Kaiser Senior Advantage and CPAP Supplies

[pine3874]

I am a member of Kaiser Permanente Senior Advantage in Georgia and my DME says that Kaiser will only pay for supplies every six months. There is no way that I can use one set of Fx Pillows for six months. According to the Medicare replacement schedule I should be able to get 2 nasal pillows every month. Medicare Advantage has to follow the same rules as Medicare as far as I know. Has anyone else had this problem or know how to solve it? Thanks

[Otter]

I'd talk to someone else at the DME. I suspect the person you spoke to is new and hasn't dealt with nasal pillows before.

[pine3874]

I spoke to the director.

[chunkyfrog]

Doesn't the default Part B cover supplies on schedule anyway?--
I thought the advantage plans were supposed to cover what Medicare does not . . .
What kind of 'advantage plan' makes you pay more for less coverage?
Maybe someone needs to call "doctor Radio" on XM--
There is a show about call-ins on insurance matters.
It is called 'Health Care Connect".

[Otter]

I suppose the next step would be to have Kaiser call the DME. Either that, or find a DME who isn't so ignorant of CPAP. While It's likely that Kaiser will only pay for x pillows in six months. I seriously doubt they expect you to use the same pair for half a year.

[xyz]

p:
> my DME says that Kaiser will only pay for supplies every six months

Who is your DME?

[chunkyfrog]

yes, Otter probably has the solution:
get insurance to talk to the DME.
Or find a smarter DME.
Oh, isn't DME just another way to spell 'dummy'?

Is Kaiser that totally messed up?

[apneawho]

I don't know for certain, but it is possible that your DME provider is telling you what Kaiser Senior Advantage has told them. Medicare managed care plans are notorious for trimming down some of the benefits in some areas to pay for the little extra they give you in other areas like Rx benefits, decreased out of pocket expenses and so on. They are for profit companies after all. I would call the customer service number on your card and talk to someone about your CPAP supply benefits so you will get it straight from the horse's mouth.

[Janknitz]

I have Kaiser in the Northern California region and they follow Medicare Guidelines. Medicare guidelines cover TWO nasal pillows per MONTH, one mask every three months. Since Senior Advantage is your Medicare benefit, by federal law I don't think they can supply you with anything less than Medicare allows (though they can limit your choice of supplier and to a particular "formulary" for masks, machines, and supplies). If Kaiser (not the DME supplier) tells you you cannot have what Medicare allows, you should file a complaint with Medicare.

The thing you must understand is that the DME supplier (I'm guessing Crapria) is NOT your DME, Kaiser is your DME. It's different than for non-HMO patients, and a little confusing. Kaiser must initiate the order, the "DME" whomever it is acts merely as the supplier when you have Kaiser. So call your Kaiser sleep clinic and get them to order what you need as long as it falls within the Medicare Guidelines (if you search this site, you will find the Medicare replacement schedule) and Kaiser's formulary (they have a limited choice of masks, hoses, and machines--for example, I cannot get the Swift FX on the Kaiser formulary).

In my region, I have to email the sleep clinic staff to tell them what I want so that my prescription has the right mask, filters, hose, etc (and Crapria NEVER gets the hose order correct!). Then I have to call a centralized Kaiser DME to place the order. THEY call Crapria, who calls me to get the co-payment first, drop ships the supplies, and then bills me for the co-payment I've already paid with the credit card I've put on file so they don't have to keep bugging me about the co-pays (grrrrrrr!!!!!). It's a pain in the neck and dealing with Crapria is never the highlight of my day.

[pine3874]

I have Kaiser in the Northern California region and they follow Medicare Guidelines. Medicare guidelines cover TWO nasal pillows per MONTH, one mask every three months. Since Senior Advantage is your Medicare benefit, by federal law I don't think they can supply you with anything less than Medicare allows (though they can limit your choice of supplier and to a particular "formulary" for masks, machines, and supplies). If Kaiser (not the DME supplier) tells you you cannot have what Medicare allows, you should file a complaint with Medicare.

The thing you must understand is that the DME supplier (I'm guessing Crapria) is NOT your DME, Kaiser is your DME. It's different than for non-HMO patients, and a little confusing. Kaiser must initiate the order, the "DME" whomever it is acts merely as the supplier when you have Kaiser. So call your Kaiser sleep clinic and get them to order what you need as long as it falls within the Medicare Guidelines (if you search this site, you will find the Medicare replacement schedule) and Kaiser's formulary (they have a limited choice of masks, hoses, and machines--for example, I cannot get the Swift FX on the Kaiser formulary).

In my region, I have to email the sleep clinic staff to tell them what I want so that my prescription has the right mask, filters, hose, etc (and Crapria NEVER gets the hose order correct!). Then I have to call a centralized Kaiser DME to place the order. THEY call Crapria, who calls me to get the co-payment first, drop ships the supplies, and then bills me for the co-payment I've already paid with the credit card I've put on file so they don't have to keep bugging me about the co-pays (grrrrrrr!!!!!). It's a pain in the neck and dealing with Crapria is never the highlight of my day.

Thank you for your detailed explanation, but Kaiser in California is completely different than Kaiser in Georgia. In Georgia Kaiser is not the DME.

[Janknitz]

Thank you for your detailed explanation, but Kaiser in California is completely different than Kaiser in Georgia. In Georgia Kaiser is not the DME.

You should receive a Medicare & You guide every year in the mail. On the back of the guide there is a number for your local SHIP which is FREE Medicare counseling. Call them and see if they can advise you on this matter. Or you can call Medicare (1-800-MEDICARE) and file a complaint. Federal law requires that even Medicare Advantage providers meet certain guidelines, and they can't provide less than the Medicare standards require. Medicare guidelines permit two sets of nasal pillows per month. You can also file a complaint with Kaiser that their contracted DME provider is not following the Medicare Guidelines.

[chunkyfrog]

Sic 'em!

[pine3874]

After going around in circles for the past week I have finally been able to resolve this problem.

So for anyone who has Kaiser Sr. Advantage in Atlanta, GA, this is how it works:
If you were refered to the Sleep Disorders Center of Georgia and diagnosed with sleep apnea, then they become your DME for the PAP machine and mask, but not for replacement supplies. They only have a contract with Kaiser for the machine and mask. For replacement supplies( nasal pillows, filters, etc.) you have to get a referral from your PCP to Apria. They are the ones that have the contract with Kaiser for supplies. I have no idea why it is done this way, but that's the way it is. Now all I have to do is call Apria every month and order what I need and they send it to me. Hooray!!!

[archangle]

Now all I have to do is call Apria every month and order what I need and they send it to me. Hooray!!!

Then call them back and return the wrong parts they shipped you.
Then call them back and straighten out the billing.
Then call them back and get them to stop sending you parts you don't need just because they're on the schedule.
Then call them and straighten out why you didn't get the parts you ordered.

[Janknitz]

Now all I have to do is call Apria every month and order what I need and they send it to me. Hooray!!!

Ha, good luck with that! There's a reason I call them "Crapria".