CPAP replacement for someone newly under Medicare

[chunkyfrog]

The doctor is likely to only know about requirements on his end.
The people who know nearly everything are at SHIP in my state.

[breathingeasy]

Here is my experience. I've been on a CPAP with 100% use since 2015 and was covered through employer insurance until 11/2019 when I moved to Medicare and a Plan F supplemental. I purchased a Resmed 10 Auto Airsense (out of pocket) last year following the Dreamstation recall. I didn't want to go through the hassle and the time it would take to get a new machine through Medicare. Several months ago I asked my sleep doctor to send a prescription for supplies replacement to a local DME who accepts Medicare. The DME told me that because my machine was a private purchase Medicare does not cover replacement of supplies. Medicare only cover supplies under their schedule if the machine is provided through Medicare. Consequently, my doctor wrote a new prescription for a Resmed 11 which will also cover future supplies replenishment.

[Pugsy]

The DME told me that because my machine was a private purchase Medicare does not cover replacement of supplies. Medicare only cover supplies under their schedule if the machine is provided through Medicare.

Well...that's another one to add to the list of "whoppers I got told".

I have never used Medicare to purchase a machine and have been getting masks paid for by Medicare since 2009.
Medicare doesn't care who paid for the machine....but the DME does care because he isn't getting the big bucks from a machine sale.

Your choice if you want to do business with liars....me...I wouldn't let them supply as much as a filter.
I would be finding a DME that wasn't a liar. I don't trust liars.

[SleepGeek]

Your choice if you want to do business with liars....me...I wouldn't let them supply as much as a filter.
I would be finding a DME that wasn't a liar. I don't trust liars.

I couldn't agree more. The thing is if they will lie about something so trivial there is no limit to what else they will lie about.

I'd be interested to know which DME that was? Apria, Lincare? or who?
My Sleep doc once leaned over and told me "They ALL lie" - love that doc.
It can be difficult to tell when they are lying and when they just don't know what they are talking about - but it doesn't matter.

fwiw - I've had good luck with this mail order place that takes Medicare - they will need a script but so will any other place.
https://verushealthcare.com/contact/
And there are other Medicare mail order places too where you won't have to put up with that BS.

[stevenal]

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.

I fail to see the economics here. Aren't insurance companies trying to make money for their share-holders? I can pay the Medicare rate for 13 months, or I can pay the same rate until the policy holder dies. And the second plan wins?

[SleepGeek]

Aren't insurance companies trying to make money for their share-holders?

Certainly they are. And they make money by denying you things that Medicare pays for w/o objection yet promising to give you more than Medicare will. And people believe it.

For example - what Medicare allows for things like let's say glucose test strips that Medicare pays 80% of their allowable rate - the Advantage HMO plans will just flat deny. Or it could be some other medicine you have been using and like.

So IMO this is pinching pennies yet promising you more like dental or eye care or transportation or OTC meds, etc.

So choose your poison carefully.

[dataq1]

So IMO this is pinching pennies yet promising you more like dental or eye care or transportation or OTC meds, etc.

So choose your poison carefully.

Indeed, But most people don't really understand WHY Medicare Advantage Plans offer "extras" like dental/eye/transport/OTC etc.

It's not because they want to, it's because they have to in order to maintain their required patient care $ to premium $ ratio. If a plan falls below the required %, the plan may be required to return premium $ to subscribers (horrors).

[chunkyfrog]

How to tell if a DME is lying:
Answer: when their mouth is moving.

[klm49]

So IMO this is pinching pennies yet promising you more like dental or eye care or transportation or OTC meds, etc.

So choose your poison carefully.

Indeed, But most people don't really understand WHY Medicare Advantage Plans offer "extras" like dental/eye/transport/OTC etc.

It's not because they want to, it's because they have to in order to maintain their required patient care $ to premium $ ratio. If a plan falls below the required %, the plan may be required to return premium $ to subscribers (horrors).

FWIW, My view on Medicare Advantage is that if it is such a great deal why do they spend so much money advertising it?
No Thanks! I'll stick with my "Unadavantage" Medicare plan that pays 100% no questions.

[no_more_headaches]

So IMO this is pinching pennies yet promising you more like dental or eye care or transportation or OTC meds, etc.

So choose your poison carefully.

Indeed, But most people don't really understand WHY Medicare Advantage Plans offer "extras" like dental/eye/transport/OTC etc.

It's not because they want to, it's because they have to in order to maintain their required patient care $ to premium $ ratio. If a plan falls below the required %, the plan may be required to return premium $ to subscribers (horrors).

FWIW, My view on Medicare Advantage is that if it is such a great deal why do they spend so much money advertising it?
No Thanks! I'll stick with my "Unadavantage" Medicare plan that pays 100% no questions.

Here is a good example of why we stay on regular Medicare. My wife went to her dermatologist a few years ago and he found a cancerous lesion on her scalp just back of her forehead. He removed it but from a cosmetic point of view she needed to see a plastic surgeon to close the wound tighter and make it presentable. However they were not available for weeks. Our son-in-law who is a ENT surgeon was friends with a private plastic surgeon facility and was able to get her in for a consult that day (Friday) and perform reconstructive surgery the following Monday. He billed it to Medicare since the initial diagnosis was a cancerous lesion.

There is no way under an Advantage plan she would have those kind of choices. She would have had to wait and maybe even get a butcher surgeon.

You just never know but choice is important to me. If I don't like the doctor I want to be able to walk.

[zorki1c]

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.

Our advantage plan is a 13 month pay then the machine is yours. It’s a PPO plan not and HMO. I think HMOs tend to be more restrictive.

[Pugsy]

Our advantage plan is a 13 month pay then the machine is yours. It’s a PPO plan not and HMO. I think HMOs tend to be more restrictive.

It's probably more that each advantage plan gets to do whatever it wants to do.
My last advantage plan, before this one I currently have, was also a PPO advantage plan and they also changed to perpetual rental.
I dumped them mainly because I found one with a lower out of pocket cost for out patient procedures...and better coverage on my medications.
But 2 years before I dumped them I saw where they changed to perpetual rental for DME stuff.

Not a big deal for me...Medicare has never bought me a machine in nearly 13 years. I buy my own...usually at a price at about what my copay would be and I don't have anyone looking over my shoulder telling me what to do.
Now I have used my insurance to get masks, etc.
At least until I changed to the Bleep and my DME refused to supply it....now they get zero business from me.
They flat out told me Medicare wouldn't cover the Bleep which is a bold face lie and I don't do business with liars.

But people need to be wary...even PPO plans can adopt the perpetual rental if they want to.
It's not limited to HMO plans.