Medicare coverage for xpap - questions ???

[Bright Choice]

I have been on an S9 autoset paid out of pocket because first psg didn't qualify me for Medicare. I finally had a series of sleep studies that met Medicare guidelines for coverage. RX is for S9 ASV w/h5i / climateline / Quattro ffm and Rem zzz's.

I have not been dealing with DME so I want to be prepared for any surprises and want to know exactly what Medicare will cover and what they won't. I was surprised that clinic told me that Medicare would cover Remzzz.

The person on the phone at DME made me a bit nervous because she was questioning my prescription and whether or not I had "failed" other therapies. She said, "You know, that's a very expensive machine." My very detailed paperwork includes a diagnostic PSG and then 2 nights of titration - which I "failed" all the way through to ASV. So, I should be ok on that point but they still made me nervous. What kind of stunts might they pull on this one?

How does the "rental" work with ASV's - should I expect that it would be the same as with any other xpap. Someone at the clinic mentioned that Medicare might just do a straight rental - do you know?

Also, how does the mask replacement work - what is the frequency? I am not sure that I am going to like the Quattro so am going to get an RX for "whatever facemask patient prefers". Are there other items covered by Medicare that I am not aware of?

And finally, how does the warranty work? Resmed's warranty would be 2 years - what does Medicare do if it breaks down before the 5 year period is up?

Thanks for your help!

[6PtStar]

My understanding on Medicare coverage of a BiLevel or ASV you had to fail CPAP before they would pay for a BiLevel or ASV. Once failure of standard CPAP is shown the 13 month rental starts over on the ASV. After 13 month rental you own the ASV. Replacement is after 5 years although I have been told that the 5 years did not start until you owned the machine at the end of 13 month Rental, I have not been able to confirm or deny this. If the machine breaks after the warrenty but not yet at the 5 year mark, Medicare will pay for the repair. If the repair is more than replacement they will replace the machine early and the rental and 5 years starts over.

I lack about a year reaching magic number so I have not fought my way through the gauntlet as of yet. Maybe someone who has been through it can confirm or correct this.

Jerry

[archangle]

Be sure to "prequalify" with medicare if that's something medicare does.

Are there some ASV machines that do full data and some that don't? Auto and non-auto machines to watch out for?

[Bright Choice]

My understanding on Medicare coverage of a BiLevel or ASV you had to fail CPAP before they would pay for a BiLevel or ASV. Once failure of standard CPAP is shown the 13 month rental starts over on the ASV. After 13 month rental you own the ASV. Replacement is after 5 years although I have been told that the 5 years did not start until you owned the machine at the end of 13 month Rental, I have not been able to confirm or deny this. If the machine breaks after the warrenty but not yet at the 5 year mark, Medicare will pay for the repair. If the repair is more than replacement they will replace the machine early and the rental and 5 years starts over.

I lack about a year reaching magic number so I have not fought my way through the gauntlet as of yet. Maybe someone who has been through it can confirm or correct this.

Jerry

Thanks Jerry! How does the supply side of it work? ie masks, climateline etc?

[Slinky]

Barring any recent changes I am not aware of Medicare will replace:
1] mask every 3 months
2] headgear every 6 months (many DMEs will not "part out" a mask and tell you a new MASK every 6 months
3] mask cushion once a month
4] nasal pillows cushions once a month
5] hose every 3 months
6] filters as recommended by PAP manufacturer
7] humidifier water tank every 6 months (I think)

Fisher & Paykel, Resmed and Respironics will replace FREE to the local DME providers most any of their masks that patients have tried and been unsuccessful w/IF the DME provider will fill out a form and return mask and form to the manufacturer W/IN 30 DAYS. Far too many local DME providers don't want to be bothered.

[6PtStar]

Supplies work just like most. In fact most insurance use Medicare guidelines on supplies. They pay 80% of what medicare sets the price at. Your secondary insurance if you have one pays 80% of the 20% that medicare does not pay. If you do not have a secondary you are responsible for the 20%. Just make sure they are a "Medicare Conmtractor" not just a "Medicare Provider". A contractor has agreed to take what medicare sets the price at. Here is the last schedule I have for supplies from Medicare.

Jerry

[Janknitz]

Slinky said:

2] headgear every 6 months (many DMEs will not "part out" a mask and tell you a new MASK every 6 months

I don't get this "mask but no headgear" thing.

Medicare lists A7034 as "Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap" and the replacement schedule for A7034 is every three months!

This info is from http://www.cms.gov/medicare-coverage-da ... tails/lcd- and http://www.cms.gov/DMEPOSFeeSched/LSDME ... PerPage=10

I think this "headgear only every 6 months" is DME baloney because they make more money parting them out separately. Any DME's care to comment????

[Janknitz]

BTW, hang on to your socks when you see the bill for YOUR 20% share of the ASV Medicare monthly rental. The allowable amount is between $493 and $580 per month (depending on what state you live in) and that means your 20% share can be as much as $116 per month.

Here's hoping you have a good Medicare Supplement policy!

[JeffH]

My DME is pretty open with me. She said her cost on this machine is around $3500. Doc K. said it would be around $100 a month rental on them. After 13 months, it is yours.

[Janknitz]

My DME is pretty open with me. She said her cost on this machine is around $3500. Doc K. said it would be around $100 a month rental on them. After 13 months, it is yours.

There's your markup. Her cost is about $3500 and Medicare will pay over $7,500 for the machine over the course of 13 months. That's NOT counting a humidifier! Jeff, it sounds like at least you're getting good care from your DME.

[Bright Choice]

BTW, hang on to your socks when you see the bill for YOUR 20% share of the ASV Medicare monthly rental. The allowable amount is between $493 and $580 per month (depending on what state you live in) and that means your 20% share can be as much as $116 per month.

Here's hoping you have a good Medicare Supplement policy!

Crossing my fingers! I have AARP supplemental which has covered everything 99.9 %

[Bright Choice]

Supplies work just like most. In fact most insurance use Medicare guidelines on supplies. They pay 80% of what medicare sets the price at. Your secondary insurance if you have one pays 80% of the 20% that medicare does not pay. If you do not have a secondary you are responsible for the 20%. Just make sure they are a "Medicare Conmtractor" not just a "Medicare Provider". A contractor has agreed to take what medicare sets the price at. Here is the last schedule I have for supplies from Medicare.

Jerry

Interesting about the contractor vs provider. I'll have to ask.
Great info Jerry - Thanks!

[idamtnboy]

I have been on an S9 autoset paid out of pocket because first psg didn't qualify me for Medicare. I finally had a series of sleep studies that met Medicare guidelines for coverage. RX is for S9 ASV w/h5i / climateline / Quattro ffm and Rem zzz's.

The person on the phone at DME made me a bit nervous because she was questioning my prescription and whether or not I had "failed" other therapies. She said, "You know, that's a very expensive machine." My very detailed paperwork includes a diagnostic PSG and then 2 nights of titration - which I "failed" all the way through to ASV. So, I should be ok on that point but they still made me nervous. What kind of stunts might they pull on this one?

How does the "rental" work with ASV's - should I expect that it would be the same as with any other xpap. Someone at the clinic mentioned that Medicare might just do a straight rental - do you know?

Here are two pertinent quotes from the Medicare Decision Memo regarding covering CPAP machines. http://www.cms.gov/medicare-coverage-da ... romdb=true

1. Coverage of CPAP is initially limited to a 12 week period for beneficiaries diagnosed with OSA as subsequently described. CPAP is subsequently covered for those beneficiaries diagnosed with OSA whose OSA improved as a result of CPAP during this 12 week period.

We remind the reader that Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are required to provide beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively. 42 CFR 424.57(c)(12). Failure to meet this standard may result in revocation of the DMEPOS supplier’s billing privileges. 42 CFR 424.57(d).

2. CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:

1. polysomnography (PSG) performed in a sleep laboratory; or
2. unattended home sleep monitoring device of Type II; or
3. unattended home sleep monitoring device of Type III; or
4. unattended home sleep monitoring device of Type IV, measuring at least three channels

We remind the reader that, in general, pursuant to 42 CFR 410.32(a) diagnostic tests that are not ordered by the beneficiary’s treating physician are not considered reasonable and necessary. Pursuant to 42 CFR 410.32(b) diagnostic tests payable under the physician fee schedule that are furnished without the required level of supervision by a physician are not reasonable and necessary.

3. A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:

* AHI or RDI greater than or equal to 15 events per hour, or
* AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.

CPAP treatment uses air pressure to maintain airway patency. There are several types of CPAP devices used in the treatment of OSA. These include: (1) conventional CPAP devices which provide a constant, steady air pressure all night; (2) bi-level positive airway pressure devices, which, instead of providing a constant pressure throughout the night, sense inspiration and expiration and vary the level of pressure accordingly; and (3) responsive ("smart") airway pressure devices that incorporate flow and pressure sensors and automatic regulation systems to continuously adjust mask pressure to the actual needs of the patient.

All CPAP machines are in the category of "Capped Rental" meaning that after 10 months you are given the option to purchase the machine. If you opt to purchase rental goes for a total of 13 months and you own the machine. You continue to pay 20% copay for supplies and servicing of the machine any time it is serviced. If you opt to not purchase the machine rent goes for 15 months total, the ownership stays with the supplier, and you continue to use the machine. You are responsible for 20% of the cost of a service contract, paid twice a year, whether or not the machine is actually serviced. It would be interesting to find out if anyone has ever exercised the 15 month option and not taken title to the machine, and what their experience has been doing that. Here is the pertinent section quoted from the Medicare Manual. This is the wording that must be given to the beneficiary.

http://www.cms.gov/manuals/downloads/clm104c20.pdf

(Rev. 1, 10-01-03)
Exhibit 1 - The Rent/Purchase Option
You have been renting your (specify the item(s) of equipment) for 10 continuous rental months. Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After making these additional rental payments, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. You are responsible for the 20 percent coinsurance amounts and, for
unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.
In making your decision to rent or purchase the equipment, you should know that for purchased equipment your supplier may charge you each time your equipment is actually serviced. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, for equipment that is rented for 15 months, your responsibility for such service is limited to 20 percent coinsurance on a maintenance and servicing fee payable twice per year whether or not the equipment is actually serviced.

[idamtnboy]

From everything I find on the Medicare website, ASVs are considered a CPAP, so are treated for payment like any other CPAP.

[mcdover]

I have been on an S9 autoset paid out of pocket because first psg didn't qualify me for Medicare. I finally had a series of sleep studies that met Medicare guidelines for coverage. RX is for S9 ASV w/h5i / climateline / Quattro ffm and Rem zzz's.

The person on the phone at DME made me a bit nervous because she was questioning my prescription and whether or not I had "failed" other therapies. She said, "You know, that's a very expensive machine." My very detailed paperwork includes a diagnostic PSG and then 2 nights of titration - which I "failed" all the way through to ASV. So, I should be ok on that point but they still made me nervous. What kind of stunts might they pull on this one?

How does the "rental" work with ASV's - should I expect that it would be the same as with any other xpap. Someone at the clinic mentioned that Medicare might just do a straight rental - do you know?

Here are two pertinent quotes from the Medicare Decision Memo regarding covering CPAP machines. http://www.cms.gov/medicare-coverage-da ... romdb=true

1. Coverage of CPAP is initially limited to a 12 week period for beneficiaries diagnosed with OSA as subsequently described. CPAP is subsequently covered for those beneficiaries diagnosed with OSA whose OSA improved as a result of CPAP during this 12 week period.

We remind the reader that Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are required to provide beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively. 42 CFR 424.57(c)(12). Failure to meet this standard may result in revocation of the DMEPOS supplier’s billing privileges. 42 CFR 424.57(d).

2. CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:

1. polysomnography (PSG) performed in a sleep laboratory; or
2. unattended home sleep monitoring device of Type II; or
3. unattended home sleep monitoring device of Type III; or
4. unattended home sleep monitoring device of Type IV, measuring at least three channels

We remind the reader that, in general, pursuant to 42 CFR 410.32(a) diagnostic tests that are not ordered by the beneficiary’s treating physician are not considered reasonable and necessary. Pursuant to 42 CFR 410.32(b) diagnostic tests payable under the physician fee schedule that are furnished without the required level of supervision by a physician are not reasonable and necessary.

3. A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:

* AHI or RDI greater than or equal to 15 events per hour, or
* AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.

CPAP treatment uses air pressure to maintain airway patency. There are several types of CPAP devices used in the treatment of OSA. These include: (1) conventional CPAP devices which provide a constant, steady air pressure all night; (2) bi-level positive airway pressure devices, which, instead of providing a constant pressure throughout the night, sense inspiration and expiration and vary the level of pressure accordingly; and (3) responsive ("smart") airway pressure devices that incorporate flow and pressure sensors and automatic regulation systems to continuously adjust mask pressure to the actual needs of the patient.

All CPAP machines are in the category of "Capped Rental" meaning that after 10 months you are given the option to purchase the machine. If you opt to purchase rental goes for a total of 13 months and you own the machine. You continue to pay 20% copay for supplies and servicing of the machine any time it is serviced. If you opt to not purchase the machine rent goes for 15 months total, the ownership stays with the supplier, and you continue to use the machine. You are responsible for 20% of the cost of a service contract, paid twice a year, whether or not the machine is actually serviced. It would be interesting to find out if anyone has ever exercised the 15 month option and not taken title to the machine, and what their experience has been doing that. Here is the pertinent section quoted from the Medicare Manual. This is the wording that must be given to the beneficiary.

http://www.cms.gov/manuals/downloads/clm104c20.pdf

(Rev. 1, 10-01-03)
Exhibit 1 - The Rent/Purchase Option
You have been renting your (specify the item(s) of equipment) for 10 continuous rental months. Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After making these additional rental payments, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. You are responsible for the 20 percent coinsurance amounts and, for
unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.
In making your decision to rent or purchase the equipment, you should know that for purchased equipment your supplier may charge you each time your equipment is actually serviced. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, for equipment that is rented for 15 months, your responsibility for such service is limited to 20 percent coinsurance on a maintenance and servicing fee payable twice per year whether or not the equipment is actually serviced.

Your info is completely wrong and outdated. No 10 month letter, no 15 month rental, and no service contract. Everything is a capped 13-month rental. There are many more requirements for bilevels than cpap. As the level of bipap increases (w/back rate, ASV) so do the requirements. For CMS to continue renting a cpap, bilevel, etc. past the initial 90 day period, the dme must demonstrate compliance and that the patient has followed up withe the prescribing physician AND he/she has documented that the patient is using the device and is benefiting from it.