Insurance question

Hi all! It's been awhile since I have been on here. After I sorted through all the newbie bumps in the road, it was smooth sailing, so I've stayed quiet.

Here's my issue: I used to have awesome insurance that covered 100% of all of my neuro appointments ($25 co-pay per visit) and 100% of all DME supplies (no co-pay at all). I had Blue Cross Blue Shield of Illinois Blue Advantage HMO.

In June, I switched company's and, after evaluating my options, decided to go with an HDHP (high deductible health plan). Now, I have to pay full price for my neuro appointments and full price for all DME supplies **until** I reach a $2,500.00 cap. Then everything after that is at no cost and covered 100% by insurance. The insurance I have now is through Allied (a TPA) and the medical network is Cigna.

I got my CPAP machine, mask, and accessories through my DME back in late March of 2014 when I was still with my old insurance provider, and paid $0 for it all. After 6 months, I'm now finding that I need a new mask, extra pillows, and filters. Eventually (maybe at the one year mark?), I will need new tubing and a new humidifier chamber, but that's later down the line. With my new insurance, I'm paying out of pocket for these supplies until I reach my deductible amount.

So my question is: Is there a place I can go to get CPAP supplies at a discounted price **and*** that my insurance will recognize as a DME provider, enabling me to apply the money spent toward my deductible? I'm asking because I don't want to spend an arm and a leg at my current DME (located in my neuro's office) if I can get things for cheaper elsewhere. But in the same vein, I don't want to spend money at a discount supplier that my insurance doesn't recognize, bc then I would be spending money that wouldn't apply towards my deductible.

Can anyone help?

WindyCityEsq wrote:that my insurance will recognize as a DME provider,

This is the part no one can answer except your insurance company.

The best thing to do is contact your new insurance and find out which DME's they consider in network. Each insurance is different so it is hard for other to answer unless they have the exact same policy.

Found some in network DMEs. They said if I wanted to... I could go to an out-of-network DME (if the regular prices at that out of network DME were cheaper) until I reached my deductible, then I could switch to an in-network provider. But that out-of-network provider has to be a legit provider. As in, they need to give me an itemized invoice with their Tax ID #, and include diagnosis codes and CPT codes. Any one know of any discount online retailers that would provide all of this? I would need to enclose it with a claim form.

Contact the host of this board...cpap.com

If your high deductable is annual based on calendar year, it probably won't mater if you need supplies before the new year.
I went 40 years without insurance and am ahead because I seldom reach the $1,000 deductable level in a calendar year. The years that I did a large portion was dental which wouldn't have counted anyway.
So even with a $40,000 year for cancer treatment I am still ahead of the game.
You need to learn to use a spreadsheet like excel to make your choice and then be prepared to live by your choice. You can also attempt to schedule your expenses to aggregate in alternating years. Avoid costs this year than plan for Jan June and Dec expenses next year.
You might choose a $5,000 or $10,000 deductable for only catastrophic expenses and lower premiums. You can than apply the premium savings to paying your own way on your own terms.

You need to be careful and ask for clarification from your Insurance company.

For example, I can use an Out-Of-Network DME and cpap.com would work for that, but the deductible for that has a higher yearly limit of $1500. In-Network DME's would have a yearly limit of $850.

So If your insurance was like mine, using an Out-Of-Network DME would work but the deductible would not have any effect on the In-Network one and is higher.

Krelvin wrote: So If your insurance was like mine, using an Out-Of-Network DME would work but the deductible would not have any effect on the In-Network one and is higher.

Thanks. For my insurance, it makes no difference. $2500 is the deductible- whether that is spent on in-network or out-of network, on RX meds or prescriptions or visits/appointments, it doesn't matter. $2500 must be paid first. THEN the plan kicks in. 100% coverage for in network providers and RX meds and equiptment. If you go out of network, you get 40% co-insurance plus a $7500 out of of pocket max. So while it makes perfect sense for me to remain in network once my deductible is met, there's no real advantage of doing it prior to that unless the in network provider is cheaper.

I had a highly informative -- heck, downright gossipy! -- conversation with a CIGNA network customer service person. She even emailed me a list of the network. I live in rural western IL, and so she gave me some national mail order places. She highly recommended Edgepark Medical. She also said that Liberty Medical (the place that advertises on TV for diabetic supplies) is a great go-to place if you need something unusual, especially a mask in an exotic size. Alas, cpap.com is NOT in their network...

A few warnings -- CIGNA contracts with a place called CareCentrix which is a cost-control company. Basically they seem to have a business model of doing everything stupid and driving patients crazy. You might get told that Lincare is in CIGNA's network. Well, yes, they are, sort of. But CareCentrix screwed them over on bills, and my local Lincare (the only "in-network" DME within 30 miles) refuses to deal with them. Quote from the CIGNA lady: "We really like them, and they used to like us. We liked it better when they liked us..." I suspect a lot of times when DMEs refuse to be reasonable it's because companies like CareCentrix use any bending of the rules as an excuse not to pay the DME. Another thing -- if you are on a CIGNA POS network, that is way more restrictive than a PPO network, and the DME might refuse to deal with you.

I'm in a different situation in that CIGNA is the network, but they are not paying the bills -- the bills are getting paid by my husband's employer and the bill payer is a 3rd-party administrator for self-employed plans. And the plan is set up by the employer with the assistance of the administrator, and the rules are for that plan, and not CIGNA's rules. So in my case, the first two months with the machine are rental, and then the third month they buy it. With regular CIGNA plans, there is 10 months of rental before you buy.

I think there is a way that insurance will recognize money spent online for CPAP supplies. I would contact cpap.com & ask to speak to someone about how this works. I think they provide an invoice that supplies all the correct billing codes, thus giving the insurance company the info they need to recognize them. After speaking to them, also contact Cigna & check to make sure they will accept this type of invoice, but I know there are forum members who have done this.

I have the high deductible plan thru my hubby's employer, but I also have Medicare & Aetna, so once the 1st insurance applies it to my deductible, my Medicare, then Aetna pay some, so I'm only out a portion on mine. Different for my hubby, all his applies to deductible, but is out of pocket. I usually meet the $3,000 amount of our deductible by March & it is a family deductible, so that takes care of it.

I have an HSA account and we use it to pay for expenses incurred during the period of meeting the deductible. If your employer offers the HSA or even a FSA these accounts can be life savers when meeting deductibles. I think to get the HSA you must have a high deductible plan, which you do, so you might want to ask if your employer offers the HSA (Health Savings Account). It may be too late to get one for this year, but next year's open enrollment will be just around the corner for most employers, so might be something to think about. In case you haven't had any exposure to them, these accounts, both HSA & FSA are in pre-tax dollars, which saves a lot of money in the long run.

Good to hear you are doing good with therapy & good luck getting the insurance vs. better priced DME issue figured out. Hope I've helped some.

Jen

cathyf wrote:I had a highly informative -- heck, downright gossipy! -- conversation with a CIGNA network customer service person. She even emailed me a list of the network... Alas, cpap.com is NOT in their network... A few warnings -- CIGNA contracts with a place called CareCentrix which is a cost-control company. ...Another thing -- if you are on a CIGNA POS network, that is way more restrictive than a PPO network, and the DME might refuse to deal with you...I'm in a different situation in that CIGNA is the network, but they are not paying the bills -- the bills are getting paid by my husband's employer and the bill payer is a 3rd-party administrator for self-employed plans. And the plan is set up by the employer with the assistance of the administrator, and the rules are for that plan, and not CIGNA's rules..

THANK YOU for your response. Thank you and HELP ME please, lol.

I'm like you. My medical network is CIGNA PPO ("Cigna Great West PPO" to be exact). But it is through a TPA (third party administrator) through ALLIED since my employer is self-insured. Cigna also referred me to CareCentrix bc the only in-network DME within 30 miles from me was in Gary, IN (we call it "scarey Gary" bc it was the murder capitol of the country for several years in a row and there's no way in heck I'm traveling to Gary, even in the broad daylight). What can I do? Advice, suggestions, tips? Can you forward that emailed list the rep sent you? Anything that you think will help. Thanks so much Cathy!

WindyCityEsq wrote:Found some in network DMEs. They said if I wanted to... I could go to an out-of-network DME (if the regular prices at that out of network DME were cheaper) until I reached my deductible, then I could switch to an in-network provider. But that out-of-network provider has to be a legit provider. As in, they need to give me an itemized invoice with their Tax ID #, and include diagnosis codes and CPT codes. Any one know of any discount online retailers that would provide all of this? I would need to enclose it with a claim form.

CPAP.COM
DIRECTHOMEMEDICAL.COM
are two I have used exactly as you described.
For others, check to see if they provide an invoice with the data your insurance company requires.

WindyCityEsq wrote:I'm like you. My medical network is CIGNA PPO ("Cigna Great West PPO" to be exact). But it is through a TPA (third party administrator) through ALLIED since my employer is self-insured. Cigna also referred me to CareCentrix bc the only in-network DME within 30 miles from me was in Gary, IN (we call it "scarey Gary" bc it was the murder capitol of the country for several years in a row and there's no way in heck I'm traveling to Gary, even in the broad daylight). What can I do? Advice, suggestions, tips? Can you forward that emailed list the rep sent you? Anything that you think will help. Thanks so much Cathy!

I called my 3rd-party administrator and they connected me to CIGNA but told me the phone number in case I wanted to call on my own -- which I did! It's 800-645-8419

I'll paste in the IL list that I got from them, but you need the Indiana list, too (I'm thinking the Iowa list isn't going to do you much good...)

They have a database search that is based upon distance, so you should try to get them to search based upon your home (which you've done, and it's Gary.) But also have them search centered on big towns near where you live, where you work -- heck, tell them you are willing to go to Chicago that should open up a whole lot of options in the South suburbs that might be reasonably easy for you to get to. Or try the other direction. I lucked out in that there are 2 in-network DMEs in the town I work in, which is in Iowa. Be aware that their searches tend to end at state boundaries, which is a pain if you live near the border. So make sure that they search based on both Indiana and Illinois towns. Because of the technical details of how those searches work, when you tell them Illinois you could easily have places pop up that are closer to where you live or work than Gary is anyway. Or because Chicago is the major metropolitan area and all the highways lead in and out of there, it's possible that there are places that are further away that are easier to get to than the ones that are closer as the crow flies. (Unless you are a crow. And then I'm sorry to say that you will NEVER find a mask that fits over your beak! )

Also, I blame YOU that I am singing "Gary Indiana Gary Indiana Gary Indiana..." from The Music Man over and over in my head now.

Dynasplint Systems Inc
IL
(800) 638-6771
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Smith & Nephew Inc
IL
(800) 821-5700
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
DJO, LLC
IL
(800) 328-2536
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Carecentrix Inc
IL
(877) 466-0164
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Alere Home Monitoring Inc
IL
(877) 262-4669
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Edgepark Medical Supplies
IL
(800) 321-0591
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Electromed Inc
IL
(952) 758-9299
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Orthofix, Inc
IL
(800) 535-4492
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Prentke Romich Company
IL
(800) 262-1984
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Advanced Respiratory
IL
(800) 426-4224
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Luna Medical Inc
IL
(800) 380-4339
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
mdINR, LLC
IL
(800) 293-3730
Participates in: LocalPlus, HMO, OAP, OAPC, PPO
Dynavox Systems LLC
IL
(800) 344-1778
Participates in: LocalPlus, HMO, OAP, OAPC, PPO

Here's a possible idea, you could check to see if the scarey Gary DME (or one from cathyf's list) could mail you supplies. I live in a small town across the river from Louisville, KY. My new DME got my necessary info from my Dr then took my order over the phone & mailed what I needed. I've never actually been to their office, since they were willing to mail to me. No postage charge either. Just a thought.

Jen