CPAP replacement for someone newly under Medicare

[no_more_headaches]

Just wanted to get a heads up on what to expect here. I have been on CPAP for 14+ years. I got my last CPAP (Airsense 10) under ACA Insurance 4 years ago or so.

I have been under Medicare for 2+ years now and expect at some point soon my machine will be ready for a replacement. I know Medicare covers CPAP and that I believe there is an initial 13 month rental schedule before its really mine. My question is are there any other hoops I need to go through besides the doctor sending a DME order for a new machine. For example will I need to do another sleep study even though I have 14 years of solid compliance my doctor can show especially with the Airsense 10 sending data directly to the cloud the last 4+ years.

[Pugsy]

Just wanted to get a heads up on what to expect here. I have been on CPAP for 14+ years. I got my last CPAP (Airsense 10) under ACA Insurance 4 years ago or so.

I have been under Medicare for 2+ years now and expect at some point soon my machine will be ready for a replacement. I know Medicare covers CPAP and that I believe there is an initial 13 month rental schedule before its really mine. My question is are there any other hoops I need to go through besides the doctor sending a DME order for a new machine. For example will I need to do another sleep study even though I have 14 years of solid compliance my doctor can show especially with the Airsense 10 sending data directly to the cloud the last 4+ years.

Medicare won't require another sleep study as long as your original sleep study is one they approve and most likely it is.
Yes...Medicare will want to do the 13 month capped rental before you officially own it.

[chunkyfrog]

As long as you have original Medicare--not an "advantage" plan,
in which case, you (and Medicare) pay forever, and NEVER own the machine.

[LSAT]

As long as you have original Medicare--not an "advantage" plan,
in which case, you (and Medicare) pay forever, and NEVER own the machine.

The Advantage plan works the same as Medicare...13 months rent to own.

[Pugsy]

The Advantage plan works the same as Medicare...13 months rent to own.

Nope. Not all of them. Depends on the Advantage plan. Mine changed a couple of years ago from the 13 month thing to perpetual rental.

People who have advantage plans will need to look at their own individual plan very carefully. More and more are going to the perpetual rental.

[no_more_headaches]

Just wanted to get a heads up on what to expect here. I have been on CPAP for 14+ years. I got my last CPAP (Airsense 10) under ACA Insurance 4 years ago or so.

I have been under Medicare for 2+ years now and expect at some point soon my machine will be ready for a replacement. I know Medicare covers CPAP and that I believe there is an initial 13 month rental schedule before its really mine. My question is are there any other hoops I need to go through besides the doctor sending a DME order for a new machine. For example will I need to do another sleep study even though I have 14 years of solid compliance my doctor can show especially with the Airsense 10 sending data directly to the cloud the last 4+ years.

Medicare won't require another sleep study as long as your original sleep study is one they approve and most likely it is.
Yes...Medicare will want to do the 13 month capped rental before you officially own it.

Good to hear! Yea mine was done in 2007 in a professional medical foundation clinic with all the data hookups and technicians monitoring and I was diagnosed as severe. AHI of 29.5 I think with 78 flat on my back.

[Janknitz]

As long as you have original Medicare--not an "advantage" plan,
in which case, you (and Medicare) pay forever, and NEVER own the machine.

The Advantage plan works the same as Medicare...13 months rent to own.

Not any more. Medicare permits perpetual rentals for HMO's and Kaiser for sure is doing it that way. I will be buying my own CPAP machines when I get to the Medicare Advantage stage (IF I stay with Kaiser, strongly considering a concierge doctor but I have a few more years to decide).

[SleepGeek]

Good to hear! Yea mine was done in 2007 in a professional medical foundation clinic with all the data hookups and technicians monitoring and I was diagnosed as severe. AHI of 29.5 I think with 78 flat on my back.

You haven't indicated if you have the good 'ol original Medicare? Unless things have changed I believe they require a min. of 120min diagnostic sleep. Some other insurances did not.

If you don't already have a copy of you sleep study I would get one and get rolling on the new cpap request - the way the back order is working it could take several months to get one. Not good if you have a failure and need one.

[chunkyfrog]

A good suggestion: get on the stick--or be stuck behind.

[Grumpy48]

Are some Advantage plans doing something they shouldn't be doing? From my experience an Advantage plan will follow basic Medicare guidelines for benefits and then go a bit further to cover the costs for the insured. If Medicare has paid Kaiser or any other insurer the rental for the 13 months and then Kaiser continues a rental, there would appear to be something unethical going on.

https://www.medicare.gov/coverage/conti ... re-devices
"You pay 20% of the Medicare-Approved Amount for rental of the machine and purchase of related supplies (like masks and tubing). The Part B deductible
applies. Medicare pays the supplier to rent the machine for the 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it."

[Pugsy]

Are some Advantage plans doing something they shouldn't be doing? From my experience an Advantage plan will follow basic Medicare guidelines for benefits and then go a bit further to cover the costs for the insured. If Medicare has paid Kaiser or any other insurer the rental for the 13 months and then Kaiser continues a rental, there would appear to be something unethical going on.

No. Not doing anything unethical. You have to understand what Advantage plans do and how they work and Medicare doesn't pay them anything for any service provided.
Advantage plans are simply a different insurance plan from Medicare and advantage plans might sort of mimic Medicare's payment schedule or whatever....they don't have to if they don't want to.

Medicare/the gov't doesn't pay Kaiser (or any other advantage plan) anything except the premiums each month go to the advantage plan instead of Medicare coffers.
When we sign up for an advantage plan our money that normally goes for Medicare premiums each month go to the advantage plan and that plan pays for any medicare allowed service and the advantage plan gets to do their own thing.
In other words Medicare doesn't reimburse Kaiser for what Kaiser might spend on behalf of one of their contracted patients.
It's just a different insurance...when you opt for an advantage plan then Medicare is out of the equation.
It's like any other insurance....the company is banking on the premiums funding the dispersal of monies on behalf of the patient. They are banking on more premiums from healthy people coming in than money going out.

When we sign up for an advantage plan of some sort we are opting out of traditional Medicare. Medicare no longer pays any of our medical bills. Medicare doesn't pay the advantage plan anything for that machine that Kaiser is supplying to someone.

Now the advantage plans often will mimic Medicare guidelines but they aren't forced to since Medicare really is no longer a factor. Advantage plans get to set their own rules if they want to within some limitations the government makes in terms of what is allowed and not allowed. That's how come the advantage plans pay for stuff that Medicare won't pay for....like dental, fitness, hearing, eye glasses. They cover what Medicare covers and then some but sometimes they cover it a little differently like the perpetual rental thing.

Just think of the advantage plan as a different insurance company with its own unique coverage and really no different than the various plans available out there for people who don't have Medicare. Advantage plans are a totally different beast just like HMO or PPO plans in the market. They get to set their own rules. I have no idea why it seems so many advantage plans opted to go to the perpetual rental thing for machines but I am sure if we asked they would come up with some reason that supposedly benefits the patient and not them. It might be the fact that if we rent something we don't own it and if a problem with it comes up then it is simply replaced without a lot of fanfare and the common 5 year rule isn't a factor delaying things. Please note I said "might be" as that is the only advantage to the patient that I can think of. I have no way of knowing for sure the "why" behind things...all I know is that they changed the way they do things and it's entirely legal for them to do whatever they want.

[LSAT]

https://www.medicare.gov/what-medicare- ... e-services

[CPAP2017]

I got a new one last year when I started Medicare Original. My Airsense 10 from my work insurance was still working, but it was five years old and I didn't want to have to go without a machine if it broke while jumping through the hoops to get a new one. I got an Airsense 11 and if it breaks I can pull the old one out of the closet as a backup. The DME coordinated with Medicare and required just two things, doctor's notes saying I needed it and data showing I used it. The doctor had the original sleep study.

Here's a link that might be useful that summarizes the process.

https://www.sleepdr.com/the-sleep-blog/ ... -supplies/

"Clinical re-evaluation between the 31st and 91st day after starting therapy, to include: Treating physician documents that the patient is benefiting from therapy; and Objective evidence of usage is reviewed by the treating physician."

(The Objective evidence: "Medicare defines adherence as using the device more than 4 hours per night for 70% of nights (that’s 21 nights) during a consecutive 30 day period any time in the first three months of initial usage.")

[Grumpy48]

Curious as a rental cost what others are paying or had paid whether through Medicare or an Advantage plan. Attached is a Medicare Summary screenshot from one of my rental months. This was for a Dream Station (original version) from my DME in Massachusetts. My Medicare BCBS supplement plan covered in full what Medicare doesn't. I believe the BCBS Advantage plan I had prior to the current supplement plan would have also covered in full DME rentals and supplies.

cpap rental.jpg (102.98 KiB) Viewed 9990 times

[no_more_headaches]

Good to hear! Yea mine was done in 2007 in a professional medical foundation clinic with all the data hookups and technicians monitoring and I was diagnosed as severe. AHI of 29.5 I think with 78 flat on my back.

You haven't indicated if you have the good 'ol original Medicare? Unless things have changed I believe they require a min. of 120min diagnostic sleep. Some other insurances did not.

If you don't already have a copy of you sleep study I would get one and get rolling on the new cpap request - the way the back order is working it could take several months to get one. Not good if you have a failure and need one.

I am on original Medicare with a plan G supplement. I do have a second machine which is a retired S9 when I got my S10. My wife who is also a hose head just happens to have appointment with our sleep doctor on Monday and we will ask what we have to do.