I'll need to digest most of this over time, but a quick question is - is it generally worth it trying to work through all this, or should I just ignore the whole 'insurance' thing and go out and buy what I want 'commercially'? I don't tend to meet my deductible each year, and I'm willing/able to pay out of my own pocket if it means getting what I need/want. By way of examples - my partner wears hearing aids. She simply buys the best model available at Costco and doesn't even consider insurance. She said the models that insurance is willing to assist with are not good enough. Another example - I needed an MRI not long ago. 'Insurance rates' for various MRI's were circa $2,000 at the 'insurance billed' rate (which wouldn't get covered since I hadn't met my deductible). I called around and got 'cash prices' for MRIs that were in the $500 range. So I simply got my MRI 'commercially' and paid cash. Money spent did not contribute towards my deductible but I didn't care. So - for a CPAP machine - can I potentially buy a good machine at a 'cash price' (no insurance) that is significantly lower than the 'list price'/'book' price that the 'insurance' route would involve? Obviously, getting '80% paid' sounds attractive, but if it's 80% of an inflated price, and/or limited to only basic machines, should I just 'go outside' the system? And - "Can" I go outside the system, or am I forced to work within the 'system'?Pugsy wrote: ↑Mon Jul 31, 2023 8:20 pmHere's some information on how Medicare does things when it comes to cpap equipment.
Medicare approves an allowed amount for whatever equipment and if deductible has been met will pay 80% of the ALLOWED amount. Please note that the allowed amount and the billed amount is usually entirely different.
DMEs/doctors bill out the pie in the sky amount and Medicare reduces that billed amount to the ALLOWED amount and pays from that amount. Your portion (or your secondary supplement insurance portion is 20% of the billed amount.
Medicare actually pays by the HCPCS billing code numbers.
Not by brand name or model name.
Most likely you will be given some sort of regular cpap/apap machine which is the E0601 code.
Doesn't matter the brand or model...Medicare ALLOWS the same amount for fixed cpap or auto adjusting capapable/apap machine. Doctors/DMEs usually choose and usually they want to dispense the brand and model that makes them the most money because remember....Medicare is going to pay the same no matter if it is a compact car or a big old caddy.
Now you can get around them choosing by asking your doctor to write the order for so and so brand and so and so model and then sign it with "dispense as written"...then the DME/supplier can't substitute a "cheaper" machine.
Typically regular Medicare does a 13 month capped rental so the payments are spread out over 13 months and then you own it and no more monthly payments. There are also some compliance usage requirements that have to be met for Medicare to pay....like a face to face with the doctor before the 90 th day of use and a certain minimum number of hours it needs to be used during that 90 day time period. The requirement is 70% of a consecutive 30 day time frame that you use the machine at least 4 hours. So 21 out of 30 days you need to use the machine at least 4 hours.
Be careful with Medicare Advantage plans....they will do the allowed amount as well but a lot of them are going to what we call a perpetual rental thing (not all of them will do it though) where you have to pay the 20% co pay forever and never actually own the machine. Be sure and check the Evidence of Coverage for any Medicare Advantage plan you might be thinking of. You will have to ask for this document....it's not usually part of the sales brochure stuff. I have a Medicare Advantage plan...when I first got it years ago it did the 13 month capped rental thing but a few years ago it changed to perpetual rental.
https://www.sleeprestfully.com/HCPCS/BTW a lot of insurance companies (non medicare) still use the general Medicare equipment allowance schedule and that all use HCPCS billing codes.CPAP/BiLevel Michine HCPCS Codes:
E0601 Continuous airway pressure device (CPAP/APAP)
E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
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In my case, I seemed to have no problem using the 'nasal mask' - I was able to keep my mouth closed all the time - apparently! But - what I'm getting at is - since I'm experiencing 'nose blockage' problems, I guess I could switch to a full face mask and then try to train myself to OPEN my mouth (not keep it closed, which I'm already comfortable doing). It's the opposite of what I was thinking, but perhaps a way I should proceed given my nose issues. Hopefully I'm making myself clear!Pugsy wrote: ↑Mon Jul 31, 2023 8:20 pmNo, full face masks are for people who can't breathe just through their nose and keep their mouths shut.Steerpike58 wrote: ↑Mon Jul 31, 2023 7:47 pmI was assuming the full-face mask was there mainly for those who couldn't keep their mouths closed from a 'pressure' perspective,
Has nothing to do with the pressures at all.
Mouth opening breathing can allow the air pressure to escape out the mouth and fail to proceed down the airway and this can cause sub optimal therapy because adequate pressure isn't maintained.
You might be able to "train" yourself to keep the mouth shut but only if you can get comfortable just breathing through your nose all night. It's not so easy though but it can be done or at least limited to very minor mouth breathing with a nasal mask and not a full face mask.