Choosing a mask

[Janknitz]

So circling back to the 'perpetual rental' issue - can you clarify with sample numbers, just to help me grasp this? Example - let's assume the DME (CPAP) is $1,000 and let's ignore supplies, etc. Insurance has a '20% copay'. So - 20% of $1,000 is $200. How much am I paying per month - $200/12 = $16.67/mo? And I pay that $16.67 per month, in perpetuity, as long as I am in possession of the machine ? So if I hold onto the machine for 5 years, I will have paid $1,000? So I would probably be better served by just getting the prescription from the doctor and finding a CPAP vendor independently - especially since that '$1,000' price is probably discounted by the vendor I choose.

I'm not sure what the co-pays are because I'm not on Medicare yet (one more year). For Traditional Medicare, Medicare determines the cost through a competitive bidding process. The cost is not the same as the retail price, it may even be MORE because of the 5 years of required maintenance and care and the documentation required. This is really frustrating--you can buy a machine for $600, but Medicare (plus your 20% and deductibles)will pay a DME $1200 for the same machine, meanwhile Medicare will not reimburse YOU for buying the same machine for a lot less, even though that would make sense and save Medicare money. Today our hosts at CPAP.com are charging $590 for a ResMed Airsense 10 Autoset.

Traditional Medicare pays 80% of the price they have set, the user (or their supplemental insurer) pays only the remaining 20% (there are some variations if you're not using a DME that accepts Medicare assignment).

I don't know how Advantage plans determine co-payments. Perhaps someone smarter than I will come along to tell us.

AND don't forget there is a DME deductible EVERY calendar year ($226 in 2023). If you don't own the machine, you might have to pay that deductible every year (not positive about this) with an Advantage plan. The 13 month capped rental for traditional Medicare was specifically designed to catch you for two deductible periods.

What you get on an Advantage plan is t 5 years of repairs, replacements if it cannot be repaired, and I'm not sure if they are constantly monitoring compliance or not. If you buy the machine on your own and it breaks down out of warranty you are out of pocket for repairs or replacements. But from what I've seen here, breakdowns are rare.

So it's not an easy calculation to determine which is best. I just don't want Kaiser owning me and my machine in perpetuity, so it's going to be worth it to buy my own machine if I stay with them and even on traditional Medicare I think I'd like not to have Medicare in my face for 13 months--with two deductibles and 13 months of co-pays I think i will still come out ahead financially.

[bwexler]

Traditional Medicare pays 80% of the price they have set, the user (or their supplemental insurer) pays only the remaining 20% (there are some variations if you're not using a DME that accepts Medicare assignment).

I don't know how Advantage plans determine co-payments. Perhaps someone smarter than I will come along to tell us.

Not smarter than you, but have been reading 2024 EOC from my current advantage plan and another that I am considering. There are only 76 plans listed in my area on Medicare.gov.
If I stay with my current plan I will own my oxygen concentrator after 13 copays (4 to date), but because my copay is less than some magic number I pay ZERO and I have no deductible. My BiLevel ASV is more expensive and would have 13 copays of about $80/month. I just started using my new to me used machine 2 days ago. I paid up front but I paid less tan the total of the copays. When I own my own equipment I am not locked into any plan from year to year.
The OTHER plan I am looking at has perpetual rental for DME. That makes them very unlikely to be my choice.

I have learned that every year every plan makes SUBTLE changes. The brag about the good, and are silent about the other. That is why I build a spread sheet every year estimating my likely usage and cost for each plan that Medicare suggests is near the top of the list as cheapest for me. Once I have done the homework I simply look at the totals and the star ratings. It becomes easy to determine that $100 is cheaper than $1,000.
Up until now my wife has been easy she just comes along with whatever I get. Now she will finally admit to need APAP and hearing aids. So I may need to do 2 spread sheets.

[ChicagoGranny]

I don't know how Advantage plans determine co-payments.

This varies from state to state and from carrier to carrier.

[Steerpike58]

So circling back to the 'perpetual rental' issue - can you clarify with sample numbers, just to help me grasp this? Example - let's assume the DME (CPAP) is $1,000 and let's ignore supplies, etc. Insurance has a '20% copay'. So - 20% of $1,000 is $200. How much am I paying per month - $200/12 = $16.67/mo? And I pay that $16.67 per month, in perpetuity, as long as I am in possession of the machine ? So if I hold onto the machine for 5 years, I will have paid $1,000? So I would probably be better served by just getting the prescription from the doctor and finding a CPAP vendor independently - especially since that '$1,000' price is probably discounted by the vendor I choose.

I'm not sure what the co-pays are because I'm not on Medicare yet (one more year). For Traditional Medicare, Medicare determines the cost through a competitive bidding process. The cost is not the same as the retail price, it may even be MORE because of the 5 years of required maintenance and care and the documentation required. This is really frustrating--you can buy a machine for $600, but Medicare (plus your 20% and deductibles)will pay a DME $1200 for the same machine, meanwhile Medicare will not reimburse YOU for buying the same machine for a lot less, even though that would make sense and save Medicare money. Today our hosts at CPAP.com are charging $590 for a ResMed Airsense 10 Autoset.

Traditional Medicare pays 80% of the price they have set, the user (or their supplemental insurer) pays only the remaining 20% (there are some variations if you're not using a DME that accepts Medicare assignment).

I don't know how Advantage plans determine co-payments. Perhaps someone smarter than I will come along to tell us.

AND don't forget there is a DME deductible EVERY calendar year ($226 in 2023). If you don't own the machine, you might have to pay that deductible every year (not positive about this) with an Advantage plan. The 13 month capped rental for traditional Medicare was specifically designed to catch you for two deductible periods.

What you get on an Advantage plan is t 5 years of repairs, replacements if it cannot be repaired, and I'm not sure if they are constantly monitoring compliance or not. If you buy the machine on your own and it breaks down out of warranty you are out of pocket for repairs or replacements. But from what I've seen here, breakdowns are rare.

So it's not an easy calculation to determine which is best. I just don't want Kaiser owning me and my machine in perpetuity, so it's going to be worth it to buy my own machine if I stay with them and even on traditional Medicare I think I'd like not to have Medicare in my face for 13 months--with two deductibles and 13 months of co-pays I think i will still come out ahead financially.

Yikes - what a mess! The good news is, this will be my only real medical expense and since I'm just coming off a VERY expensive 'exchange' (obamacare) plan (huge premiums and no DME coverage), paying even $200/mo for something isn't going to feel too bad. But I'd still rather know what I'm getting into, and make the 'buy on my own vs get through insurance' decision early.

I do know that with the Kaiser Medicare Advantage plan, they have a 20% copay for CPAP machines. And if we make a simplifying assumption just for the sake of this discussion that the CPAP machine is $1,000 (the price Medicare has agreed with the DME), that suggests I'm on the hook for $200. Given what you have posted up above (from the Kaiser MA plan EOC you posted), this would be paid monthly and in perpetuity, so $16.67 monthly or $200 / year forever. And since the DME deductible is $226, I'm not going to hit the deductible. If the most I have to pay is $200/year forever, that I can live with. Now, it's looking like I'm going to need an ASV as opposed to a CPAP, which sounds like 2x or 3x the price of the CPAP - but then, would the deductible kick in and still limit me to the $226 / year level?

[Janknitz]

I don't know about whether the deductible would kick in for the ASV, but the ASV is probably a higher monthly co-pay. Still, that might be a better deal than buying an ASV out of pocket, UNLESS you can find one for a good price, i.e. from our member LSAT.

I think under federal law, health care providers are supposed to tell you what your out of pocket costs are going to be now. But they may not have to tell you until you are already on an advantage plan.

There's an agency called HICAP--Health Insurance Counseling and Advocacy Program (in other states, this is called SHIP). This is a federally funded Medicare counseling service--no cost to you, and they do NOT sell insurance. They may be able to answer your questions. In California call 1-800-434-0222. Another place to look for this number is on the back of your Medicare and You booklet everyone on Medicare or about to be on Medicare gets in October, and the number is also posted for your state on www.MEDICARE.gov. I think they may be able to answer all these questions.

[bwexler]

I do know that with the Kaiser Medicare Advantage plan, they have a 20% copay for CPAP machines. And if we make a simplifying assumption just for the sake of this discussion that the CPAP machine is $1,000 (the price Medicare has agreed with the DME), that suggests I'm on the hook for $200. Given what you have posted up above (from the Kaiser MA plan EOC you posted), this would be paid monthly and in perpetuity, so $16.67 monthly or $200 / year forever. And since the DME deductible is $226, I'm not going to hit the deductible. If the most I have to pay is $200/year forever, that I can live with. Now, it's looking like I'm going to need an ASV as opposed to a CPAP, which sounds like 2x or 3x the price of the CPAP - but then, would the deductible kick in and still limit me to the $226 / year level?

I am in the middle of evaluating what to do for 2024.
I currently have Medicare Advantage from Alignment in San Diego. I have had a variety of issues over the past few months, so I got connected to a senior concierge specialist. She has actually helped make some things happen.

One of the things she did was to contact my only in network DME and get a real estimate of my cost for a new Resmed Aircurve 10 ASV. It was about $80/month for 13 months, then I own it. That should provide a reasonable guesstamate of cost for your ASV machine. If you stay with Kaiser that would certainly meet your annual deductible.
I have personally been involved with Kaiser on and off since I was a kid. I have seen several cases where someone has died or Kaiser "recommended" to withhold care and allow them to die. One of these was my wife's brother. She told Kaiser to find another specialist, he lived at least 6 more years. Another was a friend who asked me to help him reconcile about $80,000 worth of bills from the hospital that saved his Wife's life after Kaiser advised him to take her home and let her die. The last time I saw them was about 10 years later at a local casino buffet.

My advice to you is to go to Medicare.gov and look for the top choices for you as selected by Medicare. Look at advantage plans, look at Medigap plans, look at drug plans. This is what I do every year and I build a spread sheet to estimate my total cost of each of those top choices. Then I glance at the star ratings and any other info I can find on the plans I am considering. Picking the right choice for me becomes easy at that point. I am now doing this for the 14th year.

I really wanted to make a change this year because of several reductions in benefits. but so far it appears that every other choice is still not competitive for various reasons.

[Steerpike58]

...
There's an agency called HICAP--Health Insurance Counseling and Advocacy Program (in other states, this is called SHIP). This is a federally funded Medicare counseling service--no cost to you, and they do NOT sell insurance. They may be able to answer your questions. In California call 1-800-434-0222. Another place to look for this number is on the back of your Medicare and You booklet everyone on Medicare or about to be on Medicare gets in October, and the number is also posted for your state on www.MEDICARE.gov. I think they may be able to answer all these questions.

Someone already mentioned HICAP, and I've talked to them - VERY helpful indeed! Biggest thing I learned was that in CA, there are many ways you can get back into a MediGap plan without underwriting, even if you have been on an MA plan for years. (Example - UHC in our area are dropping the local hospital group (IPA - Independent Practice Association) from the MA plan coverage, and that automatically entitles you to join a MediGap plan. Another example - if Kaiser were to raise their MA plan rates by a small percentage, that would trigger the ability to join a MediGap plan without underwriting. He said this was a CA-specific thing, lots of consumer protections here). But sadly, he said he couldn't help me with DME specifics. Note that HICAP seems to be county based, so I had to dig to find the HICAP number for my county. But was really, really informative!

...
I have personally been involved with Kaiser on and off since I was a kid. I have seen several cases where someone has died or Kaiser "recommended" to withhold care and allow them to die. One of these was my wife's brother. She told Kaiser to find another specialist, he lived at least 6 more years. Another was a friend who asked me to help him reconcile about $80,000 worth of bills from the hospital that saved his Wife's life after Kaiser advised him to take her home and let her die. The last time I saw them was about 10 years later at a local casino buffet.

My advice to you is to go to Medicare.gov and look for the top choices for you as selected by Medicare. Look at advantage plans, look at Medigap plans, look at drug plans. This is what I do every year and I build a spread sheet to estimate my total cost of each of those top choices. Then I glance at the star ratings and any other info I can find on the plans I am considering. Picking the right choice for me becomes easy at that point. I am now doing this for the 14th year.

I really wanted to make a change this year because of several reductions in benefits. but so far it appears that every other choice is still not competitive for various reasons.

I have no love for Kaiser and don't plan to stay with them any longer than I have to; I just want to see this sleep study through to conclusion (they just gave me a date of 12/21 for the study). Some people really do like them. Interestingly, they always seem to get VERY good ratings (star ratings); I presume that's because they are cheap and most people will vote for them because of that!

[ChicagoGranny]

Interestingly, they always seem to get VERY good ratings (star ratings); I presume that's because they are cheap and most people will vote for them because of that!

No, it's because Kaiser lets the ones that don't like them die.

[Janknitz]

I have no love for Kaiser and don't plan to stay with them any longer than I have to; I just want to see this sleep study through to conclusion (they just gave me a date of 12/21 for the study). Some people really do like them. Interestingly, they always seem to get VERY good ratings (star ratings); I presume that's because they are cheap and most people will vote for them because of that!

My husband thinks Kaiser is great. They've been pretty responsive to him--exception for an Orthopedic "triage" ON LINE exam when they asked him to hold up his hand to the camera and concluded that ally the symptoms that point to a particular diagnosis can't be that diagnosis.

But in my professional life I see terrible things they do to seniors to save a buck. And when my daughter was little needed therapy and orthotic devices, every time it was a fight when they would try to tell me they didn't cover X and I would have to point out that is NOT what's in the EOC. They would still deny things and I had to go to higher levels of appeal.

I can advocate for my husband and my daughter, but who will advocate for me?

[chunkyfrog]

. . .
but who will advocate for me?

We need advo-coops.
Imagine a cooperative of medical ombudsmen who eventially need help themselves.
Why not?

[Janknitz]

We need advo-coops.
Imagine a cooperative of medical ombudsmen who eventially need help themselves.
Why not?

That's a really good idea!

I grew a doctor (pediatrician) who hopes to work for Kaiser (she's a very "in the box" thinker). I can't imagine her advocating for me if this is her employer. UGH!

When I worked in health care I could never have worked for them.

[ChicagoGranny]

I grew a doctor

How deep did you plant her?

[Scois67]

I wanted to share my experiences with dealing obtaining an ASV CPAP machine under the Kaiser Medicare Advantage Program utilizing the Kaiser Martinez California sleep lab and Walnut Creek physician. As a new sleep Apnea patient I found the experience overwhelming and i am trying to still comes to grips with it. Thanks for the contributors to this thread, they really helped. Aside from the issues with Apria customer service and billing practices the lack of transparency in the whole process was difficult to come to grips with. Being told your machine has been ordered and you have no one explaining the rules and costs associated with the arrangement was difficult to deal with if you are the kind of person that likes to nail down specifics with some degree of certainty and accuracy. The perpetual rental arrangement is particularly difficult to swallow, especially as I plan to move to an area that is not served by Kaiser within the forseable future.

All of the Kaiser people i dealt with were super nice and tried to be helpful within the limits of the constraints they were working under. They have heard all the complaints about Apria and their program and seem to be sympathetic to the patient. They know what a mess it can be.

I had three in facility sleep tests. Two in Martinez, one with an independent contractor facility Kaiser uses. The end result was that the physician recommended an ASV machine. He told me he ordered it and almost exited our discussion before talking costs. He explained the perpetual arrangement of payments over thirteen months. He did not know the monthly costs of the machine noting the variation in types of plans.

Next morning i called the Martinez sleep study facility and asked for costs. They declined to give any costs and referred me to customer service. I also requested a copy of the prescription for which i was told to contact the physician. I was told the equipment was being sent to my home and would arrive in four to six weeks. An appointment was set up for 30 days latter to go over the gear. Before exiting the conversation i asked what had been ordered on my behalf from Apria. I was told by the sleep center the following equipment had been ordered: ResMed Air Curve 10 ASV with Humid Air, ResMed Airfit P10 pillow, tubing and filter.

I called Kaiser customer service and they used their line to call Apria to obtain costs. We were connected in 15 seconds. Apria could not give any costs as they had not received the prescription yet from the physician. The Apria representive estimated an inaccurate amount of $300/month for the CPAP. She also explained the shipment process. Three calls are supposed to be made to the patient to obtain approval from the patient for shipment. Fees are discussed at that time. She was ambiguous as to whether a written confirmation of fees is sent to the patient. If the patient does not respond to any of the calls the order is placed in a suspended status.

I then contacted the physician for a prescription. The next morning I received an emailed pdf prescription with a hard copy coming in the mail. The prescription was well prepared and provided options for me to select my own mask and obtain an Equivalent Responics ASV unit.

Two hours latter the local Apria office representative contacted me on my cell phone and said he wanted to discuss the machine with me. I wasn't clear if the machine was available now or not. I told him to cancel the order. Feeling that I had not gathered all the information I needed I stopped by the Apria office and interacted with the Apria representative via the receptionist. I learned that he had called to seek approval for a $134.50 "setup fee" I had never heard of that. The monthly invoice for thirteen months useage of the AirCurve 10 ASV with humid air was $80 per month under the Kaiser Medicare Advantage program. No additional costs were asked about.

I had decided to purchase the ResMed AirCurve 10 ASV outright. I may have underestimated the costs of buying the ASV unit as it is proving difficult to source a reduced price on the unit. It does not seem to receive that same price considerations in the open market that the Airseries 11 and 10 receive.

[ChicagoGranny]

What a morass! Typical for CPAP equipment.

I would like to suggest one thing. Give the HCPCS code for an ASV machine to your insurance company. Ask them what your part of the cost is. Which state are you in? Unfortunately, not all states have outlawed balance billing. Balance billing is when the DME can charge the patient with the difference between the insurance benefit and the billed price.

For the ASV, the HCPCS code is,

E0471

Respiratory assist device, bi-level pressure (BiPAP) capability, WITH backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

Good luck!

[bwexler]

Scois67

The information you have received so far all sounds plausible.
Things you MUST insist on include receiving a complete detailed copy of all sleep study reports, you already have your prescription. You may need all of the above for years to come and for situations you may be totally unaware of today.
NEVER provide any credit or debit card information to Apria or any DME that deals with your insurance company. Doing so would be like posting it on a billboard on the side of US 101 or I 5.
I have found the best way to pay DME bills is to use the bill pay function on my checking account. That way there is no way for the recipient to post recurring bills without you explicit involvement.

ASV machines list for over $4,000. Not all DMEs will stock or provide them. I have bought 2 used machines from members on this forum, and am happy with both transactions. Second wind is another source that has a good reputation here. Last time I checked CPAP.com does not deal with ASV machines.

Food for thought. you might do the rental through Kaiser while you are researching what insurance you will have in 2024, and where you choose to acquire your permanent machine. That can take the pressure off in the short term for a relatively small amount of cash.
Don't forget to post your credit card info on a billboard.