I want to scream!

[Emilia]

I chatted with a cousin today who is a pharmacist and she said pretty much what jules has said here. They may very well say I can have the best machine but that they will only cover what they would normally cover for their 'vacuum cleaner' -- leaving me the balance. With what they charge, that may be far more than just buying out of pocket.

Believe me, it wasn't my idea to have an HMO! Over my years as an educator, I watched our benefits package get worse and worse. When I retired from the system, I had to take what they provided to the employees, and that has deteriorated over the last 6 yrs. as well. Recent newspaper articles seem to indicate it will be even worse come Jan. I have considered this, too --- if the coverage changes as of Jan. I would be in limbo again with this therapy. Another reason to consider just buying outright at this time..... I have another 5.5 yrs until Medicare when my local benefits will cease.

I am not giving up just yet..... I will see what transpires for the next few days first.

[GumbyCT]

I chatted with a cousin today who is a pharmacist and she said pretty much what jules has said here. They may very well say I can have the best machine but that they will only cover what they would normally cover for their 'vacuum cleaner' -- leaving me the balance. With what they charge, that may be far more than just buying out of pocket....

I am not giving up just yet..... I will see what transpires for the next few days first.

This is where you may find that it is in fact cheaper to just buy from cpap.com and get your supplies from the EMP group.

Do your homework so you know when you hear their numbers, do NOT wait.

[jules]

get what they offer you, meet their compliance criteria and then use it as a backup / travel / use with batteries during outages machine and get what you want at cpap.com

some ppl do okay with HMO - we see stories where they don't - the red tape is horrendous - some even lose with non- HMO's not very often but it happens

when I started working in LOL (land of lincoln) we were promised if we put in our 20 years (state university employee) we would never have to take medicare - I don't have the quarters - but I will have to take it when I reach that magic age (and use my husband's SS info for it) or I face major penalties - I can't get half of his SS $ for a spousal benefit as I have my own government pension but I have to use his info for insurance - I am pissed about that as then I have to pay for Medicare B and all - now my insurance premium is paid in full as a benefit - yeah the coverage goes down and the copays go up but .....

[Emilia]

Jules -- I have a friend who is a retired Ill teacher. Her district never participated in SS and with the state pension fund in dire straits she is panicky. She moved to FL a number of years ago, and now is trying to earn enough SS credits via adjunct work at a local college to get a little something. It is just a travesty.... I think I've read that Illinois's pension fund is in the red big time.

I was thinking along the lines of what you suggested. Get what they offer and have that as my backup machine. I've gathered compliance is a hit or miss thing from what folks report here. If I were to buy a good machine out of pocket, I wonder if I can use that info for compliance data rather than from the basic machine that I foresee coming my way. Using them for the supplies is a given... I am entitled to a new mask every 3 mos.; filters, hose (for their machine, not mine)..... and it is covered at 100% so I will definitely take advantage of that.

[jules]

it isn't just the pension funds - look at this letter about our insurance - how far behind they are

http://www.state.il.us/cms/download/pdf ... _Delay.pdf

and if a doc wants his/her money we got to pay them and hope they reimburse us promptly when they get their money from CIGNA - had one who accepted assignment then balked and wanted it NOW and that was a hassle getting his office to send me the money when they got paid

and businesses in IL are hurting too - social services - anything that depends directly or in the first few links in the chain on state money

[Emilia]

it isn't just the pension funds - look at this letter about our insurance - how far behind they are

http://www.state.il.us/cms/download/pdf ... _Delay.pdf

and if a doc wants his/her money we got to pay them and hope they reimburse us promptly when they get their money from CIGNA - had one who accepted assignment then balked and wanted it NOW and that was a hassle getting his office to send me the money when they got paid

and businesses in IL are hurting too - social services - anything that depends directly or in the first few links in the chain on state money

Good grief! It is like a crap shoot.... go to the doc or dentist, pay up, and you might get reimbursed with they have the funds at that time!!

[jules]

yep - the delay has been pretty consistent in the time I have watched but then if the doc/dentist accepts assignment then whines we want it now and you pay, they don't pay you back in a timely manner and their ppl get rather nasty when you ask politely for YOUR money back after waiting - hell they got paid on time, why can't they give it back to us without us waiting another few months - sorry but I have had to deal with just this - most offices have been nice and will wait but .......

[SleepingUgly]

Isn't it a matter of how hard the doctor is willing to fight to get you the machine you want?

[Kevin G.]

Would suggest that if the delay in obtaining the equipment is unreasonable, you define unreasonable, then you write a letter to your employer, the insurance company, and the firmhandling the process stating that the delays are unreasonable and are delaying your treatment and putting you at additional risk. Note that if prompt action is not taken that you will file a complaint with the state agency regulating insurance companies. Copy your physician.

[rosiefrosie]

So, has anyone seen Sicko?

[mattman]

Isn't it a matter of how hard the doctor is willing to fight to get you the machine you want?

Yes and no. It mostly depends upon how the actual contract the Insurance Company writes up is worded. And pure HMO plans - in my experience - have tended to be the most restrictive and difficult. I have seen HMO plans that specified not just how the amount you bill them and the amount they will pay you but then also the exact make and model of machine you will provide the patient and exact supplies you will provide.

Put into the scenario laid out in this thread, if a patient has an RX that is written for a specific make or model of CPAP other than what the HMO spells out OR if the patient simply wants something different there are 2 choices:
1) Go back to the prescribing doc and request a new Rx that's just generic 'CPAP at x pressure' and take what the HMO provides
2) Go through the HMOs Medical Review/Non-standard request/whatever they call their special process and try to get something different approved. Just be aware it usually takes months and is immensely time consuming.

Also remember many HMOs will specifically disallow "upgrading" or "upcoding" where, say, a provider bills for the El Cheapo brand device the HMO allows, provides the patient with an upgraded model and bills the patient the difference. It varies wildly of course, but HMOs are where I've seen that prohibited the most. Trying to get a patient into an APAP when the plan only covers a CPAP is the most common reason for trying this.

mattman

[akcpapguy]

So, has anyone seen Sicko?

Wasn't that a film adaptation of an autobiography?

[akcpapguy]

I was thinking along the lines of what you suggested. Get what they offer and have that as my backup machine. I've gathered compliance is a hit or miss thing from what folks report here. If I were to buy a good machine out of pocket, I wonder if I can use that info for compliance data rather than from the basic machine that I foresee coming my way. Using them for the supplies is a given... I am entitled to a new mask every 3 mos.; filters, hose (for their machine, not mine)..... and it is covered at 100% so I will definitely take advantage of that.

If you decide not to take the machine they offer (not sure why one wouldn't especially if it's covered 100%) as a backup and purchase your own from an online supplier only. Call your HMO manager and ask if they will still cover your supplies thru the local DME, you MAY find that they won't. As jules has stated, HMO's operate off a different set of rules, so it's always worth calling and asking.

[Emilia]

If you decide not to take the machine they offer (not sure why one wouldn't especially if it's covered 100%) as a backup and purchase your own from an online supplier only. Call your HMO manager and ask if they will still cover your supplies thru the local DME, you MAY find that they won't. As jules has stated, HMO's operate off a different set of rules, so it's always worth calling and asking.

The ongoing saga.....

1. EMP called me today (!) to let me know they had forwarded the Rx for the AutoCpap to BCBS for medical review
2. I asked EMP if, hypothetically speaking , I decided to buy my own machine if they would still provide my supplies. Answer: YES
3. Since EMP only supplies cpap and bipap machines (no Autos at all !!..and she could not tell me why) she said it will be up to BCBS to decide if they will approve the Auto, and if so, delegate that to another supplier; however EMP will continue to provide all supplies. So the ball is in BCBS's court at the moment.
4. If they deny the Auto, I assume they will set me up with a cpap, and I will find out what the compliance requirements are for that and if I want to bother with it in order to have it. I suppose it would be a decent backup machine to have after the 13 mo rental period is over. I just don't know if I want to deal with having to meet their compliance on a subpar machine. Decisions, decisions.....

So.... I will call BCBS and dog them on the process. If it appears it is going nowhere fast, I can buy my own machine and know I can still get my masks, hoses, and filters for free from EMP. Good to know that much at least!

[jules]

have you asked EMP what machine they would issue you if you got it from them?

get the manufacturer and model name / number

in other words what is all the headache and frustration about? what model would you get from EMP versus the S9 APAP