Medicare and equipment

My father is going to be getting a CPAP machine. With a prescription can he buy online and get medicare to pay for it or do they only work with the DME's.

He's likely going to buy it himself and not deal with the DME's at all, but I thought I would ask since medicare is an option for him.

Thanks,

For Medicare to pay, you must go through a DME that accepts Medicare. The cost will be much less going through Medicare. Our machines would have cost us less than $20 a month for thirteen months. They sell for over $1700 through the online sellers.

There are some online DME/cpap retail suppliers that will file with Medicare and accept what Medicare allows and are happy with the 13 month capped rental that Medicare makes them do but most regular online DMEs like cpap.com or some of the others won't file Medicare and if you buy from them you can't file yourself and get reimbursed.

If he has Medicare "advantage", ask what they will dispense--sometimes it's not so good.
It makes sense to get the best you can for as little as possible.
Full data is an absolute MUST.
Auto is advisable for anybody--it can help you reach optimum treatment quickly.

Medicare will pay for ANY CPAP machine (CPAP or APAP). They require a 13 month "capped rental" and that means you also must pay two annual DME deductibles since it spans more than 1 year. Medicare sets the monthly rental and pays 80%, your dad or his Medi-Gap insurance policy pay the remaining 20%.

Most people on Medicare are in "competitive bidding" areas. That means they are limited to which DME companies they must use. If the insurer is a PPO or Advantage plan, he may have no choice as far as which DME he can use.

So the firs step is to determine which DME providers he can use with his Medicare plan. Medicare will not reimburse for online retailers although there are a few certified Medicare DME's that work online for people not in a competitive bidding area, but they generally are not very good to deal with--they tend to have a limited formulary of machines.

Your dad should do the math between what he will pay out of pocket himself with Medicare and without it. It's usually more to buy his own (unless he wants to buy used) but far less hassle.

Now the next hurdle is this. Medicare pays by HCPCs code (billing codes). All CPAP and APAP machines are the SAME billing code, whether it's a cheap brick or the top of the line machine. If the DME foists the cheap machine on your dad, they make more profit. If your dad wants the top of the line, they will do everything possible to discourage him from getting that machine because it eats into the profit margin. So whether your dad plans to pay out of pocket or use his insurance, he should decide what machine he wants to get. Then decide if it's worth arguing and fighting with a DME to get what he wants or just buy his own. While he may save having Medicare pay, the hassle factor should be considered if he can afford to buy it himself.

Keep in mind that if he goes through Medicare to get his machine, the DME is obligated to service the machine if it breaks down in the next 5 years. Otherwise he is stuck with the manufacturer's 1-2 year warranty and may have to mail in his machine and be without it while it's being fixed.

Note: some of the posters above have suggested full data, but be aware we are talking about full EFFICACY data. All machines record usage because you have to prove compliance for Medicare to pay. But machines with full EFFICACY data will help your dad dial in the best treatment.

And my rule is NEVER, NEVER, NEVER, EVER, EVER, EVER Trust what a DME tells you about ANYTHING. Always check--with Medicare, his insurer, his doctor, us before believing what they tell you. Their goal is not to provide the best therapy for your dad, they are in the business to make money. If that happens to coincide with your dad's needs great, but his health is not their primary concern.

Janknitz wrote: ↑

Mon May 20, 2019 1:48 pm

And my rule is NEVER, NEVER, NEVER, EVER, EVER, EVER Trust what a DME tells you about ANYTHING. Always check--with Medicare, his insurer, his doctor, us before believing what they tell you. Their goal is not to provide the best therapy for your dad, they are in the business to make money. If that happens to coincide with your dad's needs great, but his health is not their primary concern.

AMEN to that !!!!!

Many of them are the slime of the earth, taking advantage of those of us that are truly suffering with a terrible condition.

And I did forget to say that Medicare Advantage plans may not pay for "any" XPap machines. They have their own formulary and can dictate the make and model you will get covered. But the same is not true for traditional Medicare.

What janknitz said re Medicare is very accurate except for the competitive bidding part. There is currently a temporary moratorium on competitive bidding in Medicare, so any enrolled DME supplier can furnish equipment. Finding one of the contracted competitive bid suppliers is not necessary for now. That moratorium could end by 2020.

The important thing to always remember is use a supplier enrolled in Medicare if you want the program to pay. Call 1-800 MEDICARE to find local suppliers, or use the supplier search tool on the medicare.gov webpage.

Suppliers will carry equipment that allows them to make a profit. So you may have to check with several enrolled companies to find what you want. That goes for most any insurance, not just Medicare...