Fustration over OHIP

[Dontwakemeup]

Hi, I'm new to this. In fact i'm getting my results of my sleep clinic on Dec 21 but have been researching everything i can on sleep apnea. I have a work drug plan and i'm covered for $2000.00 on the cpap unit itself but was told i have to first go through my provincial plan first (which can take up to 3 months)and my plan would pay the rest. Ohip has a cap on how much it will pay and i must stay within these guide lines..... I cannot go over this but it seems you get the cheapest unit and mask. From my understanding i cant get my work plan to kick in to get the unit i want. I also see i must buy it from an approved OHIP vendor and the U.S. does not qualify..... Even though the price is much cheaper.. i'm saving them big bucks but as any government buraucrecy they dont care. Has anyone gone through OHIP and bought a unit from CPAP.com and got their private insurance pay the rest. If so how did you get this done. Any suggestions you have to help me would be appreciated.Maybe CPAP.COM can help?

[Julie]

Why not call them? I got my orig. through Vitalaire in Halifax on my ex's insce, so OHIP wasn't a factor, but if you can afford out of pocket at all and have insce, Cpap.com will likely accept it in that you submit the script, then buy and submit the invoice/receipt to your insce. co (but check with them first of course). Cpap.com doesn't want to handle the paperwork, esp. being in the US, but I did it the way I described here thru them.

You can also get stuff from various Can. distributors (DMEs) which would also allow you to get Resmed products as they won't ever ship outside the US except to the dealers here, though it won't be cheap.

[Cpapian]

Ok I am from Ontario and just got my unit last October.

Ontario has either the best or close to the best xpap program in Canada.

The Ontario Government negotiated prices on our behalf. CPAPs are $860 and XPAPs are $1,020. I could be off a few dollars. An OHIP approved vendor cannot charge you more.

The govt pays 75% and you or your extended health care provider pays the balance. You get everything in the package, including a mask. I didn't take my free mask, so I have no idea what it's like.

The DME I went to, didn't want the government's 75% upfront, so I just paid the 25% balance and the insurance company reimbursed me within a week. The DME had prepared a pre-determination earlier for me, so the purchase was already approved.

For some unknown reason, the machine I have is priced as a CPAP, even though it's an APAP. the DME is therefore very reluctant to sell it, as a result. My doctor wrote the model (and it is ONLY the "for her" model) on the script. So I got it for the $860 price for an APAP. Sweet deal.

You have some misinformation in your post. OHIP has a list of all the units it covers. And it covers all the major good, data capable, latest units. I am totally happy within my machine. Couldn't be more pleased.

CPAP.com does not ship ( ResMed and Respironics) outside of the US so that is not an option anyways unless you want to set up a US postal box and have it forwarded. There is a good online Canadian provider (CPAPmachines.ca) and they will do the predetermination. Their mask prices are half of the DMEs prices.

Also, remember US dollars cost us about $1.30. So top those US prices with an additional third and you will get a rough equivalent of what it's going to cost you.

In Quebec and Alberta, the government pays nothing and the DMEs charge close to $2,000 - so be glad you live in Ontario.

Edited to add items in Italics - to correct information as provided by Pugsy and to provide the name of the Canadian Online provider.

[Julie]

Ummm - Cpaps and Apaps use the same codes for insurance submission and therefore are never different prices based on the modes... only different if they're actually bipaps or ASV machines... and that's the same in the U.S. The reason is not 'unknown'.

And Cpap.com ships outside the US all the time, just not Resmed equipment.

Careful what you pass on here...

[Pugsy]

Cpap.com can't ship any ResMed or Respironics products to addresses outside the USA. Not so much as a nasal pillow or name brand anything.
Cpap.com would love to but ResMed and Respironics have it worded in their contracts so that it is prohibited. Same contracts prevent suppliers in other countries from shipping outside their country. So far with cpap.com the only brands are the ResMed or Respironics that I know of with this restriction.
Cpap.com will ship machines and other stuff outside the US...just not anything ResMed or Respironics.

It used to be that only ResMed was this way but Respironics jumped on the band wagon a few years back with the same restrictive contracts.

The work around if someone wants something that cpap.com can't ship outside the US....either ship to someone in the US and have them forward to you or one of those package shipping places or have a post office address in the US and drive across the border and pick it up.

[Cpapian]

Ummm - Cpaps and Apaps use the same codes for insurance submission and therefore are never different prices based on the modes... only different if they're actually bipaps or ASV machines... and that's the same in the U.S. The reason is not 'unknown'.

And Cpap.com ships outside the US all the time, just not Resmed equipment.

Careful what you pass on here...

Julie, I know you hear a lot about the US practices on this forum, however, Ontario's ADP program does not follow US and/or Medicare practices. They had their own negotiations and set their own prices according to what they negotiated.

See link to Ontario Government's ADP Program Prices for Respiratory Devices where you will see clearly (Page 3) that the price for an APAP is $1,060 and the price for the CPAP (Page 4) is $860. So, in Ontario DMEs are paid a different amount for CPAP then for APAP.

However there is an "unknown" factor in there because for some "unknown" reason, the ResMed AirSense 10 AutoSet for Her is classified as a CPAP machine and thus the DME is reimbursed at the CPAP rate of $860. The regular ResMed AirSense 10 AutoSet is classified as an APAP and the DME is reimbursed at the APAP rate of $1,060.

So have a look at the Website for Ontario's Assistive Devices Program (ADP) or follow the link below to the PDF they provide.

http://www.health.gov.on.ca/en/pro/prog ... manual.pdf

[Cpapian]

Here is a rough and ready comparison for a person living in Ontario viewing to purchase CPAP.

There are three options - to purchase online at a Canadian Website CPAPMachines.ca, or through an approved Ontario DME (i.e. registered with the Ontario Government ADP Program) and the third option is to purchase through our US forum provider CPAP.com.

All prices and exchange rates are as of today, December 19, 2017 (note Dec 17/17 is a typo).

This ignores the process to get a machine from the US to the purchaser's home and the exchange price is from the web. Credit card companies may charge different rates, usually higher as there is usually a spread between buy and sell rates. However, consider this illustrative only.

Many people look at US prices as being so much better than Canadian prices, however, the currency exchange significantly alters the comparison to the extent that purchasing from the US is the MOST expensive option.



While Ontario sets the machine prices for approved DMEs, they sky is the limit for everything else. To get best prices, I included going online for the climate line hose, filters and mask.

[Arlene1963]

Hi Dontwakemeup,

Cpapian has provided excellent info and I don't have anything to add except a cautionary note based on my own experience.

I bought a lot of ridiculously overpriced and completely unnecessary extras (cleaning brush, pillow etc) from the local supplier who was on the "approved list" I was given by the sleep clinic.

I only discovered later how this company had gouged me on everything other than the machine which is the first item listed. .

This is how they make their money, so be aware of this.

Here's the bill I paid.

Please learn from my mistake and don't get taken for a ride. I should simply have bought the CPAP unit from them to qualify for the ADP funding, and bought everything else online from a company like cpapmachines.ca for example. The mask is listed online for less than half the price I was charged, including shipping.

[Pugsy]

Here's the bill I paid.

Please learn from my mistake and don't get taken for a ride. I should simply have bought the CPAP unit from them to qualify for the ADP funding, and bought everything else online from a company like cpapmachines.ca for example. The mask is listed online for less than half the price I was charged, including shipping.

Ouch. Did you at least get a kiss after getting screwed by them?
$12 for one filter...geez. Was it at least ResMed brand? I got a package of 12 name brand filters for $18 and that included shipping a while back off EBay.

[Arlene1963]

Not even a peck on the cheek.

But honestly, I was foolish, my mistake. I paid without paying too much attention to the individual items.

Not to be repeated! Recently I received an email from the company telling me it is time to replace my mask etc. Right into the spam folder that went.

[Cpapian]

Yea. ....... I paid high prices for my mask and hose, but I wanted the first set up to be problem free. The DME set up my machine for the mask and hose , plus if anything were to have gone wrong, I wanted to be able to complain to only one place. Nothing did. But the DME was very nice and helpful. The insurance company picked up the tab. They were fine with those prices.

However, in future all masks, tubs, etc will be purchased online through cpapmachine.ca in Richmond Hill. Good prices. And they come recommended by Arlene.

[unityco]

For some unknown reason, the machine I have is priced as a CPAP, even though it's an APAP. the DME is therefore very reluctant to sell it, as a result. My doctor wrote the model (and it is ONLY the "for her" model) on the script. So I got it for the $860 price for an APAP. Sweet deal.

Wow! I'm well-overdue for my next system and have just started the research again. Do you know if the prescription HAS to be for that specific model? What if my prescription simply says "CPAP"? Do you think I could get that model on a non-APAP prescription?

I had considered paying out of pocket just so I didn't have to jump through hoops to get the machine I really want, but that system with the ADP program would be great!

[Cpapian]

As far as ADP program goes, the "for her" model is a CPAP. The paperwork for ADP reimbursement was for a CPAP.

As far as the DME goes ???? The DME was the one who insisted the script specifically identify the "for her" machine. I presume because their profit is less on the "for her" model.

Call your DME and see what they say. Just ensure you get someone registered with the ADP program.