Replacement schedules/quanities for CPAP supplies with New York State medicaid?

[bdcs64]

I have been having a back and forth struggle with my DME (CrApria) on the amounts and frequency of replacement supplies.

My insurance company Healthfirst Managed Medicaid is not very helpful, and only says they will pay for whatever is "medically necessary".

Does any one know of a resource that would summarize the allowable replacement schedules/quantities for CPAP supplies with medicaid in New York State?

I have searched and searched online. Medicaid office says there is an official amount (I am sure there must be!) but no one can actually find out what it is (I am still waiting for a callback form them).

The past few years I have normally received supplies that allow for replacing:

Every 2 weeks:
Nasal cushions
Disposable CPAP machine filters

Every 3 months:
Mask frame (not including the headgear)
CPAP tubing

Every 6 months:
Mask headgear
Chin strap
Humidifier water chamber

CrApria is now saying these amounts are incorrect based on my insurance.

[sleepye]

That is certainly a LOT of supplies. I have no idea how often replacements are allowed by New York State medicaid. Just as a comparison, I can't remember the last time I replaced anything other than filters (every 2-6 months) and pillows (every 6-12 months).

[LSAT]

That' enough supplies for several people....If they are being used in that quantity, there are too many going into land fills.

[jas32]

OP, I'm from Michigan and on Medicare and your schedule is exactly what I have for my CPAP supplies. The supplies do not come to me automatically but have to be ordered. However with my Medicare Advantage coverage I pay (out-of-pocket) 20% of the inflated MSRP cost of the supplies. Comes out to about 1/2 price of online pricing.

Yes it is a lot of supplies but since I partly pay for it, I only buy about 1/3 to 1/4 of what is allowed.

[Pugsy]

OP, I'm from Michigan and on Medicare and your schedule is exactly what I have for my CPAP supplies. The supplies do not come to me automatically but have to be ordered. However with my Medicare Advantage coverage I pay (out-of-pocket) 20% of the inflated MSRP cost of the supplies. Comes out to about 1/2 price of online pricing.

Yes it is a lot of supplies but since I partly pay for it, I only buy about 1/3 to 1/4 of what is allowed.

Something is wrong. With Medicare Advantage plans we are supposed to only pay the 20% of the Medicare allowed price for the item....NOT the MSRP. Big difference between what DMEs bill out and what Medicare ends up actually allowing for anything. DME is supposed to write off the difference.

I suggest you call up your insurance company and ask what the deal is.

[Pugsy]

To the OP here....unless you happen to stumble on a forum member here who is using the New York Medicaid system it is unlikely anyone here will know the replacement schedules.

Your past items replacement time frame and amounts do happen to be what Medicare allows. A lot of state medicaid systems as well as other private insurance companies just go by what Medicare allows but not all do.
Some years ago I knew of one person on Medicaid in a state in the south and she was allowed only one nasal pillow replacement per 12 months.

Perhaps your NY state medicaid has decided to not go by Medicare allowances any more.
Perhaps your Apria supplier is simply up to their usual tricks to screw with people.

Either way you need to contact your insurance and keep asking until someone gives you an answer.

[Grumpy48]

A 2013 HHS.GOV document link attached and a screenshot of Medicare/Medicaid replacement 'schedules'. I don't believe much has changed for Medicare, but it does appear each state may have it's own replacement guidelines for Medicaid.

https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf

medicaid cpap.jpg (126.2 KiB) Viewed 1208 times

[bdcs64]

A 2013 HHS.GOV document link attached and a screenshot of Medicare/Medicaid replacement 'schedules'. I don't believe much has changed for Medicare, but it does appear each state may have it's own replacement guidelines for Medicaid.

https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf


Thanks for your reply.

I came across this report as well, and yes, each state has its own Medicaid fees/schedules etc for all DME supplies.

It is very odd (and frustrating) that this is what an online search finds - a report from 2013! This report does include conclusions/suggestion that it should be standardized across states.

[lazarus]

It isn't even always standardized among the various Medicaid-plan providers within each state.

But the day they get, say, Georgia, on the same page as, say, Massachusetts, with how Medicaid plans work is the day that lasting peace in the Middle East starts to look easy.

[bdcs64]

In can anyone else come to this post looking for similar info:

I found what seems to be the current New York State medicaid guidelines for allowed quantities and frequency CPAP supplies. It is the "DME_Fee_Schedule" spreadsheet https://www.emedny.org/ProviderManuals/ ... hedule.xls

which is found on from the site https://www.emedny.org/ProviderManuals/DME/index.aspx

Please note, as per the document
https://www.emedny.org/ProviderManuals/ ... ptions.pdf
that the “MAX UNITS” column is “for medical/surgical supplies, the maximum allowed per month”.

[palerider]

Does any one know of a resource that would summarize the allowable replacement schedules/quantities for CPAP supplies with medicaid in New York State?

For the past five years I have received:

Every 2 weeks:
Mask cushions and/or nasal cushions
Disposable CPAP machine filters

Every 3 months:
Mask frame (not including the headgear)
CPAP tubing (heated or standard)

Every 6 months:
Mask headgear
Chin strap
Humidifier water chamber

This is the kind of flagrant waste that drives up costs for all of us.

[/quote]
Every 2 weeks:
Disposable CPAP machine filters[/quote]
For something that the *manufacturer*says to replace every 6 months. (or more often if you live in a dusty environment.)

the same for the rest of the things. I've been using the same tubing for six years or so, because *it still works*. why contribute to landfills by throwing away something that's functioning perfectly fine?

[Pugsy]

To the person who continually flags several of the posts here and is creating a lot of extra work for me.

Just because someone thinks that the replacement use is excessive doesn't mean that is a reason to remove the post.
All it means is someone thinks it is an excessive amount of supply usage.

Now there was one post where there was a direct personal attack and the OP was specifically called a lazy ass along with some other uncalled for comments. I did remove that post.

So quit with the flagging of the posts you don't like. I am not going to remove those posts because each of those people have a right to their opinion and they didn't personally attack you or call you derogatory names. All they said was that your apparent supply frequency appeared to be excessive in their opinion. No name calling. No direct personal snarky ass retorts...no nothing that really is actionable.
Now the personal attack and lazy ass comment....that was actionable and I took action.

Continued abuse of the reporting button can result in a loss of privileges and/or getting the thread locked.
It really doesn't have any other value now anyway. Question has been asked and answered.
Let it die and move on off the page.

[bdcs64]

To the person who continually flags several of the posts here and is creating a lot of extra work for me.

Just because someone thinks that the replacement use is excessive doesn't mean that is a reason to remove the post.
All it means is someone thinks it is an excessive amount of supply usage.

Now there was one post where there was a direct personal attack and the OP was specifically called a lazy ass along with some other uncalled for comments. I did remove that post.

So quit with the flagging of the posts you don't like. I am not going to remove those posts because each of those people have a right to their opinion and they didn't personally attack you or call you derogatory names. All they said was that your apparent supply frequency appeared to be excessive in their opinion. No name calling. No direct personal snarky ass retorts...no nothing that really is actionable.
Now the personal attack and lazy ass comment....that was actionable and I took action.

Continued abuse of the reporting button can result in a loss of privileges and/or getting the thread locked.
It really doesn't have any other value now anyway. Question has been asked and answered.
Let it die and move on off the page.

The posts that I have reported are OFF TOPIC, which is a reason/option listed in the choices offered when reporting posts.

Others who come to this forum will have to read responses which are not helpful, not related to the original post's topic, and have a negative effect on this online community.

[Pugsy]

The posts that I have reported are OFF TOPIC,

Well....actually the posts commenting on frequency of replacement of said items are on topic since you brought up the replacement schedules or quantities.

It is the opinion of several members that your usage was/is excessive.
They get to have their opinions.

And I get to decide what is off topic or rude or hateful or whatever.

Your original question has been answered...move on.
And you reported another post after I asked you not to.

I think this thread has gone beyond its useful life since there is zero need for further responses or action.
Has disintegrated to just bull shit nit picking.

Thread is now locked.
Move on.