Medicare and CPAP

[BeanMeScot]

I've been on CPAP for over 10 years now and I'm doing fine. I was diagnosed early and took to it quickly so I won't qualify for Medicare for over a decade. However,I have an online friend who is on Medicare who has been diagnosed for the 2nd time with SA. She failed the first time. You know the drill, crappy machine, crappy mask, no help = failed CPAP. She is working on doing this a second time. Her split sleep study is done and now she is getting a prescription. I warned her to get a prescription for a the exact machine she wanted which would have been a Resmed 10 Airsense Autoset. I am trying to help her with this but we are doing this online and she is getting impatient with everything so I thought I would ask the experts here what is really going on.

My understanding is that Medicare, like regular insurance, pays the same amount no matter what machine you get. Has something changed?

Some relevant pieces of the conversation:

Her: "I get the dream machine thing. That's what Medicare will pay for. If I want something better, it's out of my pocket.

(Or HSA account.)"

I let her know that she can pay for any machine she would like with an HSA account but reiterated that Medicare will pay the same amount for any machine.

When I asked who was telling her this:

"The person who does this all day long."

I told her unless the person worked for Medicare, it wasn't necessarily the correct information but she is getting impatient and doesn't think I understand.

"I have a script for one of two machines. She looked it up while I was sitting there.

Listen. This is how it worked last time. I'm going with the professional. I'll pay for it with our HSA. It's all I can do. I do not think she's wrong. This is what it's like on Medicare."

I don't know what the two machines are yet. I will be inquiring about that next.

So CPAPTalk experts, what's really going on here? Is she right? Not using Medicare, I don't know much about it. She lives in a small town in Kansas, if that makes a difference.

[LSAT]

Medicare has nothing to do with the choice of machines. They don't care what machine you get since, as you said, they pay a set amount regardless of the machine. (Unless you need something more powerful that a traditional CPAP). It's the DME that is giving you the run around. They want you to take the machine they make the most money on. You can go to another DME...you do not have to go to a DME that will not work with you. Find another Medicare approved DME in your area. Use this supplier directory.
https://www.medicare.gov/supplierdirectory/search.html

[Comfortably Numb]

I will provide this link that Pugsy posted on my first post:
https://maskarrayed.wordpress.com/what- ... me-part-i/

Outstanding information! Good luck.

[Pugsy]

Medicare pays by the billing code...not brand, not model within a brand.
There are 3 different types of machines with 3 different HCPCS billing codes.
Assuming plain jane vanilla OSA the usual machine is the E0601 HCPCS billing code machine.
This code covers all the basic bare bones no frills cpaps up to and including the apap capable machine.
The ResMed AirSense 10 Autoset mentioned is a cpap machine with apap or auto adjusting mode capabilities. We call it an apap but in actuality it is a cpap, per insurance nomenclature and billing codes, machine (as opposed to the other types which are the bilevel devices and get a different HCPCS billing code) that has another mode available..

You know the drill...DMEs will push the brand that they got the best wholesale deal on and they will often push the bare basic machine because Medicare is going to pay the same no matter what brand or model because that's the one they make the most money on...those apap capable machines simply cost a little more..
And then they blame the insurance instead of owning up to the fact by saying that so and so brand or model "is all your insurance will pay for".
I hate being lied to...I have more respect for a DME that simply says up front "this is what we make the most profit on so this is what we dispense when the RX lets us". I don't like it but at least they are honest about it.

They could dispense and apap capable machine even with a cpap RX not stating apap if they would just do it. An apap machine can easily be set to CPAP mode and the RX requirement be fulfilled. They just don't want to because they can make more money pushing the bare bones machine.

Sounds like the DME is pushing the Respironics DreamStation machine because that's the one they have the best wholesale contract with and then blaming it on Medicare. It's a bold face lie. Medicare doesn't care the brand or the model.

If she is in a rural area of Kansas she may not have a lot of Medicare DMEs available in her area to do any shopping around to see if another DME would supply the machine she wants. I am in SW Missouri in a relatively rural area and I have 2 options unless I want to make a 45 minute drive into Springfield. But she might check around to see if another DME close by will supply the machine she wants.

Now if the doctor puts the brand and model on the RX and says "dispense as written" the DME has to follow the RX but if he just says (and most of the time that's what is said) "CPAP with humidifier at so and so pressure" the DME legally can substitute brand and dispense the bare bones basic brick machine. Legally they can do it...it sucks but they can do it.
Obviously the best choice is to get the doctor to be very specific with what they write but often docs don't want to get involved for whatever reason.

Sometimes when a patient will push back and just threaten to go elsewhere the DME will relent and dispense brand and model requested when threatened with "so and so will give me what I want, if you don't want to do that I will go elsewhere"...Given the choice between making no money or a little less than they wanted..they will often opt to make at least some money.

Sounds like your friend is unable to stand up for herself and too trusting that the person she is talking to
A...actually knows what they are talking about
B...has her interests at heart
If you can find out the exact DreamStation model being offered you might have more ammunition...Respironics makes a nice little DreamStatioin comparable to the ResMed AutoSet. But they also have a half assed brick like ResMed also makes.

There is another option...let the DME supply whatever and buy the AutoSet out of pocket using HSA funds. Once Medicare compliance requirements are met she could use the AutoSet and keep the Medicare supplied machine for backup or travel.

But if she is being told "this is all Medicare will pay for" she is being lied to. Medicare doesn't care what brand or model as long as it meets the HCPCS billing code requirement for a E0601 cpap machine (assuming that is what has been ordered for basic OSA with no special requirements).

[BeanMeScot]

Medicare has nothing to do with the choice of machines. They don't care what machine you get since, as you said, they pay a set amount regardless of the machine. (Unless you need something more powerful that a traditional CPAP). It's the DME that is giving you the run around. They want you to take the machine they make the most money on. You can go to another DME...you do not have to go to a DME that will not work with you. Find another Medicare approved DME in your area. Use this supplier directory.
https://www.medicare.gov/supplierdirectory/search.html

She was getting this from the doctor's office. Not the DME. I don't think she has seen the DME yet.

[Pugsy]

She was getting this from the doctor's office

Doesn't matter who told her that Medicare only pays for "so and so machine"... Medicare doesn't require brand or model.
All it requires is a diagnosis code to support the HCPCS billing code used to order the cpap machine.

If the doctor's office has anything to do with supplying a machine it is against Medicare rules.
CPAP equipment cannot be supplied by any facility where the doctor has a financial interest.

[BeanMeScot]

Thanks guys, that's what I thought. I don't really understand why the doctor's office is giving her the run around but whatever. Nice to know things haven't actually changed.

[Guest]

I think your other questions have been answered. If her doctors office is giving her that kind of advice and steering her to one DME or one brand of equipment she may be better off finding another sleep doc or sleep lab.

She can call Medicare directly if she has questions. I think she can still go thru Medicare for supplies or later for cpap - she will need a copy of her sleep study and her drs. order. Also she will be required to have both a face-to-face with her doc and show compliance very 6 months.

So CPAPTalk experts, what's really going on here? Is she right? Not using Medicare, I don't know much about it. She lives in a small town in Kansas, if that makes a difference.

To this I will say that if/when using HSA or buying out of pocket she will not have to meet any sort of compliance. That may help her or it may hurt her - seeing as she has already failed once.

[D.H.]

Here's something for those turning 65 soon. Please try to time it so that your private insurance replaces your CPAP shortly before you turn 65! This way, you have a new CPAP when you start medicare. When it's time to replace that one, it would be very hard for them to say you don't need one!

[AirPump]

Hi - I just went through all of this, so here's my story.
The woman getting the runaround about "what Medicare will / won't pay for" might be on a Medicare Advantage plan (Part C) where there is an insurance company in the loop. And insurance companies are used to calling the shots with our healthcare.

I had to switch sleep doctors after transitioning to Medicare because the Medicare Advantage plan I chose had mistakenly included my doc in it's book of "in-network" providers, when in fact, my doctor wasn't. The insurance company apologized for the directory error, then failed to pay my claim (typical health insurance company behavior that I thought was behind me as I turned 65).

Medicare requires that you renew your prescription for CPAP therapy at least once per year. So my 2013 vintage prescription was no good for getting supplies under Medicare. I first had to switch doctors, wait 2 months to get into see him, then pick the DME and have the doc write an update prescription naming that DME. Then the DME took a couple weeks to respond. So five months after going on Medicare, I'm finally "connected" with it for CPAP supplies and at long last, have a new hose and mask to replace my 8 month old stuff.

In my case, my Part C policy contract in Washington State clearly says that CPAP / DME coverage is limited to certain pre-approved brands and models of CPAP machines. Of course, the insurance company doesn't publish a list of which are "approved" because that would box them in. I didn't need a new CPAP machine so I haven't tested this, and by the time I do, I most likely will have fired my current Medicare Advantage insurance company and found a better one.

There is no way the doctor would know which machine is approved for a given Medicare Part C policy, but the DME might know which insurance companies are most likely to deny a claim in your State.

Also, I have found (and been told by all of the eight DME's I shopped to supply my stuff) that Medicare is very picky, and that all the paperwork should include the right codes for each specific thing you need: the make/model of the CPAP unit, humidifier, hose, mask, filters, headgear, chinstrap etc. I learned a lot by calling around to find a medicare-approved DME that would work for me.

I also agree with other comments in this thread that it is very likely the DME who is giving this patient the runaround. If the patient gets the "fresh" prescription she needs for a Medicare claim, it will have to include the details of what machine is prescribed. Then the DME has to fill the prescription. So the patient should ask the doctor for the machine she wants, and duke it out with the doctor to get it written on the script for the DME.

All that said, my new Medicare-approved DME tells me that it's easy to change to a different mask should I desire once I'm on the medicare reimbursement train. I don't know if/how that applies to the more expensive machine.

And one more thing: the ONLY way Medicare will pay for a CPAP is for the patient to RENT the machine for 13 months, after which the machine is owned by the patient. During this rent-to-own period, compliance is monitored and problems with the machine can be resolved by another (different) machine if necessary and supported by the physician. Medicare won't cover a new machine until five years have lapsed since your last machine was purchased. My S9 is 4 and a half years old. My DME says I can qualify for a new machine in another 6-7 months if I need it.

Good Luck. And plan ahead. Another poster here recommended that you get fresh supplies right before you go on Medicare. I agree with that recommendation .

[Pugsy]

Medicare requires that you renew your prescription for CPAP therapy at least once per year.

I see this statement being made but I have yet to see actual documentation at the Medicare website.
Does anyone have a link to said documentation? I have looked and can't find it.

Saying "my doctor said Medicare says" or "my DME said Medicare says" doesn't make it a Medicare regulation.

I have seen documentation about what is necessary for initial cpap coverage...compliance hours and face to face before the 91st day but I haven't seen any statement about a renewing the RX once a year published at the Medicare website.
And I have seen documentation about what is needed when someone turns 65 and goes on Medicare and had the cpap prior to going on Medicare.
But I can't find this "one year renew" thing that people talk about.
Anyone have a link to documentation at the Medicare website???

I am sitting here scratching my head how I keep getting cpap stuff and I haven't seen the sleep doctor or renewed the RX since Aug 2009.
And all I pay is the 20% of the allowable Medicare amount.
No one has ever said "sorry, you can't get your stuff until your doctor renews your RX".

[Guest]

The woman getting the runaround about "what Medicare will / won't pay for" might be on a Medicare Advantage plan (Part C) where there is an insurance company in the loop.

Good point. People on an Advantage Plan need to say they are and should contact their Plan for advice since they are ALL different.

Medicare requires that you renew your prescription for CPAP therapy at least once per year.

Maybe your Advantage Plan does - Medicare does not.

So my 2013 vintage prescription was no good for getting supplies under Medicare.

Advantage Plan again.

I first had to switch doctors, wait 2 months to get into see him, then pick the DME and have the doc write an update prescription naming that DME.

I would have used that as a reason to escape their grip. Who knows what future surprises are awaiting?

[chronic]

Pugsy, I am on Medicare since 2012. My machine is older than that. I have original medicare and a supplement. Prior to 2012 my regular dr. told me I would need to begin seeing a sleep dr. I have been going once a year. To my knowledge, and I almost know this for a fact, he doesn't, hasn't written any new prescription. He always tells me I am doing great, sends me to his clerks who make a new appointment for next year and tell me that they fax something to my dme to show I have seen the dr. This cycle repeats itself over and over. I occasionally ask my dme about a new machine and they give me some bs depending on their mood, which is usually bad. I think they are suffering from pms and esp. My machine is still working ok, but, I guess when it breaks I will just need to throw a fit and fall in it to get what I want. The way it works for me, I don't pay a dime for supplies. Not sure what they will try to push on me when I need a new machine.

[Pugsy]

Pugsy, I am on Medicare since 2012. My machine is older than that. I have original medicare and a supplement. Prior to 2012 my regular dr. told me I would need to begin seeing a sleep dr. I have been going once a year. To my knowledge, and I almost know this for a fact, he doesn't, hasn't written any new prescription. He always tells me I am doing great, sends me to his clerks who make a new appointment for next year and tell me that they fax something to my dme to show I have seen the dr. This cycle repeats itself over and over. I occasionally ask my dme about a new machine and they give me some bs depending on their mood, which is usually bad. I think they are suffering from pms and esp. My machine is still working ok, but, I guess when it breaks I will just need to throw a fit and fall in it to get what I want. The way it works for me, I don't pay a dime for supplies. Not sure what they will try to push on me when I need a new machine.

I haven't seen a sleep doctor since Aug 2009. I get my 6 months new mask allowance from the DME and if I want a nasal pillow only...I go in and they look to make sure I am "allowed" per the Medicare replacement schedule and I walk out with what I want. In fact they will usually say "don't you need so and so you haven't had new hose or whatever in a long time"...and I just say thank you I am fine and I will let you know if I need something.

I do see a PCP for blood pressure issues and while he knows about the sleep apnea it is never on any of his notes and he certainly has never given me a script for anything related to cpap.

So far the only ones saying that Medicare requires a yearly renew to get cpap stuff have been people reporting what they have been told by either their doctor or the DME. No one has been able to show me any actual documentation from the Medicare website.
My experience doesn't support it and I haven't seen any real documents from Medicare.
Now the DMEs and doctors may make up their own rules...and that's fine and certainly within their rights but until I see proof I am thinking they are doing the usual...adopting their own in house rules and blaming Medicare or any other insurance instead of being up front about it.