Anyone else had their insurance company tell them this?

[Bobby269]

My insurance is a Medicare advantage plan and they say the same thing.

[70sSanO]

I think some of this is the insurance companies reaction to the Affordable Care Act in sort of a "we told you so approach" because most insurance companies didn't want it. And some of it is a valid concern that some people/DMEs have ripped off insurance companies with excess supplies and then people they sell them off on ebay.

As for me, I use a FFM and 3 years ago a went to a brick and mortar DME who sent me a new mask every 3 months along with a new hose and filters. Before this time I ordered replacement masks, cushions, filters online without going through my insurance company.

I am still using the original mask and hose and bought a replacement cushion outside of my insurance company for around $40. I also buy my own filters.

For those people who can't really afford to buy outside of the insurance companies, I am hoping that when the dust settles, this won't be an issue and those supplies will be deemed "medically necessary" and will be shipped without delay.

For those who just want to pound on the table and shout on principle that I have insurance they better pay up for these supplies, all the while they pour thousands of dollars of gas into their 6mpg RVs; it may be time to take a step back and assess who is getting hurt by saving a few dollars here and there.

Like I said, I have a FFM and for over a decade I have been able to squeeze the maximum longevity out of each one.

John

[Sharrykb]

I think some of this is the insurance companies reaction to the Affordable Care Act in sort of a "we told you so approach" because most insurance companies didn't want it. And some of it is a valid concern that some people/DMEs have ripped off insurance companies with excess supplies and then people they sell them off on ebay.

As for me, I use a FFM and 3 years ago a went to a brick and mortar DME who sent me a new mask every 3 months along with a new hose and filters. Before this time I ordered replacement masks, cushions, filters online without going through my insurance company.

I am still using the original mask and hose and bought a replacement cushion outside of my insurance company for around $40. I also buy my own filters.

For those people who can't really afford to buy outside of the insurance companies, I am hoping that when the dust settles, this won't be an issue and those supplies will be deemed "medically necessary" and will be shipped without delay.

For those who just want to pound on the table and shout on principle that I have insurance they better pay up for these supplies, all the while they pour thousands of dollars of gas into their 6mpg RVs; it may be time to take a step back and assess who is getting hurt by saving a few dollars here and there.

Like I said, I have a FFM and for over a decade I have been able to squeeze the maximum longevity out of each one.

John

Just to clarify, I'm not looking for anything more than what I need and have no intentions of accepting supplies in excess of what I need. I intend to get the most use out of each item as humanly possible. I just want to have an extra of each item on hand in case something breaks because I don't want to go without therapy while waiting to get a replacement from the DME. As soon as I have a spare of each item I will not accept any more supplies from my DME until something breaks. I am still using my original nasal pillow that I got when I started therapy almost 2 months ago and I intend to use it until it no longer works, even though I do have 2 spares in the drawer of my nightstand. The only reason I have 2 spare instead of 1 is because that is how my DME sells them. And someone from the sales department of my DME (not the lady I normally work with) called me yesterday and said I am going to be eligible for 2 more nasal pillows in a few days and could they ship those out to me. I said no, I don't need them yet. She tried to tell me that I have to throw out my nasal pillow at least once per month and switch to a new one. Nice try lady, but I'm not buying that story. Just because my insurance is willing to pay for it doesn't mean I want it or need it.

[Jeannh]

Talk to your DME... they will know what your insurance requires and what the replacement schedule is. They will also want to sell you as much as they can, so if your insurance allows new nasal pillows every month, or every 3 months, they will do what they can to get them to you on schedule and collect their money.

This is not the case if you have an HMO that capitates the DME. in that case, they get a set payment for you each month, so the less they offer, the more they make.

We're it me, I'd ask the insurance company for my DME co-pays, deductible and any annual maximums. Also, be sure to stay in their network for maximum benefits. Any insurance company who covers Medicare beneficiaries follows the Medicare fee and replacement schedule, and it's darned hard to have separate rules for Medicare and non-Medicare members, so I'd guess the person you spoke to was incorrect.

Medical necessity is the basis for all medical insurance, nothing new there. The ACA did nothing to DME benefits. Always ask for a backup of anything a DME or insurance company tells you in writing, and write to your regulator if refused documentation.

Just my opinion, YMMV.

[bloodgain]

This is good information. My mask (Nuance Pro) just broke last night: one of the gel cushions came out, probably due to the rosacea treatment and sweat, as that's the side I lay on. I can still use it, but I think it's time to replace the frame, and probably the nasal pillow. I guess it's time to call my company rep and then my DME.

Thanks for posting, folks, it's been really helpful!