine and supplies, and, of course, you should be clear on any deductible and co-pays you are responsible for. Some plans will rent your machine for 13 months after which you will own it outright. You will need to demonstrate compliance for this to happen.... using the machine faithfully 70% of the time with a minimum of 4 hours per night. As for 100% coverage...that is usually found in HMO plans, but the reason they can afford to do that is because they will only authorize a cheap brick of a machine. This is why I bought my own machine outright.

I have a Premera PPO. The re are no deductibles or co-pays for medications, emergency room or doctor visits or anything.

Specifically there is no deductible for in network services nor any maximum benefit for the durable equipment benefit (although, there are maximum benefits for vision, dental, hearing aids, etc.) . The only limitation I see for durable medical equipment is that it does not cover "special or extra-cost convenience features."

Besides sleep apnea I also have type II diabetes and hypertension which are controlled by medications.

I have been trying to find out what will be allowed but one DME told me that this is confidential proprietary contractual info and that they bill the insure $3,400 (I think for any machine) but that is not what they get paid. Someone else told me that what the insurer pays is what is "usual and customary."

My concern is that any machine beyond a basic compliance one can have what someone might consider "special or extra cost convenience features."

I am unclear whether an APAP versus a CPAP is a "convenience" feature, nor if data logging is a "convenience" feature.

Can anyone provide any insights?

You won't know what YOUR insurance covers unless you read the nitty gritty details of your plan.... get the booklet from them that delineates coverage! Every plan is different so telling you what my plan covers will NOT tell you what YOUR plan covers.... You must do your homework. APAP is often considered a convenience feature by insurance...but other companies insist that is the only type of machine to give out. Others are convinced a data-less brick, cpap is sufficient. Your company has its own rules, and you must get familiar with them. Read Janknitz's column on DME and Insurance: http://maskarrayed.wordpress.com/what-y ... me-part-i/

Specifically you need to ask what your DME (Durable Medical Equipment) benefit is.

I have a BCBS plan that is not the greatest for DME; my copay is 50% of the approved charge and they don't pay anything for the "A" codes (which are things like masks, hoses, filters, etc.). Each plan/policy is different.

Our BCBS has sizable deductibles; but fortunately, I have been told (by them) that out of network purchases apply toward in-network deductibles (in our group). So, CPAP.com gets to sell us a bunch of stuff--I just have to pay careful attention to the timing and file all the paperwork. --myself.
This way, If we don't make our deductibles, we still get way more supplies for the same money.
I just hope after Medicare kicks in, we can get reimbursed--that would be sweet.

I have BCBS of Alambma and can download policies from their web site.
The "Management of Obstructive Sleep Apnea" policy document tells me everything i need to know. Including all the changes they made last year.

I

I have Premera BCBS PPO although my employer is self-insured. My benefits for DME are 100% with no deductible and no co-pay. BCBS does not allow balance billing.

I found the following information on another board about a (non-Premera) BCBS PPO which compares what the DME bills BCBS, what BCBS pays and what APAP.com charges for an S9 AutoSet. The DME which which i am still proceeding at this point told me they charge BCBS $3,400 compared the $2,990 shown below: