What does your insurance cover?

[oregondiver]

I seem to be in the minority (i think) in that my health insurance plan gave me my machine the morning of my sleep study (I was put on cpap during the study). Zero cost to me, no compliance requirement, and not put on a rental. The gal who got her machine at the same time (we both "failed" our sleep study, haha) had to pay 20% based on her health plan.

The listed costs for the machine/mask were similar or lower than listed on cpap.com. Maybe my health plan buys enough of them, that they don't need to mark them up even more before "reselling" to the patients? Anyway, based on posts...was just curious.

Do most health plans require "compliance" or rental first?

Once I decide to "keep" my current mask, I will be going to the mask swapping link and see if someone can use my med and large fx pillows in exchange for additional smalls.

[greatunclebill]

tricare prime covers 20% of any equipment and supplies. on cpap's they leave it up to the dme whether they want to do a 13 month rental or an outright purchase. most dme's opt for rental. the one dme that blindsided us with outright purchase no longer gets our business. now we know to ask first whether its purchase or rental. there is no compliance requirement with tricare.

[squid13]

Medicare requires compliance and 13 month rental. My BC/BS federal picks up what Medicare doesn't pay. My out of pocket is zero.

[Pugsy]

My insurance does whatever Medicare does except I don't have the Part B Medicare deductible to mess with for CPAP supplies.
I only have to pay out of pocket the 20% of the allowable amount established by Medicare's allowable amounts.
My replacement schedule is the same as Medicare's replacement schedule.

[StuUnderPressure]

It is up to the Insurance Company (& not the DME Provider nor the patient) as to whether or not they will buy the equipment outright or rent it.

In my almost 14 years (3 Machines), my BCBS POP Insurance has always purchased the machines outright & has never required specific documentation Re compliance.

For the very 1st machine, the DME Provider did ask me if I was using the machine, so that they could tell the insurance company yes. That machine did not even record the hours of usage.

I never got asked that again for either the 2nd nor 3rd machine.

I also got my 1st machine the next morning after the Titration Study.
A rep from the independent DME Provider was there with the machines for 4 of us.
Everybody got the same machine.

My Sleep Study was a 2 night study with the 2nd night being the Titration night.

[Xney]

I've had BCBS (blueadvantage now), PPO. (Though now it's an HSA plan)

They generally have covered 80% of all costs (rent-to-own or supplies/purchases) up to my deductible, and then they cover 100% if I follow their replacement schedule (which I do).

[xenablue]

I paid a $50 co-pay when I picked up my machine and mask. That was 2 years ago and I haven't paid another cent since, despite regular replacements - except for a couple of items I chose to purchase. Even my chinstrap was covered.

Cheers,
xena

[themonk]

I have BCBS and I am on some kind of rental, but I had to 'buy' the humidifier. I have had my machine since June and I have paid about $120 so far.

As far as compliance, I assume I don't have any requirements since I have never used it for >4 hours in any month so far and they haven't bothered me. I do have it in 'my file' that I am having issues so maybe that is saving me? Either way, I am probably not going to keep it so it is no harm/no foul if they do come and get it.

[Xney]

BCBS doesn't seem to check compliance, but other insurance carriers do.

BCBS seems to cover 100% of scheduled replacement parts, from what I remember.

[Spektor]

BCBS doesn't seem to check compliance, but other insurance carriers do.

BCBS seems to cover 100% of scheduled replacement parts, from what I remember.

Do you have to meet an annual deductible before they cover replacement masks, headgear, etc.???

[brucifer]

I have CIGNA PPO. I paid a 15% co-pay for my machine and supplies, and my machine was a purchase, not a rental. CIGNA does not require compliance. My only major complaint with CIGNA is that none of their in-network DME suppliers are online retailers. As a result, my 15% co-pay for going in-network is not that much more of a savings than what I would pay if I went out-of-network with the 40% co-pay. Essentially, CIGNA is screwing itself and its customers because its in-network DME suppliers are limited to a small pool of over-priced companies. CIGNA needs to address this issue.

[Xney]

BCBS doesn't seem to check compliance, but other insurance carriers do.

BCBS seems to cover 100% of scheduled replacement parts, from what I remember.

Do you have to meet an annual deductible before they cover replacement masks, headgear, etc.???

Pretty sure, yes. I'm paying 20% until deductible is met. But that applies to all replacement gear, which is filters, mask parts, humidifier tank, etc. so it ends up not being too much since it's 20% of cost. (It IS, however, 20% of the ridiculously overpriced "we can charge insurance XX" amounts rather than the true cost of that kind of gear)

[RogerSC]

Have an UHC EPO with the company that I work for. Once I had a sleep study, and my doctor had written a prescription, there was no out of pocket to pick up the CPAP, etc. I do think that my doctor had to verify compliance to the insurance company, but there was no rental required, either. I'm not sure how long compliance was required, I didn't have any trouble complying (4 hours a night isn't really a lot *smile*), so no cost for the big stuff. I've picked up a few things on my own to make life a little easier and more fun, pillow, battery, inverter, 12 to 24VDC converter, stuff like that, those should be useful for some time.

So I'm pretty happy with my insurance company. Going on Medicare soon, with a Medicare Advantage plan (so I can use the same doctors as I've been using for years now), we'll see how that goes.

[Spektor]

BCBS doesn't seem to check compliance, but other insurance carriers do.

BCBS seems to cover 100% of scheduled replacement parts, from what I remember.

Do you have to meet an annual deductible before they cover replacement masks, headgear, etc.???

Pretty sure, yes. I'm paying 20% until deductible is met. But that applies to all replacement gear, which is filters, mask parts, humidifier tank, etc. so it ends up not being too much since it's 20% of cost. (It IS, however, 20% of the ridiculously overpriced "we can charge insurance XX" amounts rather than the true cost of that kind of gear)

You only have to pay 20% until the deductible is met? You don't have to pay 100% of the cost until the deductible is met, and then after you pay 20%?

[chunkyfrog]

I have a $400 in network 'deductible' and an $800 out of network 'deductible' with our custom BCBSNE plan.
(We pay 100% of the 'allowed amount' until we have paid the entire deductible)
'Co-Pay' in my plan is a percentage of the allowed amount, doubled for out of network.
If you add together all deductible and co-pay expenses, they call that 'out-of-pocket', and there may be a maximum yearly amount, after which insurance pays the co-pay. (this amount is astronomical, so don't get your hopes up)
Note, all expenses must be either 'medically necessary' or scheduled expenses, or they are not covered, and the provider is under no restrictions pertaining to what they can charge.
Also note, prescription drugs have no deductible and no max OOP.
I put some words in quotes, as I suspect insurance companies are not consistent with their terminology,
playing fast and furious with definitions, as our failure to understand what is going on serves to profit them.