Prices on masks

[jlsmithseven]

Can someone suggest a good place online to get a decently priced mask? I wanted to try the f30i but they’re asking more than $150 wherever I go online. Which means insurance is probably charging like $179 for it?

[Janknitz]

It's important to understand who the players are here. Insurers vs. DME's.

Insurance doesn't charge for masks, insurance covers a percentage of the cost they determine is reasonable for a mask. Typically insurers set a flat "reasonable" cost for all masks of a certain type, and then pay a percentage of that amount, you pay your share. So let's say that the insurer decides that $150 mask is reasonably worth $100 (EXAMPLE). The insurer pays 80% which is $80 and you pay 20% of the INSURER's reasonable cost or $20.

It's illegal in most states for the provider to "balance bill"--that is charge you the whole difference between the insurer's reimbursement ($80) and the full retail price ($150 - $80 =$70). All you have to pay is the 20% of the insurer's price or $20 (UNLESS you haven't met your deductible, in which case you pay $100, not $150). NOTE: This may not apply if your insurer require you to use a "preferred" or "network" provider in order to get better pricing.

A DME (Durable Medical Equipment provider) can charge anything they want retail. If you don't have insurance and you're a sucker, you might pay the full retail price out of pocket. But the DME's price is a fantasy of what they wish they could get. They have contractual arrangements with insurers to receive far less than the retail price.

Now the insurer may have set the reasonable cost at $100 but you find the same mask online for $80. And I bet you think you only have to pay 20% of the $80 but in most cases you'd be wrong. Most insurers will only pay for suppliers they contract with, and they don't contract with most online providers. Even then, they may still say the reasonable cost is $100 because the provider has to do a lot of extra paperwork for them.

So if you have insurance and you only want to pay $20 out of pocket, you get it from the supplier who charges $150 but has a contract with your insurer.

Hope that makes sense.

[ChicagoGranny]

Can someone suggest a good place online to get a decently priced mask? I wanted to try the f30i but they’re asking more than $150 wherever I go online. Which means insurance is probably charging like $179 for it?

Do you have insurance that covers masks for you?

[jlsmithseven]

yes but my deductible per year is 5000.00 so its not worth it

[Julie]

Secondwindcpap.com... great to deal with and cheaper than brand new.

[Janknitz]

I don't have any DME coverage so I buy masks on Amazon and here on cpap.com. It's $117 on Amazon right now for the whole thing (they call it a "visor kit" ). No Rx needed. You have to buy it part by part on eBay and it's a pain.

I learned with a high deductible plan to calculate how much it would cost out of pocket to spend more on a higher plan with a lower deductible, and learned I came out ahead on a higher cost lower deductible plan. Especially after one ER visit. And now I can afford my inhalers. With just the inhalers, I would have broken even, but not have to shell out $500 more dollars every month for 5 months before I could actually get them covered.

[ChicagoGranny]

yes but my deductible per year is 5000.00 so its not worth it

Are you sure the deductible applies to DME? With many health policies, the deductible doesn't apply to DME. And $5,000 per year sounds like an out-of-pocket maximum, not a deductible.

I always recommend insureds talk to their insurance company about details. Ask for a supervisor if the rep you speak to doesn't seem sure.

[palerider]

yes but my deductible per year is 5000.00 so its not worth it

Are you sure the deductible applies to DME? With many health policies, the deductible doesn't apply to DME. And $5,000 per year sounds like an out-of-pocket maximum, not a deductible.

You obviously haven't looked at insurance "coverage" in the last 10-15 years.

[chunkyfrog]

Deductibles and co-pays are often different for just about anything.
Get a hard copy of the declaration of coverage for YOUR policy.
Insurance companies can count hospital, doctor's office, prescriptions,
and durables separately--and the numbers will be different for network
and "out of network" providers.
The system is so complicated that you need to get it IN WRITING.
If there are parts you cannot understand, you are not alone.
Your state department of insurance may be able to help you understand--
Or they could be even more confused than the rest of us.
Of course, it is different EVERYWHERE.
Sorry I could not be more help.

[ChicagoGranny]

yes but my deductible per year is 5000.00 so its not worth it

Are you sure the deductible applies to DME? With many health policies, the deductible doesn't apply to DME. And $5,000 per year sounds like an out-of-pocket maximum, not a deductible.

You obviously haven't looked at insurance "coverage" in the last 10-15 years.

Looks like you don't know insurance terminology in the last 15 years or today.

No health insurance policy quotes deductibles as dollars per year. Only out-of-pocket maximums are quoted that way.

[palerider]

yes but my deductible per year is 5000.00 so its not worth it

Are you sure the deductible applies to DME? With many health policies, the deductible doesn't apply to DME. And $5,000 per year sounds like an out-of-pocket maximum, not a deductible.

You obviously haven't looked at insurance "coverage" in the last 10-15 years.

Looks like you don't know insurance terminology in the last 15 years or today.

No health insurance policy quotes deductibles as dollars per year. Only out-of-pocket maximums are quoted that way.

Ever considered talking to actual people?

[Janknitz]

No health insurance policy quotes deductibles as dollars per year. Only out-of-pocket maximums are quoted that way.

Many Silver and Bronze "Affordable" Care Act plans have $5000 plan deductibles in California. I used to have one that high.

Now I "only" have a plan with a $2,500 deductible. And I happen to be looking right this minute at a Kaiser Evidence of Coverage for a client. They have a chart which clearly delineates the Plan Deductible, the Drug Deductible, and the Plan Out-of-Pocked Maximum ("OOPM" ) for the "Accumulation Period" (a.k.a. calendar year) This client's Plan DEDUCTIBLE is $2,700.

Where did you get the idea that "no health insurance policy quotes deductibles as dollars per year"? How else are they supposed to quote them, because everyone has a certain deductible to be met every calendar year???

Not all goods and services are subject to the deductible, which is why Chunky's advice to get a hard copy of your policy is a good one. The document you must request is the "Evidence of Coverage" (EOC). It's the contract between you and your provider you've never seen unless you know to ask, and it will spell out in DETAIL what is subject to the deductible and what does not. You MIGHT find out that CPAP supplies are NOT subject to the deductible, but probably is.

And jlsmithseven, I don't appreciate that you changed the question I was responding to about who is in charge of CPAP mask prices. It makes it look like I was being snide. I wasn't, I was trying to help you understand how medical supply and equipment pricing works.

[mets123]

I would recommend looking at cpap masks express, they sell the f30i complete mask for $91.

[KathyJL]

Thanks for your post! I have a very high deductible and needed a good resource, too! Keep ‘em coming! Also didn’t realize that DME could be separate from deductible, so need to look up my benefits.

[chunkyfrog]

Any insurance with a $5,000 deductible better be damn cheap;
because it's not worth much at all.