Insurance or go it alone?

[Atxtrr]

Hi all,

I just received a scrip for a CPAP machine with a 8 pressure. I have Cigna coverage and for DME they pay 80% but only after a $2,000 deductible. When i talked to the DME referred by my doc, they told me I only have the choice of 1 machine (a Resmed S9 autoset) for $2000 and change, including all hoses, humidifier, etc. I said it seemed suspicious that it's the same price as my deductible and she said that it's the contract rate from Cigna and that's all they have. I could alternatively rent for a month at $600 and pay $150/mo for a year in a rent-to-own deal. She also made the point that insurance doesn't care what machine so they push the best machine which is an APAP since cigna charges $2K even if they gave me a low-price brick.

I'm asking the group if it makes more sense to just buy the machine,mask, humidifier etc online at cpap.com and don't even involve insurance. The reviews sound like it's a good machine and fully data capable but as a newbie i'm not sure what i'm getting into by going it alone with the online route and not having someone to fit me and help me through the initial setup. Insurance would also cover replacement of maintainable parts so i guess eventually I'd recoup any extra money spent by going with the insurance within a year or so. Not sure what annual expenditures are for stuff that wears out.

Any advice?

[The Latinist]

That's an outrageous price for an Autoset. If you do not think you will meet your deductible in the remainder of the year, buy a machine from CPAP.com instead. You can choose between he S9 Autoset (an excellent machine) or the Philips Respironics System One Auto. Hell, for $2,000 you could buy a bilevel machine outright.

[chunkyfrog]

When I started, my PSG's and my machine shared a single deductible;
so I used insurance for that year. The second year, I tried, but found that "in-network" supplies
and out "of network" supplies were separate deductibles, that would not be combined. Dirty, dirty!
I then proceeded to use the graciousness of our hosts to find masks that fit me.
Now on Medicare, I still get the first one of any mask from our hosts,
and any supplies that are off the CMS calendar.

[JDS74]

It depends.

First does your insurance allow you to purchase online and then accept the bill to be aplied to your deductible?
Does your DMEallow for multiple mask swaps? This might be important since failing to get a correct mask fit is the most important factor in non-compliance.

Is the $2000 deductible just for machine purchase or is it the general deductible for all reimbursable medical claims?
If a general deductible, how do your medical claims go year-to-year? Will meeting your annual deductible all at once give you a significant benefit for the rest of the year?

Finally and perhaps most important, is your impression of your DME lead you to believe that the relationship will be cordial and helpful? Sometimes, the DME relationship can be less than cordial.

I will let others comment on whether the particular model ResMed machine is a full data machine.
For a $2000 out of pocket cost, you likely can get an auto bi-level machine which can be set up as a single pressure CPAP but has added capabilities in case you have problems with a single pressure and the built-in EPR function doesn't quite do the job in terms of comfort and usability.

In the Respironics line, this would be a 760. I'm not familiar enough with ResMed to name the corresponding model in their line.

[Atxtrr]

It depends.

First does your insurance allow you to purchase online and then accept the bill to be aplied to your deductible?
Does your DMEallow for multiple mask swaps? This might be important since failing to get a correct mask fit is the most important factor in non-compliance.

Is the $2000 deductible just for machine purchase or is it the general deductible for all reimbursable medical claims?
If a general deductible, how do your medical claims go year-to-year? Will meeting your annual deductible all at once give you a significant benefit for the rest of the year?

Finally and perhaps most important, is your impression of your DME lead you to believe that the relationship will be cordial and helpful? Sometimes, the DME relationship can be less than cordial.

I will let others comment on whether the particular model ResMed machine is a full data machine.
For a $2000 out of pocket cost, you likely can get an auto bi-level machine which can be set up as a single pressure CPAP but has added capabilities in case you have problems with a single pressure and the built-in EPR function doesn't quite do the job in terms of comfort and usability.

In the Respironics line, this would be a 760. I'm not familiar enough with ResMed to name the corresponding model in their line.

Hi-

The deductible covers all reimbursable items- this is the only medical expense i typically have so i'll need to meet every year for cpap. Cigna will let me submit receipts for an online purchase to go towards the deductible and the $2K is for the machine, mask, humidifiers, etc. not just the machine. I called a second DME and he was pretty upfront that any DME around here is going to charge the Cigna deductible for the cpap package. So his price was the $2K and I could choose between a Resmed S9 autoset or a Respironics System ONe package and he makes house calls to setup and choose a mask. I assume also a trade in policy if i dont like the mask.

So i guess it comes down to saving money online and fitting myself, or paying more for the added service of a person helping me out one-to-one and getting reimbursed for wear and tear items at 80%

[Pesser]

Do you live in Canada?

[Atxtrr]

Do you live in Canada?

Nope- I'm in Austin Texas

[library lady]

I just looked at the purchase agreement for my PRS1 that I got in Feb. The total amount for everything was just a little over $2,000 (mask headgear, machine, humidifier, heated hose and the cords, power brick, and case). Much of that is covered by Medicare through my Medicare Advantage Plan. Private insurance usually follows the Medicare schedule. So it looks like that's the right price, it would be the same for your AutoSet per Medicare schedule.

You don't say if you have Medicae, but either way,do check with your insurance company to see what they will cover of that amount; the rest would come out of your deductible... It might be that you won't have to use up most of your deductible right away, but you'll never know unless you ask...

[BlackSpinner]

Hi-

The deductible covers all reimbursable items- this is the only medical expense i typically have so i'll need to meet every year for cpap. Cigna will let me submit receipts for an online purchase to go towards the deductible and the $2K is for the machine, mask, humidifiers, etc. not just the machine. I called a second DME and he was pretty upfront that any DME around here is going to charge the Cigna deductible for the cpap package. So his price was the $2K and I could choose between a Resmed S9 autoset or a Respironics System ONe package and he makes house calls to setup and choose a mask. I assume also a trade in policy if i dont like the mask.

So i guess it comes down to saving money online and fitting myself, or paying more for the added service of a person helping me out one-to-one and getting reimbursed for wear and tear items at 80%

For a new person who needs to find a good fitting mask the second DME sounds good. You don't have to stay with them forever, but this year, having met your deductible, you will have hands on help with the mask and adjusting. This is where most people have problems or get screwed. Good help in setup and masks is worth its weight in gold the first year for most people. Next year buy from cpap.com

[Pugsy]

You don't have to buy a machine from a DME to use them for masks. People assume that they are tied together but they are not tied together.

Ask the DME what the mask swapping/trading/exchanging policy is with them when a mask doesn't work.
If a liberal policy then might be worth it but if they have one of those "one swap withing 30 days and that's all that's allowed"...then I don't know if it would be worth it.

Personally...I would buy online and use DME for masks if they had a nice liberal allowance. The ability to swap during a liberal trial period is worthwhile. DMEs are free to make their own in house rules on mask swapping though and often they just say 30 days or 1 swap and that's it. Need to check directly with DME to get the exact rules they go by. Mine does 60 days and no limit on number of swaps during that time frame..and not just for newbies but that includes someone like me...and I have never bought a machine from any DME...always been private purchase.

You can get the S9 Autoset with humidifier for $883 and another $40 for the CLimateline heated hose.
Total $923 for machine, humidifier, heated hose and other accessories (travel bag, SD card).

You can buy a lot of masks for the additional difference between $923 and 2 grand. Though it's doubtful you would have to do that.
Depending on what you want to try...I might be able to help you out for postage costs only. Send me a PM for further details.

[sc0ttt]

Here's the comparison I made.



With your insurance, the left column would be $2000. With no no other expenses expected for the rest of the year, I'd buy on-line for sure.
And yeah, maybe get a fitting for a mask from the DME, but you could make a lot of trial and error for the difference in cost.

[lido14]

I suggest using craigslist for the machine and masks. People sell new and used stuff and I've bought used stuff and its been fine. Just wash and wear.

[Atxtrr]

Ok it sounds like I should just buy this all myself directly and use this forum to figure it out... Looks like i can go on cpap.com and buy everything i need to start for much less than the $2K through a DME.

I'm a bit nervous doing it this way but $900 savings is hard to pass up.

Looks like I should get cpap.com to get my prescription uploaded to them before checking out?

[spmccord]

Just remember....the $2000.00 is just the MSRP. The insurance company will allow a lower amount that the DME has to accept.

So make sure you ask your insurance what their allowance is.

*haz worked in health insurance for 30 years*

[chunkyfrog]

Good point. The insurance company's negotiated price is also your price--even if you have not met your deductible.
Generally, these prices are fairly close to online. Never pay full retail!