Medicare and Cigna, coordination of benefts

I have a general question (and specific details) that perhaps someone can explain.

With Medicare how does coordination with insurance work (just turned 65 so am new to this). Medicare is primary in my case and I have a CIGA (not preferred provider version) through the university I retired from. It is clear that Medicare will pay 80% (if covered and subject to all their requirements). It is also clear CIGNA will not look at a claim until they know what Medicare has done.

I have had been given two explanations for what happens next.

If I understood CIGNA right, after they get the Medicare data, they would look at what they would have paid, and if more, pay that amount. Since I have a 10% copay, for in network suppliers (the only one I have located so far is Apria), I would expect this mean I end up paying 10% if I in network. If a supplier is out of network I would gain nothing since they pay only 70% and this would be less than the 80% Medicare pays.

The other answer I go from an out of net work supplier is that CIGNA would pay the out of network rate on what was left. This would be 70% of the remaining 20%, or $14%, leaving me with only 6%).

Which is correct?

The context is that Apria is the obvious supplier, but appears to be difficult enough to deal with (and far enough away) with that I may prefer to use another if it costs only a little more. (which would be the case if out of network I pay only 6%).

In a previous purchase (before eligible for Medicare), Sleepmed indicated a willingness to adjust prices so that I paid the same amount as if they had been in Network, and after some problems it appears they did. They have a well located office so it is actually possible to make an appointment for a mask fitting and go there, although the one time I did this, they brought only one size of the mask and fitted that.

I realize another complication is that the reimbursement prices Medicare negotiated and Cigna negotiated may be different, but I do not know what they are or just what happens when they differ.

Your Medicare will cover 80%; cigna should cover the remaining 20% (once again call a provider and have their insurance folks run the insurance). Being Medicare primary you will have to: 1) Wear the cpap for >4hrs per night for 21 out of 30 days and 2) have a follow-up visit with your doctor between days 31-90 of your cpap therapy. These things must be met in order for Medicare to make payment.


I also read your other post about wanting the quattro. You should not have an issue obtaining this mask, since your insurance is Medicare primary.

Also, how old is your original CPAP??

cpapquuen1 wrote:Your Medicare will cover 80%; cigna should cover the remaining 20% (once again call a provider and have their insurance folks run the insurance). Being Medicare primary you will have to: 1) Wear the cpap for >4hrs per night for 21 out of 30 days and 2) have a follow-up visit with your doctor between days 31-90 of your cpap therapy. These things must be met in order for Medicare to make payment.

Also, how old is your original CPAP??

So your understanding is hat between the two I should end up fully reimbursed? Nice.f I can survive the paperwork and find a supplier that gives me no problems.

I can understnd Medicare wanting some proof I need CPAP, but it sounds rather silly if you have been being treated by years (am on third machine) you should need to see a doctor just for their requirements. Hopefully, this applies only to patients who just started treatment and for who follow up may be needed.

My machine is fully paid for and still working, so wha i need to do to get a new machine may not be an issue. However, if it appears there is a much better machine out there than the M series Bi Auto I use, would have just started Medicare mean they would pay for a new one even thugh the older one was less than 5 years old and still working?

The kicker may be that your unit is less than 5 years old. 5 years is Medicares 'mgaic numbert' that most providers follow across the board regardless of the insurance.

There really hasn't been many upgrades from the unit you have. If it were me, I'd go to a supply get my supplies at 100% coverage and wait my 5 years out. There are some pretty nice unit changes on the horizon. I would hate for you to get a new unit now, then be stuck with it when the new units come out.

I will disagree w/this. Medicare did NOT pay for that first bi-level so there should NOT be a problem w/their purchasing a new bi-level. HOWEVER, Medicare does require a current sleep study.

No new sleep study needed as long as the intial PSG meets the qualifications. The 5 year mark is what most providers follow.

cpapqueen1 wrote:The kicker may be that your unit is less than 5 years old. 5 years is Medicares 'mgaic numbert' that most providers follow across the board regardless of the insurance.

There really hasn't been many upgrades from the unit you have. If it were me, I'd go to a supply get my supplies at 100% coverage and wait my 5 years out. There are some pretty nice unit changes on the horizon. I would hate for you to get a new unit now, then be stuck with it when the new units come out.

While I am not considering a new unit now, what changes do you expect? It seems that for may people there could be issues of strategy in when (or if) they upgrade. As you note with a 5 year rule, if you had just upgraded you might be foreclosed from getting a new feature that was really needed.

There is probably scope for improving the algorithms for detecting apneas, etc. but it appears hard to learn what they are now, and hence it will be hard to know if there is a real improvement (much less if it will help you).

It is not clear what you mean by "go to a supply get my supplies at 100% coverage". I assume you mean I should find my supplies are 100% covered between two plans and that I should just get supplies (and I assume masks) as needed and wait until there is a clear reason for a new machine.

The immediate issues have to do with the logical supplier (Apria, who may be the only one who is on both list) apparently expecting me to drive across town (35 minutes each way by Mapquest) for a mask fitting (they may be willing to mail one), or if I pay just a few dollar more with an out of network supplier dealing with someone who is more convenient (possibly Sleep med), gives better service, and works well with my doctor. Potential supplies are unable (or reluctant) to give quotes without all of the paperwork in place, and the doctor's nurse will probably be reluctant to be faxing a pile of paperwork to every potential supplier.

One reason for discussing these issues here is that I suspect there are many others with similar issues (Medicare is very common and Cigna is also big).

Your comments do suggest there may be some strategy issues for someone who is almost eligible for Medicare. If financially pressed, they may benefit from waiting till they are covered and then having two insurance plans (assuming your understanding is right that in the end everything will be covered). Possibly other would benefit from getting some things done before Medicare and then being able to use Medicare. Some are implying you could for instance get a machine or a sleep study now, and then Medicare might pay for another later, when Medicare would not pay for two in rapid succession.

Given the paperwork problems, at least some might want to get supplies or masks before Medicare is involved simply to avoid problems (Cigna and I think most similar retirement plans stop paying if Medicare will so you will have to go through Medicare to get anything).

Although not a sleep apnea issue, I made the mistake of having my children's pediatrician give me a flu shot while giving them to the children (convenient and showed the children that it need not hurt much). Pre-medicare eligibility they had just sent this through and my insurance paid for it. However, once I had Medicare I discovered they were not able to bill Medicare (pediatrician apparently have too few over 65 patients to do what is needed to get a Medicare number, etc). The result was a $165 bill (they apparently bill for looking in you mouth for a second and calling that a physical) which Cigna rejected since I had not gone through Medicare first.

I had previously found one supplier (Sleepmed) was willing to settle for the Cigna out of net-work amounts on a mask, but I think Medicare rules make it hard to do such deals.

Some just approaching the start of Medicare may want to buy supplies etc. before hand just to avoid the hassle of getting the documentation required by Medicare to their supplier.

I will address the insurance issues first. Medicare will indeed pay 80% of their allowed amount. As your insurance is not a Medicare supplement you will very likely be subject to deductibles and co-pays. There could be a difference between in in-network payment % and an out of network payment %. You could also be subject to a separate deductible for in-network versus out of network claims. You also alluded to separate allowables. These can be tricky as some "carve out" the 80% that Medicare pays as their allowable and then pay $0.00. I will show you various scenarios:

Medicare allows $100.00:
Pays $ 80.00
Medicare Supp $ 20.00
You owe $ 0.00

Medicare allows $100.00
Pays $ 80.00
in network ($200 deductible) pays $ 0.00 Until November when deductible is met
Then pays 20% $ 20.00

Medicare allows $100.00
Pays $ 80.00
in network ($200 deductible) pays $ 0.00 Until November when deductible is met
Then pays % of their allowable (80% of 20%) $ 16.00
You pay $4.00

Medicare allows $100.00
Pays $ 80.00
out of network ($200 deductible) pays $ 0.00 Until November when deductible is met
Then pays % of their allowable (70% of 20%) $ 14.00
You pay $ 6.00

Medicare allows $100.00
Pays $ 80.00
Medicare "carve out" (allows $80.00 and since Medicare already paid this amount they pay $0.00)
You pay $20.00

The carve out insurance is good for those item Medicare does not cover but not so good for Medicare covered items and services. The only way to know for sure what your insurance will pay is to call and ask. Give them the costs and ask what you will be responsible for.

As for your equipment:

Sleep studies are good for life (for Medicare) as long as you meet their qualifying criteria. Medicare does not care if you own equipment (as long as Medicare did not buy it). You can wait until your patient owned wears out or get new. If you wait you can choose to get new equipment whenever you are ready. Medicare will still pay for supplies as long as your provider informs Medicare that the supplies are used with patient owned equipment and all qualifying documentation (like the sleep study and a current doctor's order) are on file. When you do receive new equipment you will be subject to the compliance criteria of 21 days out of 30 with at least 4 hours continuous usage per night.

Hope this helps!

To give you an idea: Resmed came out wlthe S8 series in 2006 and the the S8 II series w/its EasyBreathe technology in 2008.

Respironics came out w/the M Series in 2006 and just this month has introduced the PR SystemOne. The PR SystemOne Auto is the only one of this series I have any information on but it is a totally new look and design and the information provided on it sounds like the darn thing will do everything for you but sleep. Check it out at cpap.com for the details on it.

I've only been on CPAP 3 years this month but it appears that the manufacturers are coming out w/newer, more sophisticated devices every 2-3 years.