ADP changes to CPAP in Ontario

Just saw this, hadn't seen a post on it, hopefully it's not a duplicate, but this looks like good news for me, I pickup my machine on the 7th of march, right after this takes effect.

To summarize, they're no longer paying for trials (which I will just be ending when it kicks in!).

The approved price is dropping from $1040 (they pay 75%, you pay $260) to $860 (they still pay 75%, but you now pay $215 instead of $260). Includes basic crummy mask/headgear too.

APAP reduced to $1020 (you pay $141 less - $255 cost if my math's right) and BiPAP capped at $1120 (you save ~$533 now, cost is $280 from $700ish min).

Looks like the finally caught on that DME's were jacking up the price once they heard ADP and selling above their regular retail/unassisted cost.

Full FAQ here: http://www.health.gov.on.ca/en/pro/prog ... 131218.pdf

Wow. Good thing I got mine when I did. Between OHIP and Green Shield I was all covered. Green Shield also covered the mask. I can get a new mask every 6 months and it's covered.

This change is good news for anyone in Ontario who is looking for a basic CPAP. However, it is likely that it will make it that much harder to get a fully-data-capable CPAP such as a Resmed Elite, or similar. According to the link in your post, DME's are not allowed to charge extra ONLY for "... the following:
- an upgraded mask and headgear;
- a service package; or
- any on-going services they provide after the initial training.> "

Thus, a patient cannot buy an upgraded CPAP by paying the difference in cost to the DME.

Ontario OHIP has it's heart in the right place by making it less expensive to get therapy for SA and preventing the all-too-common DME jacked-up prices. However, the unintended consequence of the way they are delivering it is to make it that much harder for patients to take charge of their therapy. The policy should have included some conditions around optional equipment upgrade prices to be paid by the patient.

Hose_Head wrote:Ontario OHIP has it's heart in the right place by making it less expensive to get therapy for SA and preventing the all-too-common DME jacked-up prices. However, the unintended consequence of the way they are delivering it is to make it that much harder for patients to take charge of their therapy. The policy should have included some conditions around optional equipment upgrade prices to be paid by the patient.

Agreed. I've set up a meeting this week with a DME to supply a ResMed S9 Elite w/H5i Humidifier and ClimateLine, and an F&P Eson Nasal CPAP Mask. I'll let them figure out how to make use of the ADP program to lower costs and win my business. It would be a shame if OHIP precluded some patients from taking charge of their therapy because of an overly rigid policy.

Hose_Head wrote:This change is good news for anyone in Ontario who is looking for a basic CPAP. However, it is likely that it will make it that much harder to get a fully-data-capable CPAP such as a Resmed Elite, or similar. According to the link in your post, DME's are not allowed to charge extra ONLY for "... the following:
- an upgraded mask and headgear;
- a service package; or
- any on-going services they provide after the initial training.> "

Thus, a patient cannot buy an upgraded CPAP by paying the difference in cost to the DME.

Ontario OHIP has it's heart in the right place by making it less expensive to get therapy for SA and preventing the all-too-common DME jacked-up prices. However, the unintended consequence of the way they are delivering it is to make it that much harder for patients to take charge of their therapy. The policy should have included some conditions around optional equipment upgrade prices to be paid by the patient.

What would you consider an upgraded CPAP to be? The Resmed S9 Elite isn't considered an upgraded unit by the ADP, and as a result should cost the end-user exactly the same as a non-data capable machine. I spoke to someone at the OHIP office last week and was specifically told the DME can't be charging more for that unit; the price is capped. It was that way before the change as well, just the overall costs were higher. Now, the DME may push the cheaper ones on you to increase their own profits, but if your doc rx's a specific machine, they really have no choice. It wasn't as big a deal before, as once they heard ADP they'd jack the price to the max allowable and increase their own profits by a couple of hundred dollars. With these changes, the government is basically paying the same amount a patient would pay out-of-pocket (as they should be to begin with).

The biggest advantage/change with the program is for the auto and bipap units, these now cost far less. Right now an APAP will cost less than a regular CPAP would have a week ago by $5.

ironhands wrote:

Hose_Head wrote:This change is good news for anyone in Ontario who is looking for a basic CPAP. However, it is likely that it will make it that much harder to get a fully-data-capable CPAP such as a Resmed Elite, or similar. According to the link in your post, DME's are not allowed to charge extra ONLY for "... the following:
- an upgraded mask and headgear;
- a service package; or
- any on-going services they provide after the initial training.> "

Thus, a patient cannot buy an upgraded CPAP by paying the difference in cost to the DME.

Ontario OHIP has it's heart in the right place by making it less expensive to get therapy for SA and preventing the all-too-common DME jacked-up prices. However, the unintended consequence of the way they are delivering it is to make it that much harder for patients to take charge of their therapy. The policy should have included some conditions around optional equipment upgrade prices to be paid by the patient.

What would you consider an upgraded CPAP to be? The Resmed S9 Elite isn't considered an upgraded unit by the ADP, and as a result should cost the end-user exactly the same as a non-data capable machine. I spoke to someone at the OHIP office last week and was specifically told the DME can't be charging more for that unit; the price is capped. It was that way before the change as well, just the overall costs were higher. Now, the DME may push the cheaper ones on you to increase their own profits, but if your doc rx's a specific machine, they really have no choice. It wasn't as big a deal before, as once they heard ADP they'd jack the price to the max allowable and increase their own profits by a couple of hundred dollars. With these changes, the government is basically paying the same amount a patient would pay out-of-pocket (as they should be to begin with).

The biggest advantage/change with the program is for the auto and bipap units, these now cost far less. Right now an APAP will cost less than a regular CPAP would have a week ago by $5.

Like most on this forum, I consider an "upgraded" machine to be one that is fully data capable and that only upgraded machines should be sold to anyone. A Resmed S9 Elite is considered to be an upgraded model because it is fully data capable, unlike the Resmed Escape which only shows compliance data. You cannot buy a better cpap from Resmed than their Elite model. OHIP's ADP program does not differentiate between the various models of cpaps.

Agreed that if your doctor writes "Resmed Elite CPAP" on your prescription, then the DME will have to provide that. The patient will have to request (demand!) that the prescription be written this way. Which points to the oft-proven axiom in this forum that the best protection for the patient is to be well-informed BEFORE ever stepping into the Doctor's and DME's offices.

Hose_Head wrote: OHIP's ADP program does not differentiate between the various models of cpaps.

It would appear that ADP only classifies machines by category (CPAP, BIPAP,APAP). I think you have the right to choose whatever model you want within the category.

I was prescribed a CPAP machine, but I wanted to purchase an APAP machine so that I could self titrate myself periodically to check for any changes in my condition. I expected ADP to pay 75% of the cost of a CPAP machine and I would gladly pay all remaining costs out of my own pocket. The DME said I couldn't get an APAP machine at all. They gave me the number of someone in the ADP office in Toronto who also said they would only pay for a prescribed machine. If I bought anything other than that, they would pay nothing. I just related this story to my sleep doctor yesterday, and he was also surprised that ADP wouldn't just contribute 75% of the CPAP unit and let me pay the remainder.

Rick007 wrote: I was prescribed a CPAP machine, but I wanted to purchase an APAP machine so that I could self titrate myself periodically to check for any changes in my condition. I expected ADP to pay 75% of the cost of a CPAP machine and I would gladly pay all remaining costs out of my own pocket. The DME said I couldn't get an APAP machine at all. They gave me the number of someone in the ADP office in Toronto who also said they would only pay for a prescribed machine. If I bought anything other than that, they would pay nothing. I just related this story to my sleep doctor yesterday, and he was also surprised that ADP wouldn't just contribute 75% of the CPAP unit and let me pay the remainder.

I had the same problem.

I also called the ADP and when I told them what I wanted to do, all they could say was, "But that's not by the book".

The sad thing is that in any other province you wouldn't have this problem. You can get what you want with no hassle but you or your insurance has to pay. In Ontario they tried to help, but for you and I it just created a hassle. It's worse, because if you do have benefits they generally want to see that ADP has paid it's portion first.

Luckily for me, my wife's benefits are excellent. My DME wrote a note saying I didn't qualify for APAP and Her insurance paid for 90% of an S9 Autoset.

For people who haven't purchased a machine yet, talk to your insurance. You may be able to swing the same thing, especially with the reduced prices.

Hose_Head wrote: Like most on this forum, I consider an "upgraded" machine to be one that is fully data capable and that only upgraded machines should be sold to anyone. A Resmed S9 Elite is considered to be an upgraded model because it is fully data capable, unlike the Resmed Escape which only shows compliance data. You cannot buy a better cpap from Resmed than their Elite model. OHIP's ADP program does not differentiate between the various models of cpaps.

So I just visited a DME for my CPAP one-month trial. The fee for the trial was $30. ADP may have covered the cost of the trial previous to March 1st. I dunno. Insurance will likely pick up the tab. If not then $30 isn't too onerous.

I suggested to the DME agent that an AutoSet is preferred to help the sleep doctor dial-in a titration or make adjustments without having to perform frequent sleep studies. That won’t happen without a change to the prescription. Well, I tried …

The DME agent didn’t bat an eye when I suggested I’d settle for an S9 Elite instead of an AutoSet. The worry that the DME will only supply an S9 Escape seems unwarranted. Things may change before my trial is up but so far I’m happy with the ADP change in policy. It appears overall patient cost will be about half.

As for the AutoSet I still have a chance when I visit the sleep doctor but the ADP requirements seem clear. Expectations are that if I want one then I will have to buy it outside ADP. If I understand correctly the main difference between the S9 Elite and the S9 AutoSet is the ramp so exhale pressure may be more comfortable when falling asleep with the AutoSet. The Elite has a timed ramp instead of auto-titration. My prescription is for 8 cmH20 so this may not be a big deal. Will see how I feel about this after a month.

SleepWrangler wrote: If I understand correctly the main difference between the S9 Elite and the S9 AutoSet is the ramp so exhale pressure may be more comfortable when falling asleep with the AutoSet. The Elite has a timed ramp instead of auto-titration. My prescription is for 8 cmH20 so this may not be a big deal. Will see how I feel about this after a month.

I think you are confusing ramp and auto adjusting pressure mode (APAP)

Both the Elite and Autoset have a timed ramp where you can select a lower pressure setting and work up to it.
In the Elite which offers only CPAP mode which is a single fixed pressure mode...ramp would start you at whatever point you start and slowly work up to your 8cm RX pressure. Once you get to 8 cm it stays there (unless you use EPR in which case whatever you are using for EPR never varies) until you maybe turn the machine off and back on for some reason.

The AutoSet...has CPAP mode available and it works just like the Elite's CPAP mode in everything it does
but it also has another mode available where the pressure can fluctuate as the machine senses the need per whatever parameters might be set and this is totally separate from the ramp function.
The auto adjusting capability is called APAP mode and we commonly refer to machines that do this auto adjusting as APAPs.
All APAPs have cpap mode available so they are like 2 machines in one.

With the AutoSet you could set the minimum pressure at say 6 and maximum say at 12...use your ramp (it's a totally separate function) until you got to 6 cm and then the machine would go to work checking your airway and if for some reason it sensed the need to increase the pressure it could do so up to the maximum of 12. If you only needed say 11 cm for 30 minutes during the night for some reason then you wouldn't have to spend all night at 11...you could spend the bulk of the night at 6 cm and let the machine increase for the 30 minutes it might need 11 cm.

So the advantage to APAP mode is the ability to use a lower pressure for most of the night and let the machine adjust as needed for special pressure needs (like supine sleeping or REM stage sleep).
With the ELite...a person has to use the higher pressure all night to cover the worst case scenario because it can't adjust upwards..it only delivers a fixed pressure.

With your 8 cm RX needs...may not be that big of a deal because that's not considered a very high pressure at all but if your pressure needs were in the double digits for part of the night and single digits for the bulk of the night..believe me you would rather let the machine go to say 15 for 30 minutes and stay at 8 for the rest of the night....while 15 all night is done all the time...8 cm is a whole lot easier on a person.
Also, some people get bad aerophagia (lots of air in the stomach that causes pain) with higher pressures all the time but can get by with using the higher pressures just some of the night.

So there are some distinct advantages to having a machine that can auto adjust if the need arises.
There are also some disadvantages also but with APAP machines...we can always go back to cpap mode but with a CPAP machine like your Elite you can't ever go to auto adjusting mode.

Just remember ramp is just for when you first turn the machine on so you can slowly work up to your fixed pressure with the Elite.
Ramp doesn't do anything except slowly increase to whatever the pressure setting happens to be and in both the Elite and AutoSet the ramp functions exactly the same.
The big difference with the AutoSet is the ability to have the pressures auto adjust throughout the night on an as needed basis. When I was using APAP machine my minimum pressure was 10 cm but sometimes I would see the need for 18 or 19 cm...and I tell you...I would rather use 10 cm most of the time than 18 all the time. Huge difference in comfort.

If I had only the Elite to use...I would have 2 choices...use 18 cm all the time to cover worst case scenario or use a lower pressure and just let those apneas that needed higher pressure just happen because the pressure couldn't prevent them.

APAP machines typically cost a little more on the wholesale level...so that's part of the reluctance to supply an APAP machine...bottom line profit margin.
There is also some stupid idea that if the RX says 8 cm that they can't supply an APAP since APAP uses a range of pressures...well that's just plain stupid if they want to use that excuse because the APAP machine can be set in CPAP mode..duh. Or it can be set in APAP mode with minimum to equal maximum which effectively makes it function like CPAP.
Personally I think that suppliers will use any excuse to supply a machine that makes them the most profit.
Sad thing is that the APAPs don't cost all that much more than a CPAP does but I suppose $50 bucks times 100 machines adds up.

Canada...they do things a little differently but they could supply an APAP if they just would...same as DMEs here in the US...
Set it to CPAP mode and they have satisfied the RX requirements.
At least Canadians don't have to go to war to get an Elite instead of the Escape...though I have had some pretty sad Canadians come to me wanting the software for their Respironics machines only to be told that the reason it doesn't work is because they have a brick....so not all Canadian cpap suppliers are dispensing full data machines.

SleepWrangler wrote:So I just visited a DME for my CPAP one-month trial. The fee for the trial was $30. ADP may have covered the cost of the trial previous to March 1st. I dunno. Insurance will likely pick up the tab. If not then $30 isn't too onerous.

I suggested to the DME agent that an AutoSet is preferred to help the sleep doctor dial-in a titration or make adjustments without having to perform frequent sleep studies. That won’t happen without a change to the prescription. Well, I tried …

The DME agent didn’t bat an eye when I suggested I’d settle for an S9 Elite instead of an AutoSet. The worry that the DME will only supply an S9 Escape seems unwarranted. Things may change before my trial is up but so far I’m happy with the ADP change in policy. It appears overall patient cost will be about half.

ADP definitely covered the trial prior to 3/1. Mine ends tomorrow and was free of any charges. If it's just $30 that's awesome.

I've spent the past 2 days calling up every DME local to me. I've been quoted as high as $2370 for the S9 Autoset AFTER the ADP contribution (it should only be $255!!!!).

Several have said they can upgrade to an APAP for a few hundred over the cost, averaging about 400-500$ out of pocket instead of the $215 for a CPAP.

ALL, with the exception of one, have told me that they will not sell me the S9 Elite for the approved price, they are only allowed to sell it for $215 out of the patients pocket, but most have quoted much higher, $350-400 on average, some forced a package deal of $500 with my choice of mask (which they cannot force, and at least a basic mask is to be included). One vendor quoted me $1100 for the Elite, AFTER the ADP, no mask.

Clearly, this is a little nuts.

As for the whole Escape vs Elite - they don't really care when it comes to the trial, if anything they'd WANT you to test drive the best to say "the escape is the one we give as the lowest cost, but the one you've been using it is so much better, right?" Trust me, when it comes to actually dropping the cash, there is a very very good chance they'll either push you towards the cheapest one they can if they know you're only going to shell out the ADP max cost, or, they'll try to tack on extras, or worse, tell you that it's an "upgraded model" and costs more, which they cannot do. They risk their ADP license doing so.

I actually just got a response a moment ago from a contact I made at the ADP office, who will be contacting a few local distributors based on the improper pricing I was issued

Pugsy wrote: Canada...they do things a little differently but they could supply an APAP if they just would...same as DMEs here in the US...
Set it to CPAP mode and they have satisfied the RX requirements.
At least Canadians don't have to go to war to get an Elite instead of the Escape...though I have had some pretty sad Canadians come to me wanting the software for their Respironics machines only to be told that the reason it doesn't work is because they have a brick....so not all Canadian cpap suppliers are dispensing full data machines.

It's not Canada. It's the Ontario Assistive Devices Program. If you want funding from the government, you must get a CPAP unless you meet very strict requirements for APAP. You have no choice. If your insurance insists that the ADP pay it's share first, you are out of luck. You have to pay out of pocket or take a CPAP. There is no flexibility. You have to get one of the approved machines off the list.

In my limited experience with two DMEs, you won't get both the Elite and the Escape for the same price.

The prescribed price for the machines is the same, but the elite "comes with the climate line hose, two upgraded masks, and the upgraded reservoir". Or something like that. It will cost you several hundred dollars more.

paradoiley wrote:The prescribed price for the machines is the same, but the elite "comes with the climate line hose, two upgraded masks, and the upgraded reservoir". Or something like that. It will cost you several hundred dollars more.

That means they're forcing an "upgraded" kit on you, which they can't do. The S9 Elite is listed on their documents, and comes with a regular hose, basic mask, basic reservoir, humidifier, case, and power supply. They are obligated to provide those items at the approved cost, or they cannot use the ADP discount. What they'd be doing is billing the ADP for the unit, and then selling you those "extras". The extras, are optional.

Not everyone needs the elite, however, so that's where it comes into play. Most users wouldn't need the Elite, or know to ask, and are fine with the Escape.

ironhands wrote: I actually just got a response a moment ago from a contact I made at the ADP office, who will be contacting a few local distributors based on the improper pricing I was issued

I phoned my sleep center office yesterday to talk about their prescribed action plan. They acknowledged that the ADP changes have thrown a wrench into the works so both the DME and sleep centers have an adjustment period. Your findings do not surprise me at all.

In my case the DME spent over an hour with me in their brick and mortar building planning a one month trial. If the loaded rate per employee is $500 per day then it cost them at least $70 - $85 just for this activity plus there is a follow-up in two weeks to review trial data. From a pre-sales perspective they are definitely investing in this relationship and prioritizing a high standard of care above cash. Essentially the $30 trial fee supplied me with a trial unit, mask, hose, and headset and I get to try other masks if the one I have chosen by default doesn't work. I also get access to an expert. All good stuff thus far.

My assumption that the DME will supply a ResMed Elite post-trial without upgrade fees under the ADP may be incorrect. I am hoping for the best but prepared for the worst. The end goal is good sleep. That's all I really care about.

Pugsy wrote: I think you are confusing ramp and auto adjusting pressure mode (APAP)

Thanks for untangling my insane ramblings. You're awesome