Replacement Schedule Sunlife Ontario: Advice

[Pekoepup]

I would appreciate help from any Canadians living in Ontario, using Sunlife Insurance, especially if you are a Federal employee. I was just visiting a relative in Ontario and discovered she is a non-compliant CPAP user or should I say a current non-user. I live in California and use CPAP myself. I sat down with her one day and tried to go over all the issues she is having. She brought down her equipment and I was appalled.

Her machine is fine, a Resmed Elite II and it is due for replacement next year at the 5 year mark. Everything else is a huge problem. The mask, Swift LT for Her, is 5 years old, along with the hose and the filters. The headgear for the mask was literally disintegrating in my hand. The mask has separated at the nose piece and the where it connects to the hose causing huge leaks. The filter was black. Her hose has multiple cracks in it and she has taped them with duct tape. She states that she feels like she is suffocating when she wears the mask. I told her I am sure she is since she has air leaking out out all over the place.

My aunt said that Sunlife only allows for a replacement mask, filter and hose every 5 years which I thought was absurd so we called the following day to verify the information. The representative on the phone said she could sympathize with my Aunt but there was nothing she could do. I can not believe that they expect a patient to get adequate therapy using the same mask for 5 years straight. These masks are not meant to last 5 years.

This aunt is in dire financial problems and actually was taken in by another relative so buying it herself is not an option. I made adjustments to her CPAP machine because she disliked the ramp setting and I gave her my Hozer to help with hose management. I needed my mask for the rest of my trip so I could not give that up. I have ordered her another mask for the time being and I have a spare hose back in California that I will send. These will help now but not fix the long term problem of ensuring that she has right the equipment to get optimal therapy. She had been using her CPAP religiously for years.

Is there something we are missing? Is there someplace else she can obtain equipment rather than Sunlife? Any help from those in the know would be greatly appreciated, I have not lived in Canada for 30 years so I am out of the loop.

[Postman]

I use Sunlife from a major bank retirees plan and I get a new mask and hose every year. She can try the "assistive devices program" from the Ontario Govt. for a subsidy, any dealer should be able to help her. Finally the Ontario drug benefit plan (for seniors) might be of use.

[Hose_Head]

I would appreciate help from any Canadians living in Ontario, using Sunlife Insurance, especially if you are a Federal employee. I was just visiting a relative in Ontario and discovered she is a non-compliant CPAP user or should I say a current non-user. I live in California and use CPAP myself. I sat down with her one day and tried to go over all the issues she is having. She brought down her equipment and I was appalled.

Her machine is fine, a Resmed Elite II and it is due for replacement next year at the 5 year mark. Everything else is a huge problem. The mask, Swift LT for Her, is 5 years old, along with the hose and the filters. The headgear for the mask was literally disintegrating in my hand. The mask has separated at the nose piece and the where it connects to the hose causing huge leaks. The filter was black. Her hose has multiple cracks in it and she has taped them with duct tape. She states that she feels like she is suffocating when she wears the mask. I told her I am sure she is since she has air leaking out out all over the place.

My aunt said that Sunlife only allows for a replacement mask, filter and hose every 5 years which I thought was absurd so we called the following day to verify the information. The representative on the phone said she could sympathize with my Aunt but there was nothing she could do. I can not believe that they expect a patient to get adequate therapy using the same mask for 5 years straight. These masks are not meant to last 5 years.

This aunt is in dire financial problems and actually was taken in by another relative so buying it herself is not an option. I made adjustments to her CPAP machine because she disliked the ramp setting and I gave her my Hozer to help with hose management. I needed my mask for the rest of my trip so I could not give that up. I have ordered her another mask for the time being and I have a spare hose back in California that I will send. These will help now but not fix the long term problem of ensuring that she has right the equipment to get optimal therapy. She had been using her CPAP religiously for years.

Is there something we are missing? Is there someplace else she can obtain equipment rather than Sunlife? Any help from those in the know would be greatly appreciated, I have not lived in Canada for 30 years so I am out of the loop.

Note that SunLife is an insurance company and not a DME as you implied in your post.

I'm not covered by SunLife but my wife was insured with them until she retired 2 years ago (she is not an xpap user). I imagine that every insurance group with them is different and cannot say what is covered by the Federal employee program. However, I assume that it's similar to what was covered under my wife's plan and similar to my own plan with Great West Life.

From my experience these plans require the insured to buy their supplies from a DME of their choice (online purchases may be OK at SunLife) and then submit the receipts for reimbursement. I don't recall there being any kind of schedule for replacements. (Under my Great West Life insurance I am covered for whatever is "reasonable". I am reimbursed for 100%. I just buy what I need and send in the bills).

My suggestion is that you contact SunLife again to discuss coverages. It does not sound reasonable or likely they only provide supplies once every 5 years. My guess is that the person you talked to on the phone is not familiar with the therapy and was confused about rules for replacement of the xpap as opposed to replacement of supplies such as hoses and masks.

Also needed is to find a decent DME that will supply your aunt. However, a word of caution here. DME's in Ontario are no better (and may be worse) than those in the USA. Unfortunately, I cannot recommend a good one because I don't know any - they all charge outrageous prices for what can be found much cheaper online.

If your aunt has 100% (or nearly so) coverage for replacement of supplies, then it may be possible to find a local DME, possibly even one who will direct-bill the insurance company.

If possible, it would be best if she could order her supplies online but she will have to be able to pay for them and wait for reimbursement later. Prices similar to those at cpap.com, but with free shipping in Canada, can be found - this gets around the problem of suppliers not being able to ship Resmed products across the border.

Hopefully there are some Canadian federal employees on this board who can provide more specific and direct advice.

Best of luck, and post back with what you find!

[Pekoepup]

Sorry, I know that Sunlife is the insurance company and I did not mean to cause any confusion. I guess I was not clear. We initially called her DME and they told us that she was only entitled to new equipment 5 years. I was skeptical but It was already late in the day so we called Sunlife the next morning. The Sunlife representative on the phone said the same thing the DME employee had. A new mask, hose, filter and machine every 5 years. I was shocked. She was not helpful and no suggestions. In fact, she said something to the effect that you can whine and complain all you want but it is not going to change anything.

To Postman, thanks for the suggestion about the Ontario Assistive Device Program. I will forward her the information and have her look into it.

I really appreciate everyone's ideas. I am already back home but I will call her tomorrow and see what else we can do. Another call to Sunlife appears to be in order. Something seems very wrong here.

[ChrisD]

If you can't get the supplies via the insurance company post a list of what she needs. I have a spare hose or two that I would be willing to donate. I can ship them to you.

I'd help with the other supplies but I gave a Phillips Respironics System One machine.

Chris

[Pugsy]

Is her machine the S8 or S9 model?
I think I have a handful of brand new S8 filters that need a good home.
I might have a couple of Swift LT nasal pillows but unsure of what size I have. What size does she need?
I don't think I have any other Swift LT gear but I will look.

[Pekoepup]

Thanks Chris and Pugsy for your generous offers. Shipping anything to Canada has become quite expensive but I would be happy to pay for any shipping fees. We could either ship directly to her home in Ontario or ship everything to me and I could send one package to her.

The machine is a Resmed Elite II S8 from what I recall. I remember the S8 from the bottom of the machine and it definitely said Elite II on the front. The manufacture date was June 2008 but she received the machine in July of 2009.

My machine does not use the same filters but I do have an extra hose so I am sending that today. She uses the medium sized pillows and I had brought a spare with me so I left that behind with her. I had some gently used Swift LT masks but I had donated them to a woman who was needed equipment but had lost her insurance.

[Pugsy]

Send me a private message with her address if it is okay with her. Shipping to Canada won't take food off my table. I am happy to do it.
I know I have some filters...those won't cost much at all. Let me go through my stash of stuff to see what Swift LT supplies I might have...I think I have a couple of nasal pillows but unsure what size.
Or I would be happy to mail the items to you and let you get a package together for her.
I don't mind international shipping though. The customs forms aren't a problem.

Let me go check out my stash of supplies to see exactly what I have and I will let you know in a little while.
If you are getting several different offers for gifts...it might be less expensive to make a one time larger package than a whole bunch of little packages. I am okay with either way though...to you or to her.

[CoastalSun]

I used to live in Ontario but now live on the West Coast - however, a friend in Ontario just started CPAP therapy. The provincial health care plan covers up to 75% of equipment. Remainder picked up by private insurance or person. Having lived there, and having dealt with SunLife in the past, more questions need to be clarified. Also, a phone call to OHIP - the Ontario Health Insurance Plan.
Here's a link to the program:

http://www.health.gov.on.ca/en/public/p ... /cpap.aspx

I now live in BC where our provincial medical plan, MSP, does NOT cover ANY cost of CPAP machine or supplies ... except if the person is on social assistance or provincial disability and has moderate to severe sleep apnea. It might be possible to get coverage if one doesn't fall into these two categories but has 'life threatening' health needs. It doesn't take much imagination to realize what the paper trail would be like in this situation!

Yes, we have universal health care in Canada but there are variables amongst the 10 provincial and 3 territorial medical plans.

[nanwilson]

I don't live in Ont. but can send any of my listed spares....
slim line hose
PR original gel nasal mask
Respcare Hybrid mask
Fullface mask

I see that she uses the swift lt, but if she would be interested in any of my spares, I can get them off via Canada post as I am in Alberta. I don't have any filters for her machine but I have a suggestion. I don't have insurance either so in a pinch I have bought a mouth/nose mask that is used in hospitals etc. and cut out several filter size squares that I can use when I am out of my own filters and short on cash . They work just fine by doubling two together... I just take it out every week and check how dirty its getting ... I have actually gotten by for a month in this manner with the same home made filter.
Let me know if I can be of any help.
Cheers
Nan

[Postman]

"Assistive Devices Program" gives a subsidy every 5 years, I use it for cpap and hearing AIDS. I would call Sun Life back (as I did) and ask about wear items vs "durable" equipment :ie the cpap machine. Totally different rules apply. If all else fails have someone contact the local social services agencies to see if there are any programs available to help her. I ordered from our host cpap.com and submitted my bills to Sun Life and they reimbursed me (minus deductible) this year.

Sun Life normally does NOT sell this type of insurance plan they administer it for a company or govt. benefits plan and the "owners'" rules apply. Your aunt should get in touch with the section of the dept. of the federal Govt who owns the plan. This might be human resources dept. or retirees section or lastly even disability section. Good luck.

[ReadyforRest]

I live in Ontario. I can give you links to several suppliers in Ontario. But Ontario's a big place. It would be helpful to know where she lives in Ontario. You can pm me if you'd prefer. I can recommend several places in the Toronto area. But ordering from our hosts here is often less expensive, even with the shipping costs, since everything is marked up a ridiculous amount here in Canada.

The Assisted Device Program (ADP) pays 75% of the cost of the xpap machine every 5 years. It does not cover replacement of masks, hoses, or accessory parts.

Private insurance (through work) will often cover mask, mask parts, filters and hose replacements on a scheduled basis, but each insurance company is different, and each plan is different. I'm not familiar with SunLife and their coverage, but Manulife covers two mask replacements per year, and one hose replacement per year. However, when you retire (like my husband did) you then have a $100 deductable, which eats into your major medical coverage.

When I first started cpap therapy almost a year ago, I called up my husband's benefits plan office (not Manulife, the insurer, but his union benefits company that oversees all union workers' claims with Manulife). The benefits office was very nice and told me, to my surprise, that Manulife does cover cpap masks, hoses and filters (see above), but not accessories like head pillows, hose holders and the like.

I hope you get somewhere with Sunlife. Is it even possible to change insurance providers, seeing that it's a Federal employee type of situation and she probably doesn't have a choice of who insures her? Does a Federal employee have the option of changing insurance providers, if it's a group plan? If not, and if the SunLife coverage truly is this awful, then your aunt has no recourse but to depend on the generosity of others to help her out with mask replacements.

But yes, if you are able to, do give Sunlife another call, and even ask them to mail you a copy of their coverage plan.

[Pugsy]

I will send you a PM in a bit.
I have 9 filters for the S8 machine you/she can have.
I have one complete Swift LT mask that has been used very little (looks pretty darn new) with one Medium nasal pillow (on the mask) and an XSmall, Small and Large unused in the package.
Perhaps the XSmall, Small and Large could be traded to Medium nasal pillows (but I know that Mediums are at a premium since they are the most commonly used size).
Anyway..yours/hers if you want them.

[Hose_Head]

Sorry, I know that Sunlife is the insurance company and I did not mean to cause any confusion. I guess I was not clear. We initially called her DME and they told us that she was only entitled to new equipment 5 years. I was skeptical but It was already late in the day so we called Sunlife the next morning. The Sunlife representative on the phone said the same thing the DME employee had. A new mask, hose, filter and machine every 5 years. I was shocked. She was not helpful and no suggestions. In fact, she said something to the effect that you can whine and complain all you want but it is not going to change anything.

To Postman, thanks for the suggestion about the Ontario Assistive Device Program. I will forward her the information and have her look into it.

I really appreciate everyone's ideas. I am already back home but I will call her tomorrow and see what else we can do. Another call to Sunlife appears to be in order. Something seems very wrong here.

This still sounds fishy.

There is one other avenue that you can try, if you still do not want to take SunLife's word for it. That is to approach the question through your aunt's pension plan. The health care benefit package (i.e. SunLife) is provided through the pension plan and the pension provider has say over what is covered and what is not (they pay the premiums). I would call the pension plan provider and ask them about what is covered under the health care benefits plan. If things are covered and SunLife is just trying to get out of having to pay benefits, then the pension plan provider can set them straight.

Good luck!

[Pekoepup]

Wow, thanks for all the responses, offers for help and suggestions. I must say that I am quite confused by "health insurance" coverage in Canada. I don't think it was this complicated when I lived in B.C.. growing up. I thought socialized medicine meant everyone would be on a Provincial health plan with the same coverage so I am not understanding Sunlife's role.

I feel like I am not playing with a full deck since I don't know all the specifics of my Aunt's situation. She lives in Ottawa and worked for Parliament. She left work but i think it was due to disability and not retirement. This may affect her coverage but I am not sure. I did not discover her situation until Thursday afternoon and that left only Friday to sort things out as I flew back to California on Saturday. She is now 60 years old.

I think having her call the Human Resources Department is a great idea and I will get her to request a copy of her plan's coverage for replacement items. I did take a look at the Assistive Device Program but it appears it will only cover the machine. The wording is not clear though so I told her to ask her sleep apnea doc about it at her nest appointment. I told her to call Sunlife again and see if she gets a different response with a different representative.

To Pugsy: I replied to your PM and I want to thank you again for the items you are willing to donate. I sent my spare hose to her this morning and the post office said it would arrive in 7-10 days.


To Nan: Thanks for your kind offers to send your spare. I don't know if she has tried or uses any other masks. She only had the one Swift LT that was falling apart. I will ask her if she would like to try any of them before I trouble you to send them.

I will keep you all posted on what I find out.