Buy versus "rent to own" insurance challenges?

[pswartz]

Has anyone gone through insurance h*ll trying to buy a BiPAP machine outright (versus “rent to own”)? I have been trying to get BCBS to authorize the outright purchase of my machine so that I can apply it to my deductible this year. Between the machine, 2 sleep studies, and supplies, I will hit my out-of-pocket max and have BCBS pick up most of the equipment cost. However, they are driving me to a 10-month rent-to-own model which will cause 2 of the 10 payment to hit next year – of course after my deductible re-sets.

I’ve had no luck on the phone with them. I did send in an “appeal” letter explaining the situation and have contacted my company’s administrator. I await answers.

Has anyone successfully gone down this path? Any advice?

Thanks!

[chunkyfrog]

Find out from the benefits manager where you work exactly what is in the contract.
BCBS has hundreds of plans with as many restrictions, varying with every location.
Bipap may not be negotiable as an upfront pay, but it's worth a try. Good luck.

[LSAT]

From my experience on Medicare, the monthly rent to own is only about $30-$35 per month on a regular CPAP. I don't know how much higher a bipap would be. Perhaps $50 per month? That would move $100 into next year. That amount will be part of your deductable for the next year.

[pswartz]

The "PR System One REMStar 60 Series BiPAP autoSV Advanced" is $320 per month or $3,200 total. Pushing into next year for 2 payments is a $640 hit which I don't want to take.

[hyperlexis]

First off, you don't have the right to demand they simply give it to you outright. If you did, every person who did so could turn around and peddle the equipment on ebay after getting a machine. Like the way they used to do. So now, the insurance companies force people to rent to own to check whether the patients are compliant and using the machines. Generally the idea is a person isn't going to use a machine for three months as part of a scam...

It sucks but you will either have to eat the cost or, as far as I know, BCBS(IL) will apply a deductible payment(s) made within the last few months of the year towards a credit for the next year. So they should apply the charges to your following year -- not forcing you to re-pay the deductible starting January 1. This happened to me and it worked out just fine. All you need to do is ask someone who knows what he's talking about. Which can be a serious challenge with insurers. Supervisors of supervisors, up and up the chain sometimes...

[Janknitz]

Ask for a copy of the evidence of coverage from your insurer. Make the request IN WRITING. Most states require the insurer to provide the EOC to you within 10 days of the request.

The EOC is your contract with tho insurer, but if you never specifically requested it you've never seen it. This will tell you whether you must rent DME for a period of time, forever, or if you may purchase it outright at some point. If the book doesn't provide for a purchase, I'm afraid you're out of luck.

[Pesser]

The "PR System One REMStar 60 Series BiPAP autoSV Advanced" is $320 per month or $3,200 total. Pushing into next year for 2 payments is a $640 hit which I don't want to take.

I’m from Canada; so up here we buy the machine at extraordinary prices. The exception is when good people like “Julie” give you advice about where to buy.

What you must mean is that the insurance company is paying $320 per month. Do I have this right?

[pswartz]

My insurance company will pay $320 per month for 10 months or a total $3,200 for this machine. This is the “negotiated” rate with the DME’s they have me use (declared to be “in network”). On paper, they charge a much higher rate, but agree to only receive this amount.

I have a HSA, which means I have a very high deductible. Between the sleep studies and other various visits, I am about $1,200 away from meeting my deductible for 2014. If I can get all of the 10 monthly payments in 2014, it means that my insurance will cover $2,000 of the machine purchase (I cover the first $1,200 through my deductible). If all of the payments don’t hit in 2014, my deductible resets and I start paying again.

I’ve asked for the “Evidence of Insurance” but they claim they don’t have one. Still chasing that one.

I also appreciate the compliance aspect of not purchasing outright. But, I am 60 days into this and the Dr. is happy with my progress. She told me I don’t need to come back until the end of the year (averaging AHI of ~2.0).

I have until the end of the year to get this sorted out.

[The Latinist]

I have a HSA, which means I have a very high deductible. Between the sleep studies and other various visits, I am about $1,200 away from meeting my deductible for 2014. If I can get all of the 10 monthly payments in 2014, it means that my insurance will cover $2,000 of the machine purchase (I cover the first $1,200 through my deductible). If all of the payments don’t hit in 2014, my deductible resets and I start paying again.

As I'm sure you can see, the insurance company is saving money by spreading this out over two deductible periods. What incentive do they have to make an exception for you so that you can save money at their expense? These policies were made for a reason, and creating just this kind of situation is part of that calculation on their part. I'm afraid that, if it's down in your contract that way, you probably have no recourse.

[pbriggs]

I have BCBS of South Carolina - I argued for months to buy the equipment out after the 3 months of compliance data. I had no luck - so best of luck to you.

I also argued about carry over from one year to the next - and I lost that one also. I a have the HSA high deductible plan and was pretty much stuck with where they sent me and paid the deductible into the new year. We do have the option to give back the equipment on rental and purchase online. In your case with only 2 months rental towards the deductible it might not be worth it. In my case it also was not worth it.

Best of luck with BCBS and not renting - unless you want to pay for the equipment.

[Janknitz]

In most states it's illegal to deny you the "Evidence of Coverage" document upon a written request. If they claim there is none, call whatever state agency regulates health care insurance in your state to find out your rights in this matter.

Generally, I find that even your insurer may not know the very specific requirements of YOUR plan--they may have several plans, even hundreds of plans, and they are all a bit different. The only way you can be sure of what your plan's policy is on purchase vs. rental is to see it in the document.

Almost nobody knows there is such a document. Particularly when we get our insurance from an employer, we think that the colorful brochure is the be all and end all of the insurance policy. But the EOC is the actual contract between you and your insurer--and you don't even know it exists in most cases--seems to violate a basic principle of contract law, that the terms of the agreement are in the minds of both of the parties when they agree. I still don't understand how they get around it.

In any case, I've been able to overturn some arbitrary decisions because the EOC said otherwise. Most notably, I helped a family whose father committed suicide, but he didn't die right away--he lingered in intensive care for 2 weeks. The insurance company refused to pay for that because it was a self-inflicted injury, but when I pointed out that the EOC did NOT provide for that exclusion, they ponied up the payment. Their excuse for the initial denial was "well, we exclude it in MOST of our contracts". No cigar!

So you may find that YOUR EOC permits earlier purchase of the machine. OR it may provide that the rental period is required. At least you'll know for sure.

[pswartz]

So, an interesting turn of events…. Not sure if my letters to BCBS or intervention from my company’s plan administrator did the trick, but I got a call from my local DME’s office manager (Apria… which I now have a direct dial to the local office – yeah!). He said they are converting my BiPAP to a “first day purchase”. As their billing is about a month behind the service date, they were able to cancel the first month’s rental and re-submit as the purchase. He was very nice and helpful.

Interestingly enough, my administrator said that CPAP’s (E0601) aren’t eligible for “first day purchase”. Glad I have the BIPAP (E0471).

Still waiting for the Evidence of Coverage – I really have no idea what the hidden policy really is and am curious to see it.

Just glad this is going to get covered. AHI of 0.29 last night, too!