First time CPAP - Any way to avoid rental with insurance?

Hi all,

I'm thrilled to have received a prescription from my doctor for an Airsense S10 Autoset recently. I'm keeping my expectations low, but I am very excited about the possibility of sleeping better eventually. My next step is to get the actual device and all of the supplies.

However, I have read many horror stories about traditional DMEs and am interested in testing my luck with alternatives like cpap.com. However, cpap.com doesn't do rentals, which seem to be necessary for having insurance cover the CPAP. Fortunately (or unfortunately, depending on how you look at it), I have hit my out-of-network out-of-pocket max with Cigna, so further out-of-network charges should be 100% covered.

Has anyone tried/heard of a first-time CPAP user who got reimbursement for an up-front out-of-network purchase through some place like cpap.com? How did/would the compliance period work?

The alternative would be to go the traditional DME approach. Cigna is pushing me to use Carecentrix, who said they would saddle me with Apria. Theoretically it would be "fully" covered, but I'm not sure whether to believe this having read so many horror stories of people who were told they were covered but weren't.

Thanks all - I'm a bit out of my depth here, even having searched the forums and reading as much of the fantastic guides that have been posted. Let me know if I can add any more detail to be helpful. Maybe I'm just being overly paranoid about physical DMEs.

Many insurance companies (and Medicare) have a rent to own policy...You rent the machine for 12-13 months and then you own it. By doing that, they can stop paying if you are not using it regularly. (I agree...Aprea Sucks).

On the bright side, you are getting a very good machine. It’s probably what most people here would recommend anyway.

On paper, the supposedly discounted insurance rate may be more than what you could just buy it for. However, if insurance is going to “cover” that, and you are meeting your deductible, your copay may be inline with or less than what it would cost to buy outright.

I paid rental for thirteen months, then I owned. The total outlay was considerably lower than what I would have paid for that machine new.

My first machine was fully paid for with my employer insurance. (With a substantial co-pay)
The second, I ordered from cpap.com, using FLEX dollars.
The current machine was 13 month capped rental, fully paid for
by Medicare and my EXPENSIVE supplement.
How much you spend depends largely on your insurance.
And then there is Secondwindcpap.com.
No matter how you slice it--guess who always pays--YOU.

My rental at the “discounted” rate would have been over double the market price, and divided across two years on my high deductible plan. In other words, it would have been totally out of pocket, for a machine I didn’t want - the Dreamstation Pro CPAP (fixed pressure).

If I had been able to choose my machine, I might have been willing to overpay a bit for the convenience of local support from the sleep lab / DME.

The only accurate answer is *it depends entirely upon YOUR insurance.*

If you are on Medicare, there's NO way around it period.

If you have private insurance--which I assume you do because you are using Carecentrix--it depends entirely on your contract with your insurance company. Bet you've never actually seen the contract. The actual contract is called an Evidence of Coverage (EOC) and you must request it in order to see it. It may be available online or you may have to make a written request. You can call your insurance company and ask how to get a copy. The EOC will specify how DME is paid for (rental or purchase, terms of rental or purchase, deductibles, co-pays) and it may or may not be specific to CPAP.

Once you have that information, do the math. Because it' s so late in the year, even if you only have to use it 3 months before an outright purchase you'd be screwed if you have a new deductible in January. Remember that a rental of 13 months or more is going to guarantee you hit two deductible periods in addition to monthly co-pays. You can buy new from an online supplier like our hosts at cpap.com or consider buying used from Craigslist or Secondwind.com to get what you want, with no hassle and possibly save money. Price it out each way.

Then decide if it's worth it to buy your own or use the insurance to pay for it. One thing in favor of using insurance is it MAY (check your EOC) help you meet your deductible so that you pay less out of pocket for other things during the year.

One thing in favor of not using insurance is you never have to deal with Crapria (or LinDoesn'tCare or any other DME). Do you remember that credit card commercial where they showed the price of things like "two tickets to Fenway Park,--$XXX, 2 hot dogs-- $2, 1 commemorative T-shirt --$X, Smile on your grandkid's face--Priceless." As far as I feel, not having to deal with Crapria ever again -- Priceless! Worth considering if the numbers are close. OTOH, it might make sense to use your insurance this year if you already met your deductible with the sleep study, at least to collect some supplies to have on hand.

You will need to contact your insurance. Most will not pay you back for a purchase, so you are stuck with their rules.

In my case, the insurance did a rental trial and then full purchase. Basically, I had 3 months to meet compliance, and then the rental was converted to a full purchase. They checked my data at 6 weeks, and that was it. No more compliance, and the machine is 100% mine.

I will say if you are in a rent to own contract, keep good records. My Anthem insurance was a 10 month rent to own contract with me pay the 20% copay. The DME billed me past the 10 months and I had their insurance representative cancel the bill and stop the recurrence. I tracked my payments and dates on a spreadsheet.

prodigyplace wrote: ↑

Wed Oct 30, 2019 2:29 am

I will say if you are in a rent to own contract, keep good records. My Anthem insurance was a 10 month rent to own contract with me pay the 20% copay. The DME billed me past the 10 months and I had their insurance representative cancel the bill and stop the recurrence. I tracked my payments and dates on a spreadsheet.

Records are essential--especially if you are not sure who you can trust . . .
And original paper can be GOLD.
Even if it makes you feel like a hoarder.
Remember, they are COUNTING on you tossing it away.

My insurance is handled by Cigna who routed my CPAP through CareCentrix.

I do not actually remember the name of the original DME who contacted me. They told me I had no choice of CPAP machine, that everyone got the same machine. I said that was not acceptable, they wouldn't budge so I called my doctor who found me another DME. Yes, through CareCentrix.

Second DME got me set up with a great machine, let me try lots (and lots!) of masks, and after 30 days compliance, billed my insurance/CareCentrix for the machine. No rental, outright purchase.

As others have said, I guess it depends on how your policy is written.

I will say, it took another year to start getting supplies covered. I paid out of pocket until then.

I have blue cross. They bill my insurance $250 a month which is discounted down to $79 and change. That doesn't include the setup and first payment of $500+

The machine is costing the insurance company and I more than 3x as much as the exact same low hour used machine I purchased (for a backup) from LSAT.

This has been super helpful, thank you all! Particularly the point re: EOY deductible reset, it seems so obvious but I hadn't thought about that at all. Called Cigna, which was... entirely useless and told me to ask the DME how much things would cost. After some math and hand-wringing, I'm going to go in for an eval at a DME to see what the estimated costs are with all this in mind. Worst case scenario, I get a free mask fitting out of it.

I extracted a "we can't tell you which of the DMEs your insurance covers is the least bad but you might want to try this one, hint hint" from my doctor's office, so I'm slightly hopeful. Not so hopeful that I'm not taking detailed notes about every interaction I have with them, but it's something.

If I pass the compliance period in the first 30d period, hopefully insurance will continue to hit my 2019 deductible. Won't be a terribly fun time if they wait until the end of the 90 days (into 2020) to charge my insurance for the cost of the machine, because then I'll have to pay the full copay of whatever inflated number the DME charges. We'll see.

Thanks again -

In summary, there is no way around doing the math and making some calls.
That is your best chance of getting the best deal for the machine YOU need.