BCBS/FL cpaper

[Emilia]

My insurance is BCBS/FL Health Options. I just learned that the only DME they use is a company called EMP that is reached by an 800 # only....no physical location near me. Ugh! Anyone have any experience with this outfit? I am going to the pulmonary doc tomorrow to get my sleep test results, but I was told I will need to sent back to the lab for a night of titration.

Any advice at this point is truly appreciated.

[Janknitz]

1. Call BCBS/FL and ask them exactly what they cover in CPAP equipment and supplies. Specifically ask them if they cover by HCPC codes or do they have different reimbursements for different types of machines (straight CPAP vs auto for example). Remember that the person you're talking to probably has no idea what he or she is really talking about, so you have to make sure that the answers you are getting make sense. Also ask about their supply replacement schedule, and what percentage of the cost they will cover. IF possible, ask for them to calculate your out of pocket share for a machine, a mask, hose, and filter.

2. Now call the DME and find out how they propose to do any mask fittings if they don't have a brick and mortar local store. What about delivery and patient education about the equipment? Learn about their return policy on masks. Find out what brand of machines they have on hand and whether they can provide another brand if your doctor orders it.

3. Ask your doctor for a very specific rx for the machine. Make sure that the RX has exactly what you want including brand and model (do a search here for the correct wording for what you want). Ask him to write "dispense as written" on the rx, so that they don't try to pull any funny stuff on you. But the mask rx should read "mask of patient's choice."

Are you on Medicare? If it's traditional Medicare (not an HMO or PPFS) you can go to any DME, but you may have to pay the 20% out of pocket. IF it's an HMO or PPFS, you MUST use the DME they contract with. There's always the option to go online, with the understanding that it will all be out of pocket if you do. Good luck!

[Emilia]

So, I got on the phone and spoke with EMP and BCBS/FL today....ugh! EMP is a middleman...they get the doc's orders and then they find a local DME here to issue the equipment. BCBS/FL tells me that they will only honor EMP for billing. My crappy HMO will not let me submit anything from any other source (i.e. cpap.com ). They will pay 100% for the 'standard' machine (whatever that means) and one mask. It is paid in full on a rental agreement for 13 mos. and then it is mine. Forgot to ask how often they will replace the machine, but I assume it a few years.

So....questions:
1. Do most folks just pay for their own extra masks out of pocket? I can't imagine only having one mask after reading the forum.
2. To buy extra masks, I need to have my Rx as I understand, but is it a Rx that just says generically a Cpap Mask, or does it have to have the specific brand, model, etc? In other words, do I need a separate Rx if I want to order masks from cpap.com periodically to try them?

I have culled info from the forum, and I will insist that the doc's office give me a copy of the full report, that the Rx's submitted to EMP have DAW on it, and I will get original copies of the Rx's for myself.

Any other advice? Thanks, again, to all the great, experienced folks here..... I'd be flying blind without you!

[Emilia]

1. Call BCBS/FL and ask them exactly what they cover in CPAP equipment and supplies. Specifically ask them if they cover by HCPC codes or do they have different reimbursements for different types of machines (straight CPAP vs auto for example). Remember that the person you're talking to probably has no idea what he or she is really talking about, so you have to make sure that the answers you are getting make sense. Also ask about their supply replacement schedule, and what percentage of the cost they will cover. IF possible, ask for them to calculate your out of pocket share for a machine, a mask, hose, and filter.

2. Now call the DME and find out how they propose to do any mask fittings if they don't have a brick and mortar local store. What about delivery and patient education about the equipment? Learn about their return policy on masks. Find out what brand of machines they have on hand and whether they can provide another brand if your doctor orders it.

3. Ask your doctor for a very specific rx for the machine. Make sure that the RX has exactly what you want including brand and model (do a search here for the correct wording for what you want). Ask him to write "dispense as written" on the rx, so that they don't try to pull any funny stuff on you. But the mask rx should read "mask of patient's choice."

Are you on Medicare? If it's traditional Medicare (not an HMO or PPFS) you can go to any DME, but you may have to pay the 20% out of pocket. IF it's an HMO or PPFS, you MUST use the DME they contract with. There's always the option to go online, with the understanding that it will all be out of pocket if you do. Good luck!

Thanks so much for the reply! As you can see, I was talking with the companies today before I saw your response. I am going to the doc tomorrow for the post study report, and then I am being scheduled for another titration overnight stay. I guess I will be fitted with masks at that time, but I am not sure what they will have on hand. The lab was super great for the study so I hope they will be well supplied! My doc's office seemed to know a lot about dealing with my insurance so I will ask them tomorrow about the codes used and what they know them to cover, replacement schedule, and extras. I'll report tomorrow on my study findings!

[brazospearl]

Emilia, that situation is absurd, imho. But it is what it is, so that's what you've gotta work with. I would think a fully data-capable autotitrating machine would be considered a "standard" machine because it uses the same insurance code as a bottom-of-the-line cpap. A bipap would be different, or "non-standard." This is just my opinion, and I'm certainly not an insurance bean counter, I'm just thinking out loud here. Under these circumstances, I think it's imperative that your doctor write the make & model of the machine you choose on the Rx along with "dispense as written." Otherwise, there are too many places for people to try to supply you with a machine that won't give you optimal therapy and (again) too many places to pass the buck about why that happened. Also, the dr needs to write "mask of patient's choice" on the Rx, so that you can get what you want. Once you have your prescription in hand, send a copy to cpap.com and you'll be able to order masks and mask parts from them forever. Looks like that'll be out-of-pocket expense for you, but at least you'll know you can get what you need. Also, try to get in writing that the insurance will pay 100% with a 13 month rental agreement. Just sayin'. I wouldn't want you to end up (like many folks) who pay more than $100 every month for 13 months as the "co-pay" on the rental...do the math, you can buy one on cpap.com for that.

[Emilia]

Emilia, that situation is absurd, imho. But it is what it is, so that's what you've gotta work with. I would think a fully data-capable autotitrating machine would be considered a "standard" machine because it uses the same insurance code as a bottom-of-the-line cpap. A bipap would be different, or "non-standard." This is just my opinion, and I'm certainly not an insurance bean counter, I'm just thinking out loud here. Under these circumstances, I think it's imperative that your doctor write the make & model of the machine you choose on the Rx along with "dispense as written." Otherwise, there are too many places for people to try to supply you with a machine that won't give you optimal therapy and (again) too many places to pass the buck about why that happened. Also, the dr needs to write "mask of patient's choice" on the Rx, so that you can get what you want. Once you have your prescription in hand, send a copy to cpap.com and you'll be able to order masks and mask parts from them forever. Looks like that'll be out-of-pocket expense for you, but at least you'll know you can get what you need. Also, try to get in writing that the insurance will pay 100% with a 13 month rental agreement. Just sayin'. I wouldn't want you to end up (like many folks) who pay more than $100 every month for 13 months as the "co-pay" on the rental...do the math, you can buy one on cpap.com for that.

Thanks for the reply, brazospearl! Yes, I agree is it absurd. Seems to me that using a middleman and a DME is more expensive since all get their cut of the pie. As I stated, I WILL be sure to have the Rx be very specific and state DAW. I questioned the insurance company about the 13 mo rental, and he said that is covered 100% - no copay. So, if I can get the machine I want and it is mine after 13 months, I will be a happy camper. We will see. Thanks for clarifying the mask Rx for cpap.com use.

I won't know until tomorrow's post study recap with the doc, but the tech at the lab told me I seemed to only have hypopneas and not apneas. My hope is that this is mild.... but we will find out soon enough.

[unadog]

.

[Uncle_Bob]

have a look over at cpapauction.com and see what you can find over there. I find masks at cheaper prices than my co pay would be through the DME.

[Janknitz]

Sounds like BC/BS is following Medicare guidelines as far as the rental (known as a "capped rental") and my guess is that a "standard machine" is anything that fits HCPCs code E0601, so you can get the top machines. As suggested, you should ask your doctor to write the script specifically for either the Resmed S9 autoset or the Philips Respironics System 1 Auto A-flex. Do some research to see which you would prefer--most people with a choice go for the Resmed S9.

So....questions:
1. Do most folks just pay for their own extra masks out of pocket? I can't imagine only having one mask after reading the forum.
2. To buy extra masks, I need to have my Rx as I understand, but is it a Rx that just says generically a Cpap Mask, or does it have to have the specific brand, model, etc? In other words, do I need a separate Rx if I want to order masks from cpap.com periodically to try them?

There's some tricks to the masks:
1. Often when you have your titration appointment, they will let you try on severl masks and give you the mask that you actually use during the titration. Keep it and pretend you don't have it when ordering your stuff--now you have a back up mask. If you like that mask, get that one as your insurance paid mask. If you don't like it, try something that sounds like it will work better (ideally you can be fitted by whatever true DME you end up with).

2. Make sure you understand the DME’s return policy on the masks. Some are giving you sample masks anyway (exactly the same as the purchased ones, but usually in cheaper packaging and meant to be trial masks), so if that one doesn’t work, they tell you to keep it and send out another. Other DME’s require you to return the mask within 30 days for a replacement, and some DME’s will stall you in an effort to make you go past the 30 days. Don’t fall for that trick! And don’t believe them if they tell you it can’t be traded—all of the major mask manufacturers have deals with the DME that allow this. If a mask is uncomfortable, don’t wait to give it a chance—call the DME the very next morning. Don’t accept leaking in your eyes, skin breakdown, or pain from a mask.

3. With a copy of your prescription, you can also purchase masks out of pocket at cpap.com or on the auction site. You do not need it to be specific, the more general the better. "Full face, nasal, nasal pillow, or hybrid mask of choice" is great.

4. Get a new mask every three months, even if you think you don’t need it. That way you will have backups, or a good auction or trade item if there’s something else you want to try instead. You can get a different mask every 3 months, so you don’t have to wear the same thing night after night. If your main mask is a nasal pillow or nasal mask, you will want a backup full face mask for times when you have a bad cold.

5. If you use nasal pillows, some of the brands need the nasal pillow cushion replaced as often as every month. Your insurance sounds like it will pay for the replacement cushions that often (Medicare Guidelines) but the masks are packaged with multiple sized-cushions and you can trade out the ones you can’t wear for the correct size on the Great Pillow Exchange here on cpaptalk.

[Emilia]

@ janknitz - thanks for these great suggestions! I am copying and pasting these into a Word doc for future reference! BTW: I added your wonderful blog to my Google Reader so I get the new posts as they occur! Great writing.....

@ Uncle Bob - thanks....I will take a look at the auction site.

@ unadog - Oh, I do hope my benefits mirror yours.... a new mask every 3 months would be great. I am shooting for the ResMed S9 as my first choice.

My insurance is via the school district from which I retired. I am 5.5 yrs away from Medicare (if it is still around)....but with all the cuts in school districts, I fear our insurance may get worse and worse. They haven't negotiated the new policy yet for the coming year, but I have my fingers crossed it will be similar to what we now have since it won't ever get better!

[Rustyolddude]

I've got BCBS Florida and I dealt directly with American Home Patient, no problems other than I'd probably been better to pay out of pocket as the deductible over 10 months was basically the cost of the machine had I bought it direct from CPAP.Com

[Emilia]

@ Rustyolddude -- thanks. My BCBS/FL is Health Options HMO and they only use EMP who then designates a local DME to supply patient. Crazy!!

I did find out today that my plan is 100% for machine, mask, hose, filter.....with new mask/filter every 3 months 100% covered. The machine is a 13 month rental then I own it. No co-pay on it.

I don't know about the humidifier.... they didn't list it, and I saw some other folks on the forum say their insurance didn't cover it. Will find out soon.

[Rustyolddude]

@ Rustyolddude -- thanks. My BCBS/FL is Health Options HMO and they only use EMP who then designates a local DME to supply patient. Crazy!!

I did find out today that my plan is 100% for machine, mask, hose, filter.....with new mask/filter every 3 months 100% covered. The machine is a 13 month rental then I own it. No co-pay on it.

I don't know about the humidifier.... they didn't list it, and I saw some other folks on the forum say their insurance didn't cover it. Will find out soon.

Glad to hear you've got good coverage. I've got Blue Options, a PPO. Take advantage of all replacements whether you need them or not. I marked the calendar and got filters, masks, seals & whatnot before my deductible reset in Jan. I've got got enough supplies to keep me going for a while or at least until I hit my deductible again, if ever. You'll need a humidifier, mine was included without mention as was a data capable machine.

[chunkyfrog]

I've been told that I need to know the HCPCS codes for replacement supplies before BCBSNE will tell me how often I can get them covered.
The lookups I have found are impossible to decipher. Is there a CPAP only list that I can reference? Please? I need to know the codes for Mirage FX small pillows, the Resmed H5i washable tank, and the h5i heated hose.

[Emilia]

I've been told that I need to know the HCPCS codes for replacement supplies before BCBSNE will tell me how often I can get them covered.
The lookups I have found are impossible to decipher. Is there a CPAP only list that I can reference? Please? I need to know the codes for Mirage FX small pillows, the Resmed H5i washable tank, and the h5i heated hose.

From another thread, I see this list of codes:

E0601 Continuous airway pressure (CPAP) device (e.g. smart CPAP, auto CPAP, CPAP)
E0561 Humidifier, used with CPAP device
E0562 Heated humidifier, used with CPAP device
A7033 Nasal pillows/seals, replacement for nasal application device, pair
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 Headgear, used with CPAP device
A7036 Chin strap, used with CPAP device
A7037 Tubing, used with CPAP device
A7038 Disposable filter used with CPAP device
A7039 Non-disposable filter used with CPAP device
A7044 Oral interface used with positive airway pressure device
A7046 Humidifier chamber - replacement
E0470 Bilevel
E0471 Bilevel with backup rate
E1399 Miscellaneous durable medical equipment items