Kaiser Permanente HMO

[Quality Zees]

I must switch to Kaiser Permanente HMO from Anthem Blue Cross PPO in a few weeks. Anthem was really no problem. I'm seeking comments from anyone with experience with Kaiser Permanente with regards to Sleep Apnea Treatment and replacement of masks, tubing and the like.

Thanks,
QZ

[Wulfman...]

Sorry to hear that........

Go up to the (white) line above labeled "Search" and type in "Kaiser" and click on Search.......and you will have about 53 pages of reading material to sift through.

Good luck.


Den

[Janknitz]

I have kaiser and I think they do a pretty good job with OSA, but it may depend on your region.

What you need to understand is that, as an HMO, they are your doctor, your sleep lab, your sleeptech/respiratory therapy provder AND your HMO. It's Kaiser's way or the highway, no choice involved. Generally they contract with Crapria to supply the machines and supplies, but your DME is Kaiser, NOT the supplier. So Kaiser dictates which machine you get and has a limited formulary for masks and other supplies. If you want something not on Kaiser's formulary, be prepared to buy it yourself. They do use Medicare guidelines for replacement supplies.

Kaiser likes to do things in groups, but it does have a good patient education program. They mostly do home testing with an Itamar Watch Pat, and you see only the sleep lab people, never the doctor.

So, the only machines available in my region are Philips Respironics. If you want anything else, you're out of luck. When I first started, Swift FX masks were not on the formulary, so I had to get my own--now they are on the formulary.

But there are some good things. They have tons of sample masks, they will fit you and let you take the mask home to try for free. You can usually get in to see them pretty quickly if there is an issue, and they do CPAP all day, every day, so they know what they are doing in the sleep lab. Personally I find the local sleep lab staff to be great.

My region does ONLY data capable machines, so they can check your data and help you with problems if they arise. But if you don't meet their criteria for an APAP you aren't getting one, no matter what. According to the horror stories other people have about sleep labs, I think Kaiser does a pretty good job.

They benefit from treating OSA well--it saves them money in the long run when you don't develop the problems caused by untreated sleep apnea. So overall, they have a vested interest in making sure you get good OSA treatment, and at least locally, I've found that they deal very well with OSA.

[Quality Zees]

Thanks Wulfman. I guess I just showed my character defects (sloth, in this case). I should have done that before posting a question.

Thanks Janknitz. I just got a new sleep study and APAP and I will be going from Kaiser to Medicare in about 18 months. There shouldn’t be a need for another sleep study and hopefully Kaiser will come through with the replacement supplies. I’ve worked with Apria before and understand the alternate name, Crapria.

When I got my Icon Auto through PPO about 10 days ago, I learned they pay a flat allowance for the PAP and if it is more than that, the patient pays the difference, which I did to get the APAP. Easy. Do you think Kaiser will do the same if I want a mask that’s not on their formulary?

[Janknitz]

When I got my Icon Auto through PPO about 10 days ago, I learned they pay a flat allowance for the PAP and if it is more than that, the patient pays the difference, which I did to get the APAP. Easy. Do you think Kaiser will do the same if I want a mask that’s not on their formulary?

Nope, no way, nada! If it isn't on their formulary, they won't pay for it. PERIOD.

I think this is part of their contract with Crapria. They have a limited formulary, so Crapria gives them a huge break on costs (and gets a GIANT volume of sales from it).

In order to get anything from Kaiser, it has to be on your order form, and they only order what's on their formulary. However, the formulary is pretty extensive. You may not be able to get the latest and greatest mask, but they have a LOT of masks on the formulary, from the major manufacturers. Don't expect to see a Hans Rudolph mask or the cloth nasal mask on there, however. Always ask, and ask again later, because they are constantly adding masks to the formulary. They WANT you to be comfortable and get good therapy because that saves them more money in the long run.