Change in Medicare replacement equipment coverage?

Random unimportant question here but I'm curious if there was some change in Medicare's equipment replacement coverage. I've been using a nasal pillow mask almost since the beginning of CPAP five years ago. In the beginning, Apria flat out refused to provide me with two pillows per month, saying that the coverage provided replacement pillows every two months. After going round and round with them, and being told from you guys exactly what is actually covered under Medicare rules, I was still simply refused that coverage. One of the reps for Apria even went so far as to tell me I was trying to defraud Medicare by getting more supplies than I used. So for a couple of years, I purchased the extra pillows myself out of pocket.

However, in just about the last year, Apria has started calling me incessantly every three months when my equipment is due for replacement. And they will continue calling until they reach me and get me to order replacement parts, including 6 pillows every three months. The calls started out of nowhere and they began pushing the pillows at the appropriate schedule.

So it's just leaves me wondering if something changed? Is it Medicare or Apria? Was there some kind of crackdown on their refusal to provide two pillows a month (I was far from the only person complaining about that)? Or is this just a fluke in my situation? Anyone?

Apria policy changed. They were in error with the every 2 month thing and someone finally woke up and realized they were missing out on a golden goose who could spit out 2 nasal pillows per month.
They were missing out on revenue and now they realize they can make more money and that's why they are pushing the nasal pillows now. Medicare won't allow automatic shipment...Medicare requires that you ask for the replacement (which implies that yours are worn out) before Crapia can ship...hence they keep at the phone calling until they get you to say "yeah, I want the replacements".

Pugsy wrote:Apria policy changed. They were in error with the every 2 month thing and someone finally woke up and realized they were missing out on a golden goose who could spit out 2 nasal pillows per month.
They were missing out on revenue and now they realize they can make more money and that's why they are pushing the nasal pillows now. Medicare won't allow automatic shipment...Medicare requires that you ask for the replacement (which implies that yours are worn out) before Crapia can ship...hence they keep at the phone calling until they get you to say "yeah, I want the replacements".

Okay, that makes sense now. The incessant calling is due to me not answering the phone until I actually need equipment. And they will sometimes call daily until I finally pick up. lol My pillows actually seem to last about 3-5 weeks and there's no predicting how quickly or how long they will take before the major leaks start - I've had two pillows now that had major leaks from the start and had to be tossed, but most last around a month. I keep a couple of extra on hand but definitely not the stockpile they would allow me to build if I replaced on schedule.

Crapria - I had forgotten that nickname! LOL

Is anyone familiar with Medicare "advantage" plans; for instance,
does replacement frequency vary from straight Medicare?
When I used Apria here, they replaced cushions at Medicare-specified intervals.
Of course, when I allowed them to do three months at the same time,
they then failed to correctly do the paperwork, and were never paid by Medicare--NEVER!
Of couse, I was off the hook, as their mistake is THEIRS completely.

Do people really need to replace the pillows that often? I think I've been using the same ones for at least 6 months now and they seems to still be working fine. Are some people wearing them out with excessive cleaning?

chunkyfrog wrote:Is anyone familiar with Medicare "advantage" plans; for instance,
does replacement frequency vary from straight Medicare?

They follow regular Medicare guidelines. Medicare advantage plans are all tied to what Medicare will allow for everything for cpap supply needs.

I have a Medicare Advantage plan. The main difference is co pays for other stuff like hospital stays or out patient surgeries. Medicare Advantage plan users assume a greater risk for co pays in exchange for substantially lower monthly premiums. Unless someone has significant health issues that puts them in the hospital fairly often so that co pays add up quickly they will usually save out of pocket costs long term.

Back when I broke my wrist and required surgery I added up my co pays for the whole thing...ER, doctor office, x-rays, out patient surgery center...and it was around $700. At the time my Advantage plan didn't cost me anything per month (now it is $29) so I still saved money even with a fairly substantial out lay of cash because a medicare supplement (if I could even find one that would cover me) would have cost probably at least $100 a month. So monthly premium for a year would have been at least $1200...vs the $700 I paid for stuff that would/could have been covered by a supplement still was a win situation for me.

Medicare Advantage plans are all tied to what Medicare allows...just like supplements are tied to what Medicare allows. The coverage isn't sub par...it's just we accept the risk of maybe paying more out of pocket if something happens vs for sure paying more out of pocket with premiums for supplements.
It's a for sure pay now vs a maybe pay later thing.

For me it works out well. I don't have health issues that increase the need for doctor visits or chances of hospital stays which would increase my out of pocket costs.
Insurance is a gamble...I am betting I won't need it and so far I have been a lot of money ahead.
Since I am under 65 with Medicare...there aren't many supplement plan insurers who will even cover me and the ones that did wanted close to $200 a month (last time I checked).

I can still get my cpap supplies on the same schedule everyone else does who has regular Medicare with the same 20% co pay. In exchange for minimal premium I pay the co pay myself. I still save a ton of money each year.

yaconsult wrote:Do people really need to replace the pillows that often? I think I've been using the same ones for at least 6 months now and they seems to still be working fine. Are some people wearing them out with excessive cleaning?

I've got nearly 2 years on my first p10 pillows, thinking I might swap out for a new one to see if I can see any difference in feel/performance, and if not, switch back to the old one, just to see how long it lasts.

If my pillows get beyond a certain age, no amount of cleaning will make them fit like new.
Maybe I'm addicted to "new pillow smell".

chunkyfrog wrote:If my pillows get beyond a certain age, no amount of cleaning will make them fit like new.
Maybe I'm addicted to "new pillow smell".

such a spoiled frog

yaconsult wrote:Do people really need to replace the pillows that often? I think I've been using the same ones for at least 6 months now and they seems to still be working fine. Are some people wearing them out with excessive cleaning?

I think they chew on them while asleep.

I've had my Swift LT pillows for about 8 years and they still work just fine. Only thing that has worn out is the head strap and I replaced the head gear earlier this year.

Medicare Advantage programs are required to provide the same classes of goods and services as traditional Medicare. The difference is that instead of fee for service, Advantage pays a capitated amount (per head) to the HMO, and the HMO pays out for services instead of Medicare. That limits your choices significantly. For example, if you have a Kaiser Advantage plan your only option is Crapria. And because you are Medicare you can't even go "out of network" because it's illegal for a Medicare certified provider to bill you privately. Your choices are more limited on some Advantage plans. Kaiser, for example, has a limited formulary for machines and masks. Want something not on the formulary? Tough luck.

You also have to watch that your Advantage provider is following the Medicare rules. When I was a practicing OT, Kaiser would routinely deny things like off the shelf braces and splints Advantage patients needed until I wrote letters pointing out they were covered by Medicare and it was illegal to deny paying for them because they were not custom items if they were allowed by Medicare.

yaconsult wrote:Do people really need to replace the pillows that often? I think I've been using the same ones for at least 6 months now and they seems to still be working fine. Are some people wearing them out with excessive cleaning?

I replace my pillows when they begin to leak and keep me or my bed partner awake with whistling leaks. That averages 3-5 weeks for me. Sometimes longer but not often. I have tried to refresh my pillows by boiling them and found that to be totally useless.

DreamStalker wrote:
I think they chew on them while asleep.

I've had my Swift LT pillows for about 8 years and they still work just fine. Only thing that has worn out is the head strap and I replaced the head gear earlier this year.

No wonder nobody wants to trade swift LT medium and small nasal pillows for Swift LT large nasal pillows ....the nasal pillows never wear out, just the headgear!