Aetna Insurance

[Emilia]

You can buy a brand new Intellipap with the humidifier for about $450 from our host or from secondwindcpap.... and still have enough left over from your deductible to buy the software No insurance needed.....and it is yours to keep!

[RandyJ]

That sounds familiar. Before telling me the S9 was not covered by insurance the DME said it would be $255 up front with $48/month for 9 months (total $687). If yours is a "lease agreement" as well - in your experience what are the on going maintenance fees etc with your arrangement? Do you find this to be more beneficial then owning outright?

At the end of the 10 months you own it. That is why they sometimes ask for an additional amount with the S9 (see Janknitz: "Don't pay that upcharge..." blog post).

Do you know if the $255 was an upcharge? or part of the rental? And is the $48/month the Aetna contracted amount? It seems a bit low. Maybe the $255 includes purchase of humidifier outright and then $48 is just rental of the S9 cpap module?

In my case I didn't have a deductible, so my 10 month rental was paid 100% by my insurance. Then rental period is almost up and at the end of December my S9 is mine outright. Insurance does it as a rental and makes the DME give them compliance reports (they ask you for the sd card periodically to read it) so that if you are not complying insurance coverage stops and the DME takes back the machine).

[Janknitz]

The question to ask your insurance company is whether they pay for ANY E0601 machine, or only a particular brand and model. In most cases, they will pay for ANY E0601 machine.

If they do pay for ANY E0601 machine, then next question is whether they permit their contracted DME providers to "balance bill" (that is, to charge you more for one E0601 machine over another). MOST (not all) insurance contracts and most state laws prohibit balance billing by contracted providers.

Figure out your out of pocket costs carefully, remembering that your rental may span more than one deductible period if it's based on calendar dates. You can buy a brand new S9 from our hosts or another online supplier for about $1100. You may also find good deals on Craigslist (but buyer beware) for much less. If you're OK with used, check out secondwind.com.

As for whether it's worth it to have a B & M DME, it may be if your machine breaks down outside the warranty period, but most of these machines are pretty well made and problems are rare.

[howkim]

I have Aetna. Three years ago, they bought my machine. They call every three months about supplies. Please check to see if they only cover that one machine or any E0601 coded machine.

[Pugsy]

Secondwindcpap has a New open box ResMed S9 Autoset with Humidifier for $799. I just now checked.
New open box means zero hours used, but a new machine . Standard 2 year manufacturer warranty.

[DHKaplan]

Obviously our plans are probably different, but I have AEtna group (with deductible met), and was just diagnosed. Almost two weeks ago Lincare delivered a Resmed S9 Elite with the heated tube... I was asked to pay $79 or so for the first month and then around $29 for the next 9 months... rent to own.

Good Luck

[Houli]

Just got off the phone w/ Aetna and they are "researching" the situation. The explanation they gave is that they do cover E0601 coded machines but that their contract w/ DME's can differ as to which specific machine - does this make sense? They also said that based on their contracted rental/lease price w/ the DME they can charge additional for machines that are not specific to the one negotiated. Does this make sense? I feel like I'm getting the run around.

I asked Aetna to please check into the situation w/ Lincare who says Aetna only covers IntelliPap. I also asked them to contact other in-network DME's to find out if any have contracted to offer S9 Autoset ......

[Janknitz]

"Just got off the phone w/ Aetna and they are "researching" the situation. The explanation they gave is that they do cover E0601 coded machines but that their contract w/ DME's can differ as to which specific machine - does this make sense? They also said that based on their contracted rental/lease price w/ the DME they can charge additional for machines that are not specific to the one negotiated. Does this make sense? I feel like I'm getting the run around. "

Yes, some insurance DME contracts work this way, especially HMO's. Usually you will see that when there's only one authorized DME provider for your plan.

[Houli]

Lincare was the closest local in-network DME. Guess I'll start contacting others. What is the best way to find out if the S9 is covered - seems like the simple way - asking - hasn't worked well the first time around. Any suggestions?

[RandyJ]

Lincare was the closest local in-network DME. Guess I'll start contacting others. What is the best way to find out if the S9 is covered - seems like the simple way - asking - hasn't worked well the first time around. Any suggestions?

I would explain that you have a prescription for an auto cpap and you want the S9 Autoset. Give them your insurance info and ask if they can supply that machine at the reimbursement rate for your plan.

[Janknitz]

First, it sounds like your doctor is on board, so if your prescription says "S9 Autoset" and "Dispense as written" that will go a long way when contacting other DME's.

Don't go in with an attitude of defeat. Take your specific RX in, give them your insurance info, and let them decide if they are going to be able to dispense as written. Tell them you want to know your out of pocket costs up front, BEFORE they deliver the machine.

[aetnauser]

I also wanted the s9 autoset thru Aetna, but since Aetna only pays $480.00 for the cpap unit itself. The DME can chose what products to distribute based on the cost insurance reimburses. I ended up with the s9 elite, I didn't need the auto function, just the data. Once my DME explained it to me, I understood.

[Janknitz]

Once my DME explained it to me, I understood.

It's a VERY BAD idea to let the DME explain insurance reimbursement to you--they are often plain wrong or deliberately LYING. You need to check things out with your insurance company.

As another member often says, "if it's midnight and a DME says it's dark outside, go check for yourself because you can't trust them." They are as bad as used car salesmen. I think they are worse, because they are taking advantage of people who desperately need the equipment to treat a medical condition, especially newbies who may still be in a brain fog.

[diekatzepap]

I agree with everyone here. I check insurance benefits for a living. I constantly have educate patients about their own benefits. Please make sure you educate yourself to know YOUR own insurance benefits as it is YOUR responsibility to do so. Never let the DME or even your Dr's office tell you what's covered. I find that most insurance plans follow the Medicare guidelines for coverage of certain procedures and treatments. Here is a link from the Aetna and Medicare web pages regarding CPAP supplies.
http://www.aetna.com/cpb/medical/data/1_99/0004.html

http://www.medicare.gov/Publications/Pubs/pdf/11307.pdf

I hope they help. Don't give up keep on researching you will prevail I just know it. You are one step ahead of the game you have found this great forum. It's been a great help to a newbie like me.

[DocWeezy]

Ditto on checking about YOUR particular insurance policy. Companies like Aetna have different policies for different companies, depending on what the company wants to buy. So information given about a particular insurance company is only relevant to that particular policy and may not apply to any other policy issued by the insurance company.

For example, I have Aetna insurance and the OSA benefits are wide-open and great. I pay a $250 annual deductible and after that, everything is covered at 80%. No question about getting an S9 Autoset and all my doc prescribed was an autoset (but the DME I went to only carried fully data capable, top of the line ResMed and Respironics machines--my choice was which brand did I want). They don't restrict how many nasal pillows I can get each month, nor do they limit how often I can replace my mask or Climateline hose. I don't abuse it and I'm careful with everything to try and make it last as long as possible, but they have never rejected a claim for supplies and I have had to reorder some things more often than the standard Medicare replacement schedule.

You can't be too informed about your own benefits! As said so often by so many here: You are your own best advocate. No one else cares about your health as much as you do. The more you know about your benefits, the better decision you can make for YOU based on your finances and your needs.

And just as an aside....the Intellipap Auto is a great little machine. I bought one for travel and once I got the settings adjusted, I can't tell the difference between it and my S9 as far as comfort and airflow patterns. I bought it from SecondWind as an open box--1 hour on the clock. With humidifier it was about $450 I think (about a year ago). I'd be happy using it as my main machine, although I would also invest in getting the software for it so I could have detailed info.

Weezy