New user with HealthNet PPO in California

JulieC · Post by **JulieC** » Wed Jun 28, 2006 10:25 am

Hi, everyone. I recently had a sleep study and learned that I have significant OSA, with AHI of only 7 (RDI 11) but long apneas (as long as 80 seconds) and oxygen desaturation to 62%. Also bradytachycardia with arousal. They recommended 7cm pressure. I'll be going to get the CPAP prescribed tomorrow.

Actually, I was diagnosed with mild OSA several years ago but couldn't stand the CPAP and never did anything else about it. I just looked back and saw that 11cm was prescribed at that time. Strange.

They tried me with the swift pillows at the recent study and said it seemed to work, so I suppose that's what I'll try. I remember back when I tried all this before that the mask really rubbed my nose.. that's why the tried me with the pillows this time.

So... my question... I have HealthNet PPO here in California, with a limit on DME of $2,000/year. I've noticed that people talk about ordering masks every six months, etc. Any suggestions on how to figure all this out? Which machine is covered? Should I go with the swift pillows? Rent for a couple of months then buy? Anyone have HealthNet?

Thanks. This board is great and has given me wonderful information. Now, if only I (and my husband) can get used to the CPAP!

Julie

birdiebaby · Post by **birdiebaby** » Wed Jun 28, 2006 12:29 pm

Welcome!

I checked at billmyinsurance.com, and it looks like your insurance will have a DME that you will be required to go through. A $2000 DME limit is not very high all things considered. (as an example, rent on my machine is $110/mo to my ins co, my mask was billed at $124.) Your insurance company may have a system that it work through... many will rent for several months before they check your compliance data. They they will make the decision on purchase.

Most insurance companies allow for supplies such as new masks, hoses and filters to be purchased every six months. That's why you see people talking about it. People who pay out of pocket don't necessarily replace a whole mask every six months, but they do replace the gaskets and sometimes headgear at regular intervals.

Your best bet is to call your insurance company and ask them what their procedures are. They should be able to tell you what DME supplier you will need to work through. It's a good idea to understand them before you start dealing with your medical supplier. For many of the larger suppliers, you will find that they stock a certain brand of CPAP equipment, which will limit your choices. I would suggest that you do a little research and talk to your doctor about the type of machine that you'll need, and then ask your Dr. to write the prescription for the specific brand and model that you'll want.

I would also strongly suggest that you make sure that you get a copy of your prescription in hand from your doctor. Some doctors will fax them directly to the DME, but it's a good idea to have your own copy.

Good luck!

JulieC · Post by **JulieC** » Wed Jun 28, 2006 2:37 pm

Thanks! On top of this new world of CPAP, I'm with a new insurance company. I was with Kaiser for years and although I like my having a choice of doctors and treatments etc, dealing with these billing issues is like having a second job! I'll use your info when I see the doc tomorrow. This board is really a big help as I navigate this whole new world!

I believe I have several DMEs to choose from, but if the cost is >$500 I have to get pre-authorization and apparently at that point they specify the kind of equipment. I know that Apria is on their list and from what I've read on this board (and in the news) I'll try to avoid them.

Thanks for your help!
Julie