How Often Can I Get A New Mask

[Ray]

The headgear on my Comfort Lite broke last night. It's about 4 or 5 months old. Will most insurance companies buy a new mask before 6 months? I can't find anything on my Aetna PPO website that details the frequency of replacement.

Also, do they replace the cushions more often than every 6 months, or do they simply buy the entire mask only every 6 months?

[bdp522]

Each insurance is different. I would try calling the manufacturer. I know innomed has been very good, i would think others would stand behind the products they sell also. My insurance will pay for a new mask every 3 months or sooner if the mask breaks, so long as it hasn't been abused.

Brenda

[wolftracker]

http://www.tricenturion.com/content/dme ... 1_cpap.cfm

aetna says it follows tricenturion and here it is

[wolftracker]

K0183 Nasal application device, used with positive airway pressure device
K0184 Nasal pillows/seals, replacement for nasal application device, pair or single piece interface
K0185 Headgear, used with positive airway pressure device
K0186 Chin strap, used with positive airway pressure device
K0187 Tubing, used with positive airway pressure device
K0188 Filter, disposable, used with positive airway pressure device
K0189 Filter, non-disposable, used with positive airway pressure device
K0268 Humidifier, non-heated, used with positive airway pressure device
K0531 Humidifier, heated, used with positive airway pressure device
The following table represents the usual maximum amount of accessories expected to be medically necessary:
K0183 1 per 3 months
K0184 2 per 1 month
K0185 1 per 6 months
K0186 1 per 6 months
K0187 1 per 1 month
K0188 2 per 1 month
K0189 1 per 6 months

[Ray]

Wolftracker:

Can you tell me the source of this information? Aetna makes reference to a Medicare website that is supposed to have this information, but I haven't been able to connect to it.

[wolftracker]

and search for cpap ... that is where i got the above info

i am federal yours may be different

but it pointed me to the link and the link contained lots
more ... but the stuff i cut and pasted was what you asked

http://www.aetna.com/cpb/data/CPBA0004.html

Note: Aetna follows Medicare DMERC rules with respect to the usual medically necessary quantity of supplies for positive airway pressure devices. See DMERC Policy on Continuous Positive Airway Pressure System (CPAP) and on Respiratory Assist Devices at the TriCenturion, LLC DMERC website, at http://www.tricenturion.com/content/lmr ... nt_dyn.cfm.

[Wulfman]

I have a question or two to those of you who can get a new mask every 3 to 6 months, or some interval.

Is that mask (purchase) subject to your insurance deductible? (if it's in a "new" year)

And, if you have a co-pay percentage (80/20), does your insurance pay up to their portion or all of it?

From the posts I've read, it sounds like the insurance is paying 100% for a new mask at various intervals, and I've never heard anyone comment about meeting their deductible or that the insurance only paid for a percentage of the mask.
I just can't imagine insurance providers being that generous.....
Also, I'd never come close to using much (if any) of my annual insurance deductibles until last year (calendar '05)..... for years I THOUGHT I had been pretty healthy.

Thanks,

Den

[wolftracker]

I dont have a deductable for dme
we have co pays for doctor and hospital visits ... not sure
if after some amount it goes away

i am not paying anything for the apap
or supplies

but we do have to use aprea of all things

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): DME, APAP

[bdp522]

Same here. I pay nothing for Dr., or equipment. I too am stuck with Apria. I have HIP HMO insurance. I will get a new hybrid every three months because it is considered a nasal interface because of the pillows. A full face mask is 1 every 6 months.

Brenda

[Ray]

Thanks for the info, Wulftracker. You found that on the website that wouldn't function for me. I appreciate the assistance.

[linda b]

Does "Nasal application device, used with positive airway pressure device" - K0183 - include the headgear? Or is headgear excluded because of the separate classification?

[tmaiberger]

Per Den's question, once my maximum's have been reached I pay 10%. In the new year, I will pay a higher %, not sure how much (my insurance is federal blue cross/blue shield). I am increasing the amount in my FSA to cover the costs next year, so I can get most of the money back. I can get a new mask every three months, and get hose, replacement cushions etc monthly. Nothing from an insurance company is free, they will nickel and dime you to death, even more so if you go out of their network (even on a PPO).

Todd

[snoregirl]

On Den's question also, I have a 20% copay on supplies (masks, filters, hoses etc through my DME). Of this I am positive. I just ordered a hose, filters, and swift pillow and was told about $16 is my copay. I know the pillow alone online is $30. Hose and fliters are cheaper online but all around better for my pocket to get it from the local DME -- this insurance year.


I THOUGHT that this was after deductable, but you make me want to call my insurance (and I will) and double check come Jan 1 about supplies for next year. Maybe with all this going on (sleep studies, APAP coverage/denial...) and all the questions and escallations for benefits etc, I am wondering if I truly asked that exact question.

I met my deducable with all my sleep studies early in the year so it was a moot point this year, but definately will not be next year. I was assuming I would never get anymore benefits from insurance on supplies since I don't expect to meet either in network or out of network deductable next year.

So as to your question of 100% coverage, definately not for all of us, and thank you for waking me up and making me think to double check to see if Durable medical goods are indeed subject to my deductable.

[Wulfman]

Thank you all for replying to my questions. I didn't mean to hijack Ray's thread, but it looked like an opportune moment to ask something that I've been wondering about for some time.
I presumed that deductibles would apply, like almost every other medical expense, but since so many plans are different, I thought I'd ask.

Thanks again,

Den

[unclebob]

On this topic, do any Canadians have experience in this regard?

My company plan makes no mention of the accessories although they paid $1000 (the max) towards the initial xPAP purchase.

Bob F