Medicare and Supplememtal Insurance

[KML2022]

I recently got Medicare with Anthem supplemental. What is the difference of using a DME store that accepts Medicare vs one that doesn’t? It seems that the DME stores that accept Medicare may not have supplies for MyAirSense 10, and I want to continue to use the same supplies. Any recommendations or information is welcome!

[Pugsy]

Stores that accept Medicare and your supplement will bill Medicare and your supplement for any supplies and you won't have to pay anything out of pocket (assuming any of your Medicare Part B deductibles have already been met)....so essentially minimal (if you need to meet a deductible) or zero out of pocket costs to you (if you have met your deductible).

Stores that don't accept Medicare leave you wide open to big costs because they will expect you to pay for everything and there is no way for you to really recoup any monies from Medicare because Medicare doesn't really want or have a way for patients to file for expenses. You would likely have to pay a lot out of pocket.

Do you not have other DME stores in your area that do accept Medicare that will either have what you want in stock or be willing to order it for you?
If you don't....there are online DMEs/cpap suppliers that will file your Medicare for you and mail you whatever you order.
There's not a lot of those online suppliers but there are a few.
Avoid Apria or Lincare ....they are well known to screw up their orders and it takes forever to get the errors sorted out.

[Pugsy]

All this below is assuming the DME accepts Medicare as a participating provide and Medicare pays them directly.
Another thing to understand about DMEs and billing and Medicare is that DMEs will bill out a pie in the sky amount but if they accept Medicare they don't get that pie in the sky amount.
They get what Medicare says is the allowed amount...80% from Medicare and 20% from you or your supplement.

Example...suppose you get a mask that the DME bills out to Medicare at $200. They will "part it out" when they do the billing like so much for cushion and so much for headgear or frame. They all do that even if the mask package contains everything.
So the cushion might be billed out at $100 and the headgear at $100 and it totals 200.
Medicare will in turn decide what the DME real allowable amount might be...
For example of that 200 total Medicare might only allow $120. The DME has to write off the $80 and Medicare will pay 80% of that 120 which is $96 and you or your supplemental insurance is responsible for the difference of $24 which is your 20% copay....all assuming your Part B deductible has been met.
If your deductible hasn't been met yet then the 120 allowed amount counts toward your Part B deductible.
Either you or your supplement will be responsible for the deductible depending on which supplemental plan you bought.

If you use a DME that doesn't accept Medicare....you are responsible for the full 200 and your supplement won't pay it either. Supplements only pay after Medicare pays and if Medicare doesn't pay...supplements won't pay either.
So if a DME isn't a participating Medicare member....Medicare won't pay and it doesn't count toward your deductible either.

[PST]

Pugsy is totally correct, of course, but I would add that AirSense 10 is a very popular device, and replaceable parts for it like masks and hoses are standard. So any DME that accepts Medicare and carries CPAP equipment ought to be able to help you.

[chunkyfrog]

Pugsy is totally correct, of course, but I would add that AirSense 10 is a very popular device, and replaceable parts for it like masks and hoses are standard. So any DME that accepts Medicare and carries CPAP equipment ought to be able to help you.

If you prefer Resmed branded equipment, specifically machines and accessories,
you need any DME that carries Resmed machines and supplies.
Sadly, there are some who dispensed cheaper machines,
-because of the higher mark-up.
These companies may have damaged their chances
for preferential treatment from Resmed.
There are plenty of Resmed dealers participating with Medicare,
but it may require a bit of traveling.

[KML2022]

Wow, this is so helpful, and validates what I was thinking. Than you all so much for being so helpful and supportive. I wonder if CPAP.com is Medicare approved? I did not see them on the website Medicare,gov. In the past they seem easier to get supplies from when I could use for my employers deductible, but I don’t know about using them for Medicare.

[Pugsy]

I wonder if CPAP.com is Medicare approved?

No...they are not a participating provider for any insurance company and that includes Medicare.
This means that they won't file your insurance in lieu of payment. They want you to pay and then you file your insurance (if you can) but Medicare won't pay even if you could file. Medicare makes it extremely difficult for patients to file their own insurance. Long time ago it wasn't that way but now it's essentially impossible.
Now if you had other insurance a lot of time other insurance companies will pay something on cpap.com purchases and put them in the "out of network" thing.

Now there are some online cpap suppliers who will file your Medicare for you.
I don't have the list handy at the moment but it isn't a very big list.

Now where cpap.com might come in handy is if you are needing or wanting something and you either don't want to burn your insurance allowance on the product or you are a long time away from when your Medicare would pay for something and you don't want to wait. As long as you are willing to pay out of pocket...they are a good source for products.

Below is the Medicare allowance schedule for when they will pay for something.
DMEs are NOT allowed to auto ship replacement parts to Medicare patients. You have to tell the DME that you need so and so. Just because Medicare allows something every so often doesn't mean that you have to replace it that often either.
Don't let anyone try to set you up for auto ship. They are breaking the law for one thing and the other is you won't need to replace some items all that often anyway. I just replaced a heated hose that probably had over 20K hours of use on it.
It developed a hole in it...probably a kitty claw puncture as I could never really isolate the leak but leak it was doing.

[KML2022]

Thank you, thank you again! I will come back if I have any other question! I hope I can continue to access this post.

[SleepGeek]

What is the difference of using a DME store that accepts Medicare vs one that doesn’t?

I think its been mentioned that your cost will be zero if you use a Medicare provider of which there are many.

IF you don't need the help of a tech for mask fittings or hands on teaching you about your cpap you might want to try a mail order Medicare supplier.

I've used this place with good success.
https://verushealthcare.com/contact/

[SummerTime]

I've used this place with good success.
https://verushealthcare.com/contact/

Hi SleepGeek, glad to know you've had success with Verus. I did too until my machine stopped working. There is a big red sticker on the top of the machine that says call Verus for service and supplies. Supplies came on time but when my machine stopped working a few weeks ago, that was a different story. I called and spoke to someone who said the people who handle this type of call would call me back. Two days later I called again. I told this person that I called two days ago and he said he couldn't find any notes about the call. He then asked me many questions which had been asked and answered in the first call. He said he would get on it right away. It's been three weeks and I haven't heard word one.

If I didn't have a neighbor who has sleep apnea and tinkers with his three machines, I'd still be waiting for a call back. Fortunately, it wasn't a major problem. I had moved the machine to a different spot inside a draw and it didn't like it, I guess. I did all the usual things we do when there is a problem, with no luck. When my neighbor came over he took it out of the draw and put it on top of the night stand where it originally was. He put in a new hose and when he set it up that was all it took. I had been using the hose the machine came with for three years but didn't think that was the problem.

Anyway, all this to say that Verus didn't know my medical history or that I had someone who could help me. For all they knew I could have gone into orbit. I still have a hard time believing that I never heard from them. I did look at their reviews and now know why they have 1 and 2 star reviews.

[SleepGeek]

When my neighbor came over he took it out of the draw and put it on top of the night stand where it originally was. He put in a new hose and when he set it up that was all it took.

Sorry to hear that. Not clear what your problem was - sounds like it was the outlet.
But meanwhile maybe you can make a recommendation for supplies to the OP?

fwiw - I only ordered supplies from Verus (who takes Medicare). No problems or BS like Apria or Lincare.