Questions about mask purchase as Out of Network Ins.

[Rogue Uvula]

In my case, it makes sense to order my CPAP equipment on-line as an out of network insurance claim.
Getting info out of BCBS is like squeezing blood from a turnip, but after a day and a half, I know the machine and humidifier are below their limits. That was my main concern, but I have some other minor items which, with your help, I would like to take intelligent guesses as I'm putting together my order.

1) I asked BCBS the limit for a mask and they told me $99.99. I plan to get the Activa LT and was a bit surprised the insurance limit was lower than my cost, but I can deal with $21. However, it later occurred to me that they might be quoting the mask w/o headgear. So, do I need to order the mask and headgear separately?

2) What about miscellaneous consumables such as filters, cushions, etc.? Can I go ahead and order a supply? Or will they only cover the one for immediate use?

Disclaimer - I fully understand that no one knows the specific details of my insurance. However, I think it reasonable to assume some standardization in how these claims are processed. In that spirit, please share your experiences with me. If I have to eat some costs because your experience doesn't match mine, I'm good with that!

[Emilia]

I think you'll find that BCBS plans differ greatly from place to place and also within the level of plan you have (HMO vs PPO). That said, even my pathetic HMO provides the supplies rather nicely... new mask every three months, hose and filters more frequently. So, ask them for your copy of the the EOC (evidence of coverage) which should give you the details of your plan. You are entitled to have a copy of this.

[akcpapguy]

Yes they are more than likely only paying for the mask, bill seperately for the chinstrap.

Here is the code.

A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE

[LoQ]

Don't forget about your copay. It is generally larger for out-of-network than if you used the in-network suppliers.

[Rogue Uvula]

I think you'll find that BCBS plans differ greatly from place to place and also within the level of plan you have (HMO vs PPO). That said, even my pathetic HMO provides the supplies rather nicely... new mask every three months, hose and filters more frequently. So, ask them for your copy of the the EOC (evidence of coverage) which should give you the details of your plan. You are entitled to have a copy of this.

Thanks Emilia,
I wonder why they don't offer the EOC document? I asked if there was a place I could access the info on the web, but I didn't know to ask for EOC!

[Rogue Uvula]

Yes they are more than likely only paying for the mask, bill seperately for the chinstrap.

Here is the code.

A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE

Got it!
Thanks!

[Emilia]

I wonder why they don't offer the EOC document? I asked if there was a place I could access the info on the web, but I didn't know to ask for EOC!

Keeping folks in the dark makes it much easier to manipulate them!

[Rogue Uvula]

Don't forget about your copay. It is generally larger for out-of-network than if you used the in-network suppliers.

Thanks for the caution, but medically it has been a very busy year for me . The silver lining is I have maxed out my co-insurance (both in and out of network) so 100% is being paid by insurance (up to their limits). So, for me, it was a choice of going out of network, filling out the claim, and getting exactly what I want; or staying in network and struggling to get them to order what I want (and likely having to compromise somewhere). Once I understood that, it was an easy choice!

[LoQ]

Don't forget about your copay. It is generally larger for out-of-network than if you used the in-network suppliers.

Thanks for the caution, but medically it has been a very busy year for me . The silver lining is I have maxed out my co-insurance (both in and out of network) so 100% is being paid by insurance (up to their limits). So, for me, it was a choice of going out of network, filling out the claim, and getting exactly what I want; or staying in network and struggling to get them to order what I want (and likely having to compromise somewhere). Once I understood that, it was an easy choice!

Have you also maxed out your out-of-network deductible? Out-of-network copays are really pretty hard to max out because first you have to max out the out-of-network deductible.

I'm sorry you've had to spend so much money. I know how that feels.

[Rogue Uvula]

Have you also maxed out your out-of-network deductible? Out-of-network copays are really pretty hard to max out because first you have to max out the out-of-network deductible.

I'm sorry you've had to spend so much money. I know how that feels.

Yep, I'm there, buddy!

[Rogue Uvula]

I wonder why they don't offer the EOC document? I asked if there was a place I could access the info on the web, but I didn't know to ask for EOC!

Keeping folks in the dark makes it much easier to manipulate them!

The sad thing is it almost seems like they are teaching that as a principal of business management these days. It is getting to be a real treat to find the rare company and personnel who get to enjoy the happiness that comes from helping people in your job as opposed to trying to dupe them. I better shut up now before I really get started!

[Emilia]

Well, I can assure you they don't teach it in business management school... I have a M.S. in Managerial Leadership, and I can tell you the emphasis was on authentic, humanistic, and ethical management. Heath Insurance is an animal all unto itself.... profit margins and greed seem to dominate their business model at the expense of the clientele (patients).

I am happy to say, though, that in the past two days, I have encountered some of the most professional help and great customer service at cpap.com and from DeVilbiss! This has taken my stress level down several notches from the utter frustration of dealing with my pathetic HMO!

[elena88]

I have bcbs ppo with a gigantic deductable..
we met the deductable last year, and they paid everything with no questions..

Unfortunately, one of my doctors who I despise screwed up my appt and I did not get any of this sleep study stuff done last year..
so its cost me a forturne.. however, the bills still go to bcbs, and then they negotiate the rate down to whomever, and then I
get that amount as a bill to pay.... for example the dme charged several thousand dollars to bcbs for my s nine auto, and blue shield would
only allow 1200.00... so thats what I paid.. but now for sure, I will be buying everything at the lowest price I can find, where I can still get good customer
service..

I bought my first machine by letting it go thru bcbs, but if I buy another, I will buy it out right, and then have whomever I buy it from bill my insurance,
so Maybe it will go to deductable.. most online stores dont do that.

I have been been buying all my filters from cpap.com and plan to buy some masks and other goodies too..

They are so fast and reliable!

[Rogue Uvula]

Well, I can assure you they don't teach it in business management school... I have a M.S. in Managerial Leadership, and I can tell you the emphasis was on authentic, humanistic, and ethical management. Heath Insurance is an animal all unto itself.... profit margins and greed seem to dominate their business model at the expense of the clientele (patients).

I am happy to say, though, that in the past two days, I have encountered some of the most professional help and great customer service at cpap.com and from DeVilbiss! This has taken my stress level down several notches from the utter frustration of dealing with my pathetic HMO!

Yeah, for me, it is nice to sidestep the local DME hassle. Being able to help support this board via my purchase with CPAP.com is icing on the cake!

[Rogue Uvula]

I have been been buying all my filters from cpap.com and plan to buy some masks and other goodies too..

They are so fast and reliable!

Indeed!
I placed my order at 3:30 CST today, and the order is already showing up on FedEx as in transit. I paid an extra $28 to get two day delivery so I'll get it all on Friday. I usually don't spring for expedited shipping but in this case I'll get 3 more nights usage for the money and since I have an appointment with a sleep doctor on Wednesday that is the difference between 2 nights and 5 nights experience wearing a PAP which I'm thinking will be pretty critical to my having some good questions and concerns so the good doctor can earn his keep!