Monthly charge from DME

[Pugsy]

If you have supplemental insurance (Wellcare?)

She went from Medicare to WellCare in Kentucky in Jan of this year. WellCare is medicare advantage plan and not a supplement to medicare. It also appears to be a Medicare advantage HMO type of insurance. I just skimmed it briefly and I am trying to find the Evidence of coverage documents right now....of course they don't make it easy when you aren't a member already.

So she's pretty much stuck with the 20% copay and the amount quoted is on par for what I have seen in the past for ASV 20% of the allowed amounts. A little more than twice what the regular machines are allowed.

[Okie bipap]

In 2017 I told our PCP that my wife was snoring and would quit breathing while sleeping, so she scheduled my wife for a sleep study. She was upset with me for doing it, but now she is sleeping much better and uses the machine every night

Has she forgiven you yet? My husband snores a lot and wakes me up several times a week. If he naps on the couch (always on his back) while I'm watching TV he's so loud that I use earbuds instead of the regular speakers. But I've never observed him stop breathing and gasp for air in the 20 plus years we've been together, so I don't think he has apnea. But come to think of it he never observed me do those things either...just some occasional snoring.

Yes she has. It took quite a while to get her pressure adjusted because she is one of the people that start having central events when starting treatment. Once she got her AHI down to a reasonable level, she started to feel much better and had more energy. Now, she uses her machine every night.

As far as snoring, both my daughter and son in law snore a lot. They have both been tested and neither have sleep apnea.

[Pugsy]

Well I wasn't able to find the actual full evidence of coverage documents for 2019.
All I could find was the generic handbook put out in 2017 and it is the condensed version...
For durable medical equipment is said 0 co pay and that's it but obviously not the case for cpap stuff. Might be for wheelchairs or oxygen or something like that....and it was for 2 years ago so no telling how it might have changed.

[chunkyfrog]

Too bad "advantage" is all some folks can afford.
They don't tell you who has the advantage.

[Smargie]

Thanks for doing all that research on my behalf, Pugsy! After I finished posting here I spent the next hour and a half opening an online account for myself on the WellCare site. It's a terrible website and they make things unnecessarily difficult. They make info hard to find even if you ARE a member. I "chatted" with an agent online and asked about whether I'd own my machine after 13 months. I won't go into detail, but it took a long time to get basic info that I already had. I think English was not her first language, and I THINK that she said that I had to have a contract with the DME if I wanted to own it. I'll call the DME tomorrow to find out about that. I was too frustrated and crabby to talk to anyone else at that point. I wasn't presented with the opportunity to own the ASV when I got it. I suppose it could be a sneaky way for the DME to get you to pay for your machine forever by not telling you that there are other options. In case you're interested for future reference CPAP does fall under durable medical equipment and the co-pay is 20%.

I don't think my husband would agree to a sleep study. He's been told a few times after being under general anesthesia that he may have sleep apnea. He doesn't remember it though because the docs always seem to come talk to him when he's still groggy, so I'm the one taking notes. I'd like him to get tested... not only because if he does have it he'd get treatment, but also so I could tease him right back about how ridiculous he looks in a mask.

[Pugsy]

Too bad "advantage" is all some folks can afford.
They don't tell you who has the advantage.

It's still not so bad for a lot of people. I have a Medicare Advantage plan...for years when I was on Medicare prior to age 65 it was my only choice because no one else would offer me a supplement unless it was at $500 a month.

You need to get past your distaste for the Advantage plans...for some people (not only those that can't afford the regular supplements) it actually works out better for them. It depends on the plan and the overall health of the person.
Some years back when I broke my wrist and required surgery....my total out of pocket or my copays for the doctor or the 20% of the stuff....totaled $682...For me to have a supplement that would have paid that $682 would have cost me over $250 dollars a month...
That was really the only medical expense I had that year. Let me see...pay nothing for the advantage plan...and I pay $682...or pay
250 X 12 which equals $3,000 just so I didn't have to pay that 682....not smart business. I still saved money that year.
I have saved money every year. Now if I was unhealthy in general and was in and out of the hospital all year long and needed all sorts of things then that might not be a good deal for me but I figure I have saved thousands of dollars in the past 10 years using the advantage plans....I can pay a lot of 20% copay expenses with the money I saved over the years by not having a traditional supplement...and the insurance companys didn't get a chance to pocket my premiums and not pay much out for me.

[Pugsy]

Yeah...that website sucks. Pretty typical though.
When you call the DME and ask...if they say you own it in 13 months...get it in writing.
Don't give them a chance to go back on their word.

It is very possible that your insurance doesn't do the perpetual rental thing because like I said...it really doesn't make good business for them either. If you pay for life so do they and insurance companies don't normally like to pay for anything any longer than they have to.

Also...remember if you ever switch back to regular Medicare...everything would likely start all over. I can't swear to it but that is what I think would happen.

[Smargie]

Also...remember if you ever switch back to regular Medicare...everything would likely start all over. I can't swear to it but that is what I think would happen.

Not sure what you mean by this. Do you mean that if I were to go back to straight Medicare in regards to the rent to own policy, the 13 months would begin again once I made the switch? I doubt I'd go back anyway. These Medicare HMO plans seem to save one a lot of money. When I lived in the Bay Area, which is huge, it was hard to find docs that you already had a relationship that would be on your particular plan. Here in Lexington, all of the docs seem to be on all of the plans. I miss my native California a ton, but in many ways life is a lot easier here. It's way less crowded which seems to make people a lot more pleasant.

Anyway, if the DME actually says I can rent to own I'll definitely go over there and sign the contract. One of the unclear things the WellCare agent said was that I could only rent to own a machine if the machine was used (?!), so I really need some clarification. I'm with you that it wouldn't make sense for the DME to pay for longer than they have to.

[Pugsy]

Yes...I mean the 13 months would maybe start all over again if you went back to straight Medicare and there was any time left on the current plan.
Technically Medicare has never bought you a machine since the WellCare plan replaces Medicare even though they use Medicare fee schedules and replacement schedules and all that. Essentially Medicare knows nothing about the machine.
Anyway, I am not sure but I want to just alert you to that potential. Typically when Medicare comes in midstream on anything they start all over with time frame...because to them it is new.

[bwexler]

If you have supplemental insurance (Wellcare?) they may pay part or all of the 20% co-pay. Check in with them--they should issue an EOB to tell you what your out of pocket share is. Or it might be the $46 because that seems kind of low for an ASV co-pay. But contact them to clarify before you pay it.

Here in San Diego area all the advantage plans I checked were perpetual rental. And I think I checked them all.
I found a good low hour resale here on CPAP. Com and paid cash.
I was doing the same arithmetic Pugsy did and refused to pay perpetual.

Does that include Kaiser?

No I don't even acknowledge Kaisers existence. I know too many people who have died there or would have died if they hadn't moved to a different hospital.
The Medicare Advantage plans in California are regional. When I moved from Riverside county to San Diego almost everything in my plan changed. So what is available in San Francisco is as different from San Diego as Kentucky.

[Janknitz]

Pugsy said:

A lot of the Medicare Advantage plans are going to perpetual rental for cpap machines...you never own it and the monthly rental never ends.

Pugsy, where is the official information about this??

My understanding is that Medicare Advantage plans MUST follow the same guidelines as traditional Medicare, and that means a capped rental. Where is the documentation allowing Advantage plans to opt out of capped rentals for CPAP?

[Pugsy]

Pugsy said:

A lot of the Medicare Advantage plans are going to perpetual rental for cpap machines...you never own it and the monthly rental never ends.

Pugsy, where is the official information about this??

My understanding is that Medicare Advantage plans MUST follow the same guidelines as traditional Medicare, and that means a capped rental. Where is the documentation allowing Advantage plans to opt out of capped rentals for CPAP?

My own Medicare Advantage plan coverage paperwork for one thing....and the last plan before I changed last fall had same thing...which BTW when I got that plan some years ago it was capped rental but they changed it to perpetual rental a couple of years after I got it.
I changed plans last fall for other reasons...and it is perpetual rental on all DME equipment.
Other people have also confirmed that was the way it was with their Advantage plan.

I never looked for the "official" stuff because the wording in the 2 plans I have seen and what I have been told by other forum members with their plans...confirms it.
Medicare Advantage plans I guess can tweak what they do for durable medical equipment is all I know....don't have to mimic Medicare for everything.

It's stated very clearly under the DME section of coverage....you rent it and you don't ever own it. I know one member here who found that out and he has an ASV machine and his DME confirmed it. I think he opted to buy from second wind when he got his new machine.

Now someone did tell me that they did push back on the perpetual rental and was given an option to covert to capped rental.
I can't tell people that all advantage plans will offer the capped rental if pushed...they need to get with their advantage plan carriers and ask if they see rent only under the DME section of their coverage.

I think Advantage plans can do what they want in some areas and don't always mimic Medicare.

[Janknitz]

Pugsy said:

A lot of the Medicare Advantage plans are going to perpetual rental for cpap machines...you never own it and the monthly rental never ends.

Pugsy, where is the official information about this??

My understanding is that Medicare Advantage plans MUST follow the same guidelines as traditional Medicare, and that means a capped rental. Where is the documentation allowing Advantage plans to opt out of capped rentals for CPAP?

My own Medicare Advantage plan coverage paperwork for one thing....and the last plan before I changed last fall had same thing...which BTW when I got that plan some years ago it was capped rental but they changed it to perpetual rental a couple of years after I got it.
I changed plans last fall for other reasons...and it is perpetual rental on all DME equipment.
Other people have also confirmed that was the way it was with their Advantage plan.

I never looked for the "official" stuff because the wording in the 2 plans I have seen and what I have been told by other forum members with their plans...confirms it.
Medicare Advantage plans I guess can tweak what they do for durable medical equipment is all I know....don't have to mimic Medicare for everything.

It's stated very clearly under the DME section of coverage....you rent it and you don't ever own it. I know one member here who found that out and he has an ASV machine and his DME confirmed it. I think he opted to buy from second wind when he got his new machine.

Now someone did tell me that they did push back on the perpetual rental and was given an option to covert to capped rental.
I can't tell people that all advantage plans will offer the capped rental if pushed...they need to get with their advantage plan carriers and ask if they see rent only under the DME section of their coverage.

I think Advantage plans can do what they want in some areas and don't always mimic Medicare.

I always want to see the authority--where's the regulation or law that allows them to bypass the capped rental regulations published in the DMEPOS? I called HICAP and asked them and the basic answer I got was "I think they can do it because Advantage Plans get a lot of leeway, but I don't know where it's written." I couldn't find anything specific on the CMS website.

So I started looking around at Evidence of Coverage for HMO's in Southern California and came across this for Kaiser of Southern California: https://medicare.kaiserpermanente.org/m ... hanced.pdf

Page 49 says:

Section 7.1. Will you own the durable medical equipment after making a certain number of payments?
"In Original Medicare, people who rent certain types of DME own the equipment after paying copayment for the item for 13 months. As a member of our plan, however, you will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan.

So yeah, they are definitely doing that, but I'd still want to see where it says they have the authority to do it (I suspect it does exist somewhere, I'd just like to see where).

It goes on to say if you move from Traditional Medicare to the Advantage plan and haven't already made 13 payments to own the equipment, you have to start paying on it again perpetually with the HMO. And even if you've made more than 13 payments with the HMO and switch to a Traditional plan after, Traditional Medicare will make you make 13 MORE payments before you own it. Someone must have one hell of a lobby to get that type of regulation in place.

Hmmm, If an Advantage plan pays $80 a month toward the rental of a machine over 5 years that's $4,800 for a machine I can buy for $700 (and they can buy outright even cheaper). There's no way they would sign on to that. I wonder if it is the fact that they are really the DME and DME like Crapria is only the supplier. So in addition to the capitated rate Medicare pays the Advantage plan each month, Kaiser's getting to keep your "rental" co-pay??? Sweet deal for them.

If I'm stuck with Kaiser when I go on Medicare in 5 years (it's getting harder and harder to find local private doctors who accept Medicare!) guess I'm just going to be buying my own machines (at least I won't have to play Crapria games).

[Pugsy]

Hmmm, If an Advantage plan pays $80 a month toward the rental of a machine over 5 years that's $4,800 for a machine I can buy for $700 (and they can buy outright even cheaper). There's no way they would sign on to that. I wonder if it is the fact that they are really the DME and DME like Crapria is only the supplier. So in addition to the capitated rate Medicare pays the Advantage plan each month, Kaiser's getting to keep your "rental" co-pay??? Sweet deal for them.

I chose a half assed HMO kind of Medicare Advantage plan last fall...no monthly premium and my copays for outpatient stuff were less and no need to wait for procedures (main reason I switch). Not a real HMO but a lot in in network stuff restrictions that I discovered after the fact....like Nationwide Medical Insurance where I could get Bleep mask supplies is out of network...no coverage.
The dental coverage...sucks.
Come this fall I may research for a different plan.
It isn't its own DME though like Kaiser....and I just don't see how or why these advantage plans have gone to perpetual rental for this stuff when they aren't the DME. Makes no business sense to me. DMEs love them though....who wouldn't.
The up side though...if you rent it you don't own it and if it craps out they have to take care of it....no more of this "you haven't had it 5 years and you are SOL on the warranty" crap.

I have not had a chance (nor do I want to do all the work) to research how all the advantage plans might handle DME stuff.
And since what is offered in my area might not be the same thing even in other parts of Missouri much less other states....all I can do is tell people to go over that Evidence of Coverage with a magnifying glass so that there are no ugly surprises.
For sure can't rely on the DME to know for sure...impossible to know what every plan out there might do or not do in general.
They do good to get it right on what straight Medicare will do.

In general though I am happy with the advantage plans....they suit my particular needs but then I am basically healthy besides the arthritis stuff and I have saved a lot of money over the years.
I look at advantage plans as sort of self insuring... I can either maybe pay 20% if I have something I have to have done or I can for sure pay the regular supplement premium (which ain't cheap) to pay that 20 % for me. This year I have spent less than $350 total and the bulk of that was for the copay for the RFA procedure I had done on my back in January. My meds are included and cost me $3 a month with the plan.
My only real hurdle right now is the Bleep ports since Nationwide is out of network. So now I am going to put my local DME's feet to the fire and try to force them to supply it. Haven't had time to start that war yet but I will.

Did you see that next year the traditional supplements (MediGap plans) for Medicare won't be able to pay the Part B deductible for people??
I think I saw that somewhere but didn't dig deep.
https://www.elderlawanswers.com/congres ... ible-15094
https://www.senior65.com/medicare/artic ... ns-c-and-f

[Janknitz]

I wonder:
1) If the co-pays for perpetual rental are really low, because I just can't see the advantage plans paying over $4K for a CPAP machine. 2) Maybe the HMO's have some deal where they all buy the machines and the user is renting from them???

My husband is really pleased with his Kaiser advantage plan and it's paying off for him. On our incredibly expensive ACA plan we can't afford the deductibles and co-pays. For $25 per month for Kaiser Advantage he gets vision (we have none on our ACA plan), dental (he won't use it because there aren't any good dentists on the cheapass Delta Dental Plan), a free gym membership (saving him $100 per month he was spending before), and even some money toward hearing aids. He went to have his eyes checked and they found "freckles" on his retina so then he was referred on to opthalmology and had expensive testing we would not be able to pay for on our regular plan because the damn deductibles are so high.

Personally I don't mind having to buy my own supplies and eventually replace my machine since it means never having to hassle with Crapria ever again.

My youngest daughter will be going off our insurance around the time I'm eligible for Medicare and that will save us a lot, whatever plan I choose.