Prices on masks

[ChicagoGranny]

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???

Mine doesn't have a deductible per year. It has deductibles that keep adding up until the $7,000 out-of-pocket maximum is reached. The out-of-pocket maximum is the sum of the money the insured spends on deductibles, co-pays, and coinsurance.

[Janknitz]

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

NOT CHEAP. $1700 month premiums just for my daughter and me. I pay less now for a lower deductible plan only because during the pandemic the premiums are capped at 7% of AGI. And the DME coverage doesn't cover CPAP or supplies . 2.5 years to Medicare . . . (but I still may have to cover her for one more year after that).

[Janknitz]

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???

Mine doesn't have a deductible per year. It has deductibles that keep adding up until the $7,000 out-of-pocket maximum is reached. The out-of-pocket maximum is the sum of the money the insured spends on deductibles, co-pays, and coinsurance.

There is a difference between the out of pocket maximum and the deductible. There has to be a cap on your deductible, it's not $7000. The deductible is how much you pay out of pocket at full price for goods and services until it is reached (e.g. mine is $2,500 per person). My out of pocket maximum is $10,000 for the "family" (my husband has Medicare so he doesn't count). So some things (my inhalers, for example) won't be covered at all until I hit the deductible, other things (preventative care, some screenings) only have co-pays and I don't have to meet the deductible. Some things are low co-pays or no charge IF I've hit the deductible (except the ^%$#@ inhalers which are tier 3 and cost almost $100 for the co-pay). Everything out of pocket counts toward the out of pocket maximum, which would only be hit in a catastrophe.

[mummmz]

I have the bill from my local DME supplier for my new ResMed Airsense 11 and mask. I have Blue Cross Basic (a federal employee/retiree plan) which will pay 70% of the allowable charge as long as I use a preferred provider. I have to use a preferred provider or insurance will pay $0. The preferred provider agrees to only charge the allowable charge so I pay 30%. I don't have a deductible but do have a max out-of-pocket of $6500. Problem is they can't tell me what charge is allowed. But the DME has a program where they look up co-pay & co-insurance. Charges for the Airfit F30 are:
item - Charge - co-insurance
frame - 244.50 - 28.83
3 cushions-298.28 - 32.89
headgear - 60.45 - 5.96
Total charge $603.23 co-insurance $67.68

Now 30% of 603.23 would be $180.97 but it's easy to extrapolate the allowable charge will be $225.60. I wonder how much this DME would charge if someone was to pay for it without insurance.

The total price for the whole set-up is $3,369.76. My co-insurance was $286.37 which extrapolates to a total cost of $954.56. Quite a difference and I feel bad for anyone who has to pay out-of-pocket if the bill is actually $3,369.76.

[ChicagoGranny]

Problem is they can't tell me what charge is allowed.

Who is "they"?

You need to be talking to the insurance company, not a DME, about prices. The reps at insurance companies can only speak sense when they are given the HCPCS codes for the items you are purchasing. Here are the codes - https://www.directhomemedical.com/direc ... -page.html

I feel bad for anyone who has to pay out-of-pocket if the bill is actually $3,369.76.

No one pays those prices.

[mummmz]

I was talking to a Blue Cross Rep. I doubt they would have bothered to look up the prices if I had given them the codes. I called 3 separate times trying to get information from them. People don't seem to want to do their jobs anymore.

[ChicagoGranny]

I was talking to a Blue Cross Rep. I doubt they would have bothered to look up the prices if I had given them the codes. I called 3 separate times trying to get information from them. People don't seem to want to do their jobs anymore.

I've had good luck with my state's BCBS provider. If I ever think the rep is not getting done what needs to be done, I ask to speak to a supervisor. This has only happened twice, and the supervisors did things that exceeded my expectations.

[mummmz]

I should have asked for a supervisor. I've been a bit stressed with all my medical issues lately and didn't think about it. I'm in Mississippi so B/C of MS is who I called.

[chunkyfrog]

Long ago, in a galaxy far, far away, Blue Cross was an insurance company.
They were big, and fairly consistent.
Now most of their business is selling the good name earned decades ago,
to any slimy outfit willing to pay the fees to use the name.

[Janknitz]

mummmz wrote: ↑Fri Jun 10, 2022 2:42 pm
I feel bad for anyone who has to pay out-of-pocket if the bill is actually $3,369.76.
No one pays those prices.

Unfortunately, there are people who don't know better who might pay the DME's retail fantasy price of over $600 for a mask . Now, with the internet though, a quick google search shows the online retail price running from $96 to $170 for the Airfit F30 mask, so I hope DME's don't get away with this very often anymore. Before there was a lot available on the internet, and when people 15 or so years ago were not so tech savvy, this happened often

The parted out retail price that DME's charge for anything is pure fantasy. DME's are most often paid by insurers on a contract basis and they have negotiated prices. They assign ridiculous prices to everything because on a regular basis they have to show Medicare what their "losses" are to try to negotiate a better allowable amount. Everybody plays this game--doctors, hospitals, nursing homes, therapy providers, and pharmacies. And Medicare and other insurers, knowing how the game is played, ignore it when setting their allowables.

The US system is seriously &^%$#@ up. People have no clue how much it costs because Medicare has to audit these costs on a regular basis in setting up their schedules. There's so much money tied up in the administrative process to "catch those cheaters" that it costs everyone, including the US and state governments, so much more to do ordinary business. But it's a convenient political football to "cut waste" by costing us millions more to play these games.