obtaining cpap rx from Kaiser

[dconeill]

I have Kaiser/Medicare health insurance, and had Kaiser before that when I was working. I've used a CPAP machine for years, and it was time to get a new one. This time around, Kaiser referred me to a company called APRIA to rent, per medicare rules, a new machine. Having read up on Apria, I decided I'd rather just purchase a new CPAP machine on the open market.

Kaiser refused to issue me a prescription for a CPAP machine, only to refer me to Apria. Specifically, across two months of trying, Kaiser ignored my queries and never responded. I emailed my primary care physician twice, had a telephone consult with him once, communicated with a sleep medicine physician there, and corresponded several times with one of the staff of the sleep medicine department. No responses about my request for a prescription so I could go to the open market.

I'm about to capitulate in order to get a new CPAP machine, though it will cost me more out of pocket than just purchasing it would. I'm unhappy with this situation and can see no reason why Kaiser wouldn't issue me a prescription.

I'd be happy enough to pay for the CPAP machine myself, out of pocket and not using insurance. Anybody have any suggestions for shaking loose a prescription for such a machine from Kaiser?

[Julie]

Unless your MD has a deal with Medicare (or Crapria), I would think he has to give you a script... but officially, any NP, dentist, plus others I don't know (others in US will) can do it for you if you can tell them what you need and they agree to do it... Get a Resmed Airsense 10 Auto - it's compatible with Oscar and is the best, but 11's may be available now too.

[zonker]

I have Kaiser/Medicare health insurance, and had Kaiser before that when I was working. I've used a CPAP machine for years, and it was time to get a new one.

by law, that rx is YOURS and i'm uncertain why they are being bulky idiots about it.

if you have the time and the inclination, you may have to show up in person to talk to someone there who will cooperate.

good luck!

[Miss Emerita]

FWIW, my primary care physician in Kaiser is happy to write a scrip for me to purchase a machine outside the Kaiser system.

[chunkyfrog]

Good luck.
The Kaiser reluctance sounds ILLEGAL.
Talk to Medicare about their trying to push you into working with Apria.
Raise a fuss. It is your RIGHT TO FIGHT.

[Pugsy]

Kaiser's Medicare is a type of Medicare Advantage plan.....I think
They very well could try to push Apria...like a HMO thing.
Remember Kaiser is an HMO and they often set their own rules and regulations
BUT....if a patient requests copies of their records and the RX is part of the records....by law they have to provide it.
No one is exempt from that particular law.

Formal registered letter requesting such records...gets it in writing and they have to comply.

[zonker]

Formal registered letter requesting such records...gets it in writing and they have to comply.

oh! most excellent point.

i keep forgetting my basic clark howard 101.

[SleepGeek]

Anybody have any suggestions for shaking loose a prescription for such a machine from Kaiser?

As mentioned you should request your equipment order (and a copy of your sleep study) in writing - but request it from both Kaiser and Apria, they both have it.

Since Open Enrollment is coming is a few weeks, I would drop Kaiser like a hot potato. With good ol' Medicare you have many more choices where to go and will have far fewer hassles.

[clownbell]

Interesting -- this is exactly the opposite of my experience with Kaiser. Perhaps it has to do with what part of the country you are in. I am in Northern California, on Kaiser Senior Advantage which is a contract with Medicare. I contacted primary care doc at Kaiser and said my wife observed me gasping for air after not breathing a while, something of which I was aware. Primary care doc referred me to the local Kaiser sleep center, which had me pick up a testing machine (WatchPat I think). I used the machine at home overnight, returned it to Kaiser, and they responded with a report in three days indicating I had sleep apnea. They issued me an AirSense 10 AutoSet from what seemed to be inventory they keep on hand, and I paid 20% of the cost as Medicare requires anyway. This was a straight-up purchase, not a rental. My contact with Apnea has been to order expendable supplies. Easy peasy. Later on I either read or was told that Kaiser is its own DME and Apria is just the fulfillment center.

Bottom line - I can't imagine why OP's primary care doc would ignore your request.

Maybe the best thing is to contact the dentist or an NP who can write the prescription.

One last item -- if OP is a vet, the VA will take care of this on request. You may need to sign up for VA medical care, which is an easy process. OP does NOT have to obtain all care from VA, can choose to obtain only sleep apnea care.

[Grumpy48]

*********** snip************

Bottom line - I can't imagine why OP's primary care doc would ignore your request.

Maybe the best thing is to contact the dentist or an NP who can write the prescription.

One last item -- if OP is a vet, the VA will take care of this on request. You may need to sign up for VA medical care, which is an easy process. OP does NOT have to obtain all care from VA, can choose to obtain only sleep apnea care.

I've seen the suggestion to have any doctor, NP, or dentist write the prescript a few times. I understand that they could, but don't they need to have the results of the sleep study to be able to do this? They would need to know the type of CPAP machine to prescribe as well as the pressure settings. The patient likely may not know this information. The patient may be able to get the prescript/medical information transferred to a prescribing physician, but from my own experience (not CPAP related) may need to sign a records release with who has the original records to allow the records/information to be transferred.

Excellent suggestion for the VA Healthcare if one can qualify. I applied for VA health coverage as a backup to my regular Medicare supplement plan, but the level of my retirement income was sufficiently high enough that the VA rejected my application. Not sure of the threshold of income.

From a bit of Googling it seems Kaiser has some very close ties to Apria and Apria appears to have physical locations within some Kaiser facilities. I could see how a Kaiser doc would try to steer business towards Apria with a close business relationship.

I believe the attached image would be typical of the prescript and information that may be required(?) Mine was similar that I recall.

[clownbell]

@ Grumpy48 - Although I'm no expert, I believe that VA may have changed their rules in recent years. I used to have too much income to be able to qualify, but I qualify now although income has not changed. Maybe you have Buffet-Gates income levels, who knows?

Of course, the prescriber could prescribe settings of 5-20 and then the patient could self-titrate using the guide in the Apnea Board wiki -- Optimizing Therapy - Section 4.

[SleepGeek]

From the OP:

I've used a CPAP machine for years, and it was time to get a new one.
...
Anybody have any suggestions for shaking loose a prescription for such a machine from Kaiser?

[Janknitz]

A couple of things:

Since Open Enrollment is coming is a few weeks, I would drop Kaiser like a hot potato. With good ol' Medicare you have many more choices where to go and will have far fewer hassles.

The problem with that idea is that the OP may be able to drop an advantage plan but may not be able to get a traditional Medicare supplement anymore.

Once you’ve left your Medicare Advantage plan and enrolled in Original Medicare, you are generally eligible to apply for a Medicare Supplement insurance plan. Note, however, that in most cases, when you switch from Medicare Advantage to Original Medicare, you lose your “guaranteed-issue” rights for Medigap. You generally have guaranteed-issue rights for six months when you are both 65 or older and enrolled in Medicare Part B. Guaranteed-issue rights ensure that you can buy any plan sold in your state, and that you won’t be charged higher premiums based on your health status.

Without guaranteed-issue rights, your insurance company may require medical underwriting before it sells you a plan. During medical underwriting, the insurer looks at your past medical history and current health status. If the company determines the risk of covering you is too high, it can refuse to sell you the plan you want, or it may charge you much higher premiums for the coverage.

https://www.ehealthmedicare.com/medicar ... o-medigap/

A stinky surprise!

Clownbell said:

They issued me an AirSense 10 AutoSet from what seemed to be inventory they keep on hand, and I paid 20% of the cost as Medicare requires anyway. This was a straight-up purchase, not a rental. My contact with Apnea has been to order expendable supplies. Easy peasy. Later on I either read or was told that Kaiser is its own DME and Apria is just the fulfillment center.

If you are on Kaiser Senior Advantage, my understanding is that you pay a perpetual rental EVERY MONTH for the life of the machine. The outright purchase is for non-Sr. Advantage Kaiser members that have a plan that covers DME. It may be that you are still getting your supplemental coverage under an Employer Group Health Plan rather than straight Senior Advantage. But most Kaiser Senior Advantage people are now stuck paying every month for life.

My contact with Apnea has been to order expendable supplies. Easy peasy

Make sure you are getting what you really ordered, they like to swap out for cheaper versions--e.g. a stiff, heavy hose instead of the lightweight performance hose that costs a few bucks more, even though my order specified the Performance Hose. And check your billing. My experience with Crapria was that EVERY bill was incorrect. I appealed an Aprial bill through Kaiser once, lost the appeal, and 6 months later their own internal audit proved my appeal was correct and I got a check. I celebrated the day I lost my Kaiser DME coverage (on an ACA plan) because I don't have to deal with Crapria any more.

Turning 62 very soon and starting to wonder if I want to stick with Kaiser for my Medicare when I turn 65. They are good in some ways and suck in others. But the availability and delivery of care "out there" has turned out to be pretty bad, too. Having to deal with Crapria again may be my deal breaker.

[backpacker]

I am on the Kaiser Medicare Advantage plan here in the Denver area as is a friend of mine. She was diagnosed with OSA after doing there at home sleep study. Over a two month period she was not able to get the CPAP machine to work for here. She had rented it from Apria as it was Kaiser's supplier. At the end of the two months she returned the CPAP to Kaiser but kept (and paid for) the water reservoir, hose, masks (she tried several) and headgear. All of her transactions were done over the phone or via email to Kaiser.

Then I was diagnosed with OSA, Learning from her experience, I had an appointment with the Doctor and a Tech (there was a copay) to discuss the results of the sleep test and to get fitted. I tried several masks and settled on the N20. I was also given the option of buying or renting for 13 months. Not knowing how well it would work for me I chose to rent. I went home with the Airsense 10 Auto, heated hose, N20 mask and headgear and two filters all in a case. After less than 2 weeks I was sold. I emailed Kaiser and changed from rent to purchase. Note: the sum of the rental payments equaled the purchase cost. This was done and in due course I received a bill from Apria for the equipment purchase cost plus 1 months rental.

So pay the copay in order to try on several masks, get properly fitted with a mask, and receive instructions on the care and feeding of the machine. Rent at first so you can return it easily if it doesn't work out for you . My friend gave the masks, hose, and reservoir to me and another friend of hers that also uses a CPAP.

When Apria sent me the bill I paid by check but also crossed out all of the verbiage about letting them send me supplies on a monthly basis. When I needed some supplies I called them up, ordered what I needed, and was given the option of receiving a bill or paying by credit card. I chose to charge it. I received everything about 4 days later.

hope this helps

[SleepGeek]

When I needed some supplies I called them up, ordered what I needed, and was given the option of receiving a bill or paying by credit card. I chose to charge it.

First mistake is never, ever give Apria a credit card, for any reason. Tell them you don't have one or IF you must -- give them a Pre-paid card. When they screw up the billing you will understand.

When you get a copy of your equipment order in your hand You can always order any supplies from someone else.
Make sure for the mask it says "Mask of Patients Choice"

I also think I would have left it on the rental rather than forfeiting the rental money but that's me and given the choice I would not do business with them to begin with.

Since Open Enrollment is coming is a few weeks, I would drop Kaiser like a hot potato. With good ol' Medicare you have many more choices where to go and will have far fewer hassles.

To OP:
IF you go on traditional Medicare do you need MediGap?
Remember Open Enrollment is coming only a few weeks away.

Think of it this way - you will kill two birds at once and hit a HomeRun!
You can pick up a co-pay to pay the 20% if you want but traditional Medicare you won't need referrals.

Start the New Year off on the right foot.