Ahh.. the Insurance changed.... WAPITB!

This is Long...

Well... Insurance is a joke sometimes...

Since June, I maxed out my copay's and out of pocket expenses with a wonderful hospital trip which made medical payments after that easy... no copay's!

I got my new Xpap Sep 9th, paid a CoPay but got it back. Machine (S9 VAP Auto BiLevel) was on rental for 10 months... No Copays... So far, 4 rental payments have been made.

Now.. Jan 1st (Actually Dec 24th), the company I work for changed insurance companies... Pretty much the same pricing and coverage BUT ... the 10 month rental ceased, and became a new 13 month rental. At first, the DME tried to tell me that the rental payments already made would disappear but when I talked to the owner and suggested he might rethink that for a second... they called back and said they would apply them to the cost of the machine.

The new insurance will buy the machine outright. Sure wish the previous one had.

So, the adjusted purchase price is close to $1233.00

However, new year, new Deductibles go into effect, same as last year but still $850. After that, the insurance covers 80% up until maximum out of pocket is reached ($4k), again same as last year.

Doing the math...

DME charges 1233.00 - $850 deductible = $383.00
Insurance then covers 80% of the balance so my "copay" is $76

So my total of pocket is $ 926 ($850 deductible and copay of $76)

Oh and of course I will now have used up all of my deductible which will effect other things that get paid like meds etc... a good thing!

Other options.

Give the machine back. I have an M-Series BiPap that is now my backup. But I actually like the S9 a lot more... so that really is not an option, plus the M-Series is quite old and I also already paid for the H5i humdifier ($0).

Buy an S9 from CPap.com... They are still selling them and they have been reduced, but it ends up costing me actually about $65 more. Funny thing is that the new insurance treats out of network durable medical just like in network so it is the same 80%/20% split and the deductible is the same one. So out of pocket that way would be closer to $993... of course the DME would end up getting the S9 itself back. So I would end up paying more but the DME would end up with a used machine and I would have a new one.

SecondWind. When I looked, they didn't have the S9 model I need. Will call them tomorrow, but then there is also the part where I don't think Insurance will use them at all, so while I could use my Flex spending for it just like the other options, I would not be reducing my Deductible which ends up making it more expensive unless they had a really good price. I don't think their price would be that good.

Find a used S9 model I need. Possible. Would have to be a real deal though... same issues with the deductable and might have issues using Flex spending.... so over all might cost too much.

I've got some time to figure it out (next rental payment is the 18th)... Sure glad I looked into this today. Was really the first day to talk to anyone since the 1st.

No real advice, just some commiseration... I got my machine on Oct 10, and hadn't seen any claims at the beginning of Dec, so I pestered the DME. They said that the prescription wasn't signed, so I pestered my PA and she promised to look for it. When I started with the DME I told them what the insurance told me -- that they would pay 2 months rental, and then the next month they would pay for the balance of the machine. Which was why I needed to get the machine in October... Today I got the insurance EOB. The DME billed for $115 on Oct 10 and Nov 10, and the Ins Co discounted it by $11.50 and paid 80% ($82.80) of the remainder and tells me I owe $20.70 for each month. The DME billed $115 for Dec 10, and the insurance company declined it with the following reason code:

"DME has been rented for at least one month. Please rebill with purchase price."

You know, it would be a whole lot simpler if people just follow directions...

Realize that if you are going to meet your deductible anyway during the year, the variable cost of buying it vs. not buying it is only 20% of the deductible. i.e. you pay $850 now, but your next $850 worth of expenses only costs you $170 in copays instead paying the full $850.

DME charges 1233.00 - $850 deductible = $383.00
Insurance then covers 80% of the balance so my "copay" is $76

From what I can tell, my insurance does that a little differently and only applies the
deductible to the portion they pay. It something like this:

$1233* 80% = $986
$1233* 20% = $246 (co-pay)
$986 - $850 deductible = $136 (What they pay)
$1233 - $136 = $1097 (What I would have to pay)

I also found out that I have 10 different deductibles: One for each family member for in-network expenses (total of 4), a completely separate one for each family member for out-of-network expenses (another total of 4), a 'family' deductible for in-network expenses, and a 'family' deductible for out-of-network expenses. With the kids away at school, it is pretty common to hit both the in-network and out-of-network deductibles pretty hard.

Blue Cross of Alabama has a 90% market share in this state and has nearly $1 billion in 'un-assigned' funds. This is money that they have collected in premium and have not distributed. This money is apparently exempt from the regulations that require them to pay out what they are taking in in order to retain their non-profit 501(m) status and other regulations for insurance companies. (Blue Cross of Alabama is not technically an insurance company).

Cathy~ Sounds like your EOB is stating that they will pay the purchase price after the first month, which would make it November.

DME's cannot submit a claim to an insurance company without everything needed which is why there was delay. Insurance companies have a timely filing limit on when claims can be submitted, Medicare's is a year. So if you received supplies on 12.12.14, the supplier has until 12.12.15 to submit the claim.

Well... further checking shows that the Insurance agent on the phone wasn't accurate as to the deductible for Out-of-Network. She said it was the same deductable, but in fact the is not. In Network is $850 and Out of network is $1,700.00. That pretty much eliminates using Cpap.com and sticking with the DME that the equipment came from.

Attempting to get a quote on what the actual cost to me will be... seems that neither the DME or the Insurance company is my advocate which is not a surprise.


Still working on it. BTW I did see a used ResMed S9 VPAP/BIPAP Auto machine on SecondWind which if I had no insurance, I would most likely get... Used for $769 with free shipping and 1 year warranty.

Your cost will actually be a little less than what you figured. You will only be responsible for the amount that is the "allowable" from your insurance, NOT the amount that the DME bills. You need to ask your insurance what the allowable is for the HCPC code for your machine. Example - the DME may bill 1000.00 but the allowable may only be 800.00. Your deductible then would be subtracted from the $800. These figures are just an example.

The amount they are talking about is the allowable amount. Not just what the dme wants to charge.

Sorry.... I misunderstood the statement: " DME charges 1233.00 - $850 deductible = $383.00
Insurance then covers 80% of the balance so my "copay" is $76". I stand corrected.