Nursing Home and CPAP Catch 22

[BeckyLC]

If anyone else has dealt with this, I could use any suggestions. My husband and I are POA for a friend who recently moved to a nursing home. She has been on CPAP for many years. She has Medicare plus really good coverage through an HMO. We took over her bills when she moved into an assisted living facility, and her CPAP supplies were always paid for with no problem. Now that she is in a nursing home, it appears that she has to pay for them herself. At this point she is self-pay at the nursing home.

As I have unraveled the issue: Since she is in a nursing home, Medicare will not pay for her supplies. Since the DME the nursing home uses is not a provider for her insurance, they will not pay for it. When I tried to go directly through her old DME provider, they refused because "since she is in a nursing home they cannot provide it." When I asked for her prescription to be sent to another DME and mentioned the problem (stupid me) her pulmonologist's nurse refused and accused me of trying to commit fraud (since nursing homes have to go through the DME they have a contract with). I do have her prescription in hand; if there truly is no way around this, I can buy her supplies way cheaper from CPAP.com than from a DME. But this seems crazy to me -- she's already paying a fortune for care, she shouldn't have to pay out of pocket for equipment that is a covered expense with her insurance!

Thanks in advance for any help.

[Sonnyboy]

Have you tried calling Medicare directly?
I believe they will help you.
Kathy

[BeckyLC]

Haven't tried Medicare yet; I may have to do that. The woman I talked to at my friend's HMO didn't understand why this was an issue; she's the one who suggested I have her Rx sent to a different DME provider. I was hoping somebody else had dealt with this.

[Janknitz]

This is complicated because it depends on the basis of her admission to the nursing home:

If she is receiving rehab in the nursing home, then the nursing home must provide everything, including CPAP supplies (with no co-pay--it's all inclusive). If she was on traditional Medicare, this is the equivalent of Part A coverage.

If she is in a nursing home on private pay, then her Part C (HMO) Medicare should be paying for supplies like this just as they would when she is living at home (with applicable co-pays). If she was on traditional Medicare, this is the equivalent of Part B coverage.

If she is on a state Medicaid (Medi-Cal in California) program, then the nursing home must provide for all of her needs, including CPAP supplies with no co-pay--her needs are included in the Medicaid coverage.

[Wulfman...]

If anyone else has dealt with this, I could use any suggestions. My husband and I are POA for a friend who recently moved to a nursing home. She has been on CPAP for many years. She has Medicare plus really good coverage through an HMO. We took over her bills when she moved into an assisted living facility, and her CPAP supplies were always paid for with no problem. Now that she is in a nursing home, it appears that she has to pay for them herself. At this point she is self-pay at the nursing home.

As I have unraveled the issue: Since she is in a nursing home, Medicare will not pay for her supplies. Since the DME the nursing home uses is not a provider for her insurance, they will not pay for it. When I tried to go directly through her old DME provider, they refused because "since she is in a nursing home they cannot provide it." When I asked for her prescription to be sent to another DME and mentioned the problem (stupid me) her pulmonologist's nurse refused and accused me of trying to commit fraud (since nursing homes have to go through the DME they have a contract with). I do have her prescription in hand; if there truly is no way around this, I can buy her supplies way cheaper from CPAP.com than from a DME. But this seems crazy to me -- she's already paying a fortune for care, she shouldn't have to pay out of pocket for equipment that is a covered expense with her insurance!

Thanks in advance for any help.

How much "stuff" does she really need? Most of these supplies last a LONG time if properly cared for.
And, in my opinion, these supplies can be obtained cheaper and with lots less hassle when bypassing the typical DME scenario.

Apparently there are "loopholes" in the coverages and supply distribution system to give those folks a way out. You would think that if it were possible, they would try to find a way.


Den

.

[chunkyfrog]

Call Medicare and RAISE THE ROOF.
Somebody is messing up, and they need a good swat on the rump to get them motivated!

[VikingGnome]

The primary issue is the new requirement that CPAP supplies must be purchased through DME that won area contract. In my case, all the DMEs are in another state. You cannot purchase any CPAP supplies from a DME that does not have the current contract and have it covered by Medicare. This Medicare rule has been phased in and started in my area about 1.5 years ago. So this may be new procedure to you and/or the nursing home.

This is totally different from the old "participating provider" mechanism where you your CPAP supplies were covered at 80% from DME of your choice that participated with Medicare and your secondary coverage paid the remaining 20%. I do not know exactly how this new contract stuff works with a secondary insurance but I sure it has been addressed.

The nursing home cannot REQUIRE you to purchase CPAP supplies from THEIR SUPPLIER and then have no coverage. You should be able to buy her supplies from a CONTRACT PROVIDER for her area. Call Medicare and they will give you the names and phone numbers of DME's that are under contract to supply CPAP supplies for Medicare. Then call the DME and discuss how the secondary insurance gets billed. It should all work out.

[mike1953]

Wisconsin SHIP Website:
http://www.dhs.wisconsin.gov/aging/EBS/ship.htm
Phone: 800-242-1060
Program Name: The Medigap Helpline
About: The Medigap Helpline will help you make wise insurance decisions. This is a state-wide toll-free number provided by the Wisconsin Board on Aging and Long Term Care. It has no connection with any insurance company. Call with questions about MEDIGAP Insurance and Counselors at the Medigap Helpline can help you evaluate your Medicare supplemental insurance and clarify many other related, and sometimes confusing, issues.

What is SHIP?
SHIP is a free health benefits counseling service for Medicare beneficiaries and their families or caregivers. SHIPs mission is to educate, advocate, counsel and empower people to make informed healthcare benefit decisions. SHIP is an independent program funded by Federal agencies and is not affiliated with the insurance industry.

Agency Name: Greater Wisconsin Agency on Aging Resources
Locations
Address Phone Number / Email Hours of Operation
Main Office:
1414 MacArthur Road, Suite A
Madison
WI 53714
(608) 243-5686
nate.vercauteren@gwaar.org

[BeckyLC]

Thank you all for your helpful replies. This sheds more light on the subject and gives me some helpful resources. Part of my problem is that I don't know who exactly was paying for her supplies before she moved into the nursing home four months ago; whether it was Medicare or HMO or both. I just know she wasn't getting billed for it herself. I will make more calls. It would clearly be easier just to order it online, but it's the principal!

[Janknitz]

Technically, HMO IS Medicare for Part C patients. But on traditional Medicare , Part B Medicare pays 80% of the cost and the supplemental insurer pays the remaining 20% (sometimes there is still a copay).

On Part C (HMO), the HMO takes the place of BOTH Medicare AND the supplemental payer. So yes, the HMO was paying for her supplies but technically they were covered by Medicare. Medicare pays an HMO a "per capita" rate (per person) and the HMO must then provide everything Medicare covers out of this pot of money. Medicare doesn't pay its part to the DME, the HMO uses the Medicare money to pay the DME itself. Confused yet?

What happens outside the nursing home IS NOT THE SAME as inside depending on her status as a rehab patient, a private paying resident, or on Medicaid/Medi-Cal. So it doesn't matter who paid before. The important thing is to sort out who pays now.

[BeckyLC]

Oh, Janknitz - yes, I am thoroughly confused (although now perhaps have a glimmer of understanding). You are obviously very knowledgeable about all of this. My friend is a private paying resident. Do you know in this case WHO should likely be paying for her supplies? Thank you again.

[chunkyfrog]

Have you still not contacted Medicare? Even though she is paying for the nursing home,
IMHO, Medicare should not be off the hook. Talk to them!
Sometimes the phone wait is not long at all.
Just plug in your cell so it won't die right when a human gets on the line.

[Sir NoddinOff]

Wow, I learned a lot reading this thread... there are some really informed comments here.

[Janknitz]

If she is private pay then she should get her supplies through the hmo's contracted DME and it should be paid for by her HMO--there may be some co-pay. This is essentially Medicare paying, but not directly.

However, if the HMO gives her a hard time, Medicare may intervene. The law is, if Medicare covers it, the HMO MUST. So let the HMO know she will file a complaint with Medicare. That may get them to do their job.

This is the equivalent of anybody who lives at home getting their supplies under Part B in traditional Meducare. Just because she changed her address to the nursing home doesn't mean she's no longer entitled to supplies under part c. This will change if she goes on Medicaid, though. The The nursing home is on the hook.

[BeckyLC]

Thank you again, Janknitz. I'll get back to her HMO before I try contacting Medicare. Luckily, when the nursing home contacted us regarding all of this because she needed a new mask (we were on vacation, of course), I knew that she had a new mask in her belongings that we had moved with her. So I've got some time to fight this out before she needs another one. I very much appreciate all the knowledgeable help from everyone.