obtaining cpap rx from Kaiser

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Janknitz
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Re: obtaining cpap rx from Kaiser

Post by Janknitz » Mon Oct 25, 2021 8:11 pm

I was also given the option of buying or renting for 13 months. Not knowing how well it would work for me I chose to rent. I went home with the Airsense 10 Auto, heated hose, N20 mask and headgear and two filters all in a case. After less than 2 weeks I was sold. I emailed Kaiser and changed from rent to purchase. Note: the sum of the rental payments equaled the purchase cost. This was done and in due course I received a bill from Apria for the equipment purchase cost plus 1 months rental.
Curious how long ago this was? It seems like in the last year or two Kaiser changed to perpetual rental forever. And Medicare has not done outright purchases for DME for as long as I've been aware of their policies. Kaiser Senior Advantage follows Medicare guidelines. However, some people may have Kaiser through an Employer Group Health Plan if they are either still employed OR coverage in retirement is an employee perk.

Here is the 2021 "Evidence of Coverage" which is the actual contract between Kaiser and a Senior Advantage member that most people never see unless they know to ask for it: https://healthy.kaiserpermanente.org/co ... eds-ga.pdf

And here is what it says:
In Original Medicare, people who rent certain types of DME own the equipment after paying
copayments for the item for 13 months. As a member of our plan, however, you will not acquire
ownership of rented DME items no matter how many copayments you make for the item while a member of
our plan
. Even if you made up to 12 consecutive payments for the DME item under Original Medicare
before you joined our plan, you will not acquire ownership no matter how
many copayments you make for the item while a member of our plan.
(Emphasis added) In other words. You make copayments in perpetuity.

This is for Georgia, because that's what showed up first in Google.

But the same for Northern California https://healthy.kaiserpermanente.org/co ... e-ncal.pdf (pg 52) and I suspect most if not all of the other regions.



Sleep Geek says
To OP:
IF you go on traditional Medicare do you need MediGap?
Remember Open Enrollment is coming only a few weeks away.

Think of it this way - you will kill two birds at once and hit a HomeRun!
You can pick up a co-pay to pay the 20% if you want but traditional Medicare you won't need referrals.
Be sure to read this before you contemplate dropping supplemental coverage altogether if you want to dump Kaiser. https://www.medicareresources.org/medic ... ge-enough/ With no out-of-pocket maximum, you have to decide how much risk you are willing to take.

Every state has a SHIP program (but in California it's called HICAP). It's listed on the very back outside cover of your "Medicare and You" booklet or you can find your state's number on www.medicare.gov. This is FREE counseling about Medicare and they are federally funded, not funded by the insurance industry. They can help you determine the best option for your personal situation and calculate your out of pocket costs for various options.

SleepGeek also said
Make sure for the mask it says "Mask of Patients Choice"
Since I am no longer on Kaiser's DME plan, I don't know if this has changed, but when I was, Kaiser had it's own formulary for masks with Crapria. I'm sure that's part of their Crapria contract to keep costs low. So the result was that Kaiser prescriptions had to specify exactly which mask, and you couldn't change to another one without a prescription for the specific mask. Some of the newer masks took a while to appear on their formulary, and masks like the SleepWeaver were NEVER on their formulary.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

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SleepGeek
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Re: obtaining cpap rx from Kaiser

Post by SleepGeek » Mon Oct 25, 2021 8:24 pm

Janknitz wrote:
Mon Oct 25, 2021 8:11 pm
Since I am no longer on Kaiser's DME plan, I don't know if this has changed, but when I was, Kaiser had it's own formulary for masks with Crapria. I'm sure that's part of their Crapria contract to keep costs low. So the result was that Kaiser prescriptions had to specify exactly which mask, and you couldn't change to another one without a prescription for the specific mask. Some of the newer masks took a while to appear on their formulary, and masks like the SleepWeaver were NEVER on their formulary.
Can you think of yet another reason to double dump Kaiser/Apria?

Oh here it is -
Janknitz wrote:
Mon Oct 25, 2021 8:11 pm
(Emphasis added) In other words. You make copayments in perpetuity.
btw - you forgot to mention the credit card problems you had w/Apria.

Janknitz
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Re: obtaining cpap rx from Kaiser

Post by Janknitz » Tue Oct 26, 2021 2:54 pm

Can you think of yet another reason to double dump Kaiser/Apria?
I'm not a huge fan of Kaiser. When my husband got a job that only offered Kaiser insurance, I told him to QUIT, that I would go to Kaiser only over my dead body. He went in to quit, they offered him more money to stay, so he did. :roll: And I've been stuck with Kaiser since. My observation is that they do some things very well, and stink at some other things. I work in a profession where I deal with a lot of clients who have issues with Kaiser--there are major issues with elderly people who are very ill or have dementia. Our system is broken for seniors in general but especially when they have dementia. and often worse when Kaiser is involved. So I hope I don't have to stay with them. But . . .

You make it sound very easy to dump Kaiser, but that's not always the case.

If you are fairly healthy and don't anticipate any major medical issues (and your crystal ball is reliable), and you are lucky, dumping Kaiser Senior Advantage to rely solely on traditional Medicare without a supplement is OK (Sleep Apnea = pre-existing condition = underwriting for traditional supplements). But you could get stuck big time if something catastrophic happens and you haven't secured a supplement plan. That catastrophe may happen years from now.

I'm not on Senior Advantage yet. But in my community, Kaiser commands nearly 70% of the medical market. So it's hard to get a doctor outside of Kaiser and even harder to get the specialists I need for my genetic issues and cardiac issues. Plus, I pay more than my house payment every month to cover my 20 year old daughter and myself on Kaiser under the ACA, add another couple of hundred dollars every month for other insurance--IF I could find the right primary care and specialists. Can't afford that.

I have to do major advocacy for myself and my daughter at Kaiser. But when we manage to get referrals to specialists the care is generally very good, and when it isn't (we've hit a few stinkers) I've learned how to handle that and find better ones.

And what I'm hearing from people who are not Kaiser is that getting care "out there" is not like it used to be. Finding doctors to take your insurance is difficult. Waiting months for appointments and for some tests (i.e. ultrasounds) is not unusual--I've never had to wait long at all for Kaiser appointments. No coordination of care--nobody looking at the big picture. Billing errors are common. So I don't see much advantage any more.

I am considering using concierge medicine instead of Kaiser when I can finally go on Medicare. It is one big annual fee, but the concierge docs will bill Medicare and waive the co-pays in lieu of the annual fee. And I would have an inexpensive supplement as well for catastrophic coverage and specialists. But I have a lot of homework to do to determine if that's the best financial decision. And I will still need to cover my youngest daughter if she's not gainfully employed with her own health insurance until age 26 (sure hope she will be but she has the same genetic condition and cannot go without insurance).

So it's easy for you to SAY "dump Kaiser". And it makes very good sense for some people to do that. But as a blanket statement, it's not so easy. People really need to do their homework first. I'm not saying don't dump Kaiser, either. I'm saying look before you leap.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

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SleepGeek
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Re: obtaining cpap rx from Kaiser

Post by SleepGeek » Tue Oct 26, 2021 9:23 pm

Janknitz wrote:
Tue Oct 26, 2021 2:54 pm
Can you think of yet another reason to double dump Kaiser/Apria?
You make it sound very easy to dump Kaiser, but that's not always the case.
This from the OP...
dconeill wrote:
Sat Oct 23, 2021 10:52 am
I have Kaiser/Medicare health insurance, and had Kaiser before that when I was working. I've used a CPAP machine for years, and it was time to get a new one. This time around, Kaiser referred me to a company called APRIA to rent, per medicare rules, a new machine. Having read up on Apria, I decided I'd rather just purchase a new CPAP machine on the open market.
...who makes no mention of being forced into Kaiser by employment or a spouse.
Janknitz wrote:
Tue Oct 26, 2021 2:54 pm
So it's easy for you to SAY "dump Kaiser". And it makes very good sense for some people to do that. But as a blanket statement, it's not so easy. People really need to do their homework first. I'm not saying don't dump Kaiser, either. I'm saying look before you leap.
I refer you again to the OPs opening statement. I did not make a blanket statement to everyone but to this OP. I do know that it makes no sense (for anyone) to pay for something when your not receiving the service you are paying for - Esp. when it comes to healthcare. If my Dr. did this to me I would be off finding someone else to take my money.

As long as you feed any business like this it will exist to screw others.

I have not been anywhere is the US where plain ol' Medicare is not accepted by most docs - well except the VA Hospital but that is another story.

HMOs are in business to make money and to do that they have to cut (corners) somewhere.

With some HMO's - if/when you move to different county even within the same state you MUST change plans and that makes you eligible to rethink things.

Whether or not you get a co-pay is up to you as is paying for someone to slow down your healthcare.

Dr.'s are like restaurants - if you don't like what they are serving find another - while you are still alive.

So unless you have some advice for this OP...
dconeill wrote:
Sat Oct 23, 2021 10:52 am
I'd be happy enough to pay for the CPAP machine myself, out of pocket and not using insurance. Anybody have any suggestions for shaking loose a prescription for such a machine from Kaiser?
...That brings us back to - Open Enrollment ...
SleepGeek wrote:
Sun Oct 24, 2021 1:17 pm

Since Open Enrollment is coming is a few weeks, I would drop Kaiser like a hot potato. With good ol' Medicare you have many more choices where to go and will have far fewer hassles.
https://www.cms.gov/newsroom/fact-sheet ... fact-sheet

.
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dconeill
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Re: obtaining cpap rx from Kaiser

Post by dconeill » Tue Nov 16, 2021 9:54 pm

Thanks to everybody who's replied, I've learned quite a bit. It's now been 108 days since I first requested a copy of my prescription from Kaiser, without any response of any kind. I've reached out to my primary care physician several times, also without response. This is not good. I've sent a registered letter, we'll see if that generates a response.

Thanks to Janknitz for the info about perpetual renting of DME. I hadn't noticed that in the Explanation of Coverage, but it's yet another reason to buy my own machine.

Apria has acted about like I expected them to act based on their reputation. They've refused to tell me how much it will cost; they've refused to tell me what equipment they're going to provide; they've refused to tell me anything about the terms of the rental agreement; and they're unable to tell me when they'll deliver. I'm reminded of the hospitals that won't tell you how much an operation will cost until after you've had it. American medical financials at their finest! On the other hand, Apria's personnel have been uniformly pleasant and polite - they just didn't have anything to say.

Kaiser was much better when I was working. I'm not too happy with them now I'm retired.

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SleepGeek
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Re: obtaining cpap rx from Kaiser

Post by SleepGeek » Tue Nov 16, 2021 10:10 pm

You do know that Apria will also have copies of that info?
https://www.hhs.gov/hipaa/for-professio ... index.html
Why folks dont like it when you treat em the way they treat you?
If you can be anything why not choose to be kind?
AC VAuto 20/14
palerider aka GrumpyHere wrote: What exactly do you think you're adding to this thread?

dconeill
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Re: obtaining cpap rx from Kaiser

Post by dconeill » Wed Nov 17, 2021 8:41 am

SleepGeek wrote:
Tue Nov 16, 2021 10:10 pm
You do know that Apria will also have copies of that info?
https://www.hhs.gov/hipaa/for-professio ... index.html
Yes, I know that, thank you.
Apria has so far pretty much refused to talk to me.

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chunkyfrog
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Re: obtaining cpap rx from Kaiser

Post by chunkyfrog » Wed Nov 17, 2021 9:24 am

Talk to your dentist..
Tell your story.
Ask for the cpap prescription from him (or her).
Resmed Airsense 10 Autoset FOR HER, p10 mask

pgevanthor
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Re: obtaining cpap rx from Kaiser

Post by pgevanthor » Wed Nov 17, 2021 12:44 pm

I have Kaiser coverage in California. I just had my 5 year old out of warranty ResMed Air Sense 10 replaced with an Air Sense 11. My 10 was making loud noise and I requested replacement from Kaiser Durable Medical Equipment. I got an order without difficulty from them, signed by MD from the San Diego Kaiser Sleep Clinic for a new device. I had been evaluated by the Sleep Clinic when I first got my machine and qualified with documented sleep apnea. The only difficulty was back ordered machines as reported by Apria.

Given my current diagnosis of OSA and the machine's expired warranty, I had no difficulty getting an order. Have you been re-evaluated for OSA given your return to Kaiser? That may be the key? Maybe I missed this information as to what you have done.

I admit I didn't read each message in this thread so I hope I am providing somewhat helpful new information.

One last bit of info. If there is difficulty using the Kaiser system, call Membership Services with a concern. They have a great deal of pull/power.

Full disclosure, I worked for Kaiser for nearly 30 years but this did not help me in dealing with this matter.

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chunkyfrog
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Re: obtaining cpap rx from Kaiser

Post by chunkyfrog » Wed Nov 17, 2021 1:17 pm

The OP says they refuse to talk . . .

Sounds like a brick wall to me.
Self pay is an excellent option--if an rx can be gotten.
Normal cpap machine runs 5+/- years--
5 years of copays is likely to be more than the MSRP.
If replacement is delayed, more $$$ down the rat-hole.

Insurance companies--pffffft!
Resmed Airsense 10 Autoset FOR HER, p10 mask

pgevanthor
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Re: obtaining cpap rx from Kaiser

Post by pgevanthor » Wed Nov 17, 2021 1:26 pm

If you would contact Kaiser Membership Services I bet they would be able to help pave the way for you to get what you are desiring/needing. Phone call to them opens a case file. They will contact people/departments to ask the important questions. I have used them to good effect.

It is like having a state government agency called by the "independent" state auditor. Not a call anyone wants to receive.

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SleepGeek
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Re: obtaining cpap rx from Kaiser

Post by SleepGeek » Wed Nov 17, 2021 5:29 pm

dconeill wrote:
Wed Nov 17, 2021 8:41 am
SleepGeek wrote:
Tue Nov 16, 2021 10:10 pm
You do know that Apria will also have copies of that info?
https://www.hhs.gov/hipaa/for-professio ... index.html
Yes, I know that, thank you.
Apria has so far pretty much refused to talk to me.
Time for you to file a HIPAA complaint against both of these places.

The reason they do this to people is because no one bothers to file a complaint or you would have had you info already.
https://search.hhs.gov/searchblox/ocr_h ... &tune.5=20
Why folks dont like it when you treat em the way they treat you?
If you can be anything why not choose to be kind?
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palerider aka GrumpyHere wrote: What exactly do you think you're adding to this thread?

Janknitz
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Re: obtaining cpap rx from Kaiser

Post by Janknitz » Thu Nov 18, 2021 3:27 pm

Contact Kaiser Medical records department and find out what you need to fill out (and maybe pay) for a copy of your record regarding sleep apnea and including the prescription. As already pointed out, the medical record and prescription belong to you and they must provide it upon request within 5 days under California law (https://www.mbc.ca.gov/Resources/Medica ... cords.aspx). If they do not, file a complaint with the Medical Board as stated on that website.

Neither doctors, doctor's offices, nor the sleep clinic will print out documents for you. You have to go through the medical records department.

Because Kaiser is in reality your DME (Crapria is merely your supplier), they are not going to facilitate you getting your machine and supplies elsewhere. They have a contractual obligation to provide DME if you have DME coverage (subject to your deductibles and co-pays). So if they told you to go elsewhere, they would be violating that contract. But you are entitled to a copy of your records including the prescription, and that permits you to go anywhere you want to pay out of pocket.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

clownbell
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Re: obtaining cpap rx from Kaiser

Post by clownbell » Thu Nov 18, 2021 9:54 pm

I have read each post in this thread. With all due respect to other posters and their experience and their opinions, I will reiterate that MY experience was 100% positive. The machine was a purchase -- the payment was 20% of the going price for the machine -- there have been no monthly payments. When I need resupply, I call Kaiser's DME phone number (different than the Apria number available to the general public). I'm not sure whether the phone is answered by Kaiser employees or by Apria employees. To me, it doesn't matter. My supplies arrive in 3-4 days. Couldn't be easier. And if I want a different mask, I simply email the Respiratory Therapist. Maybe my experience is different from others, but that IS my experience.
ResMed AirSense 10 Autoset with built in humidifier
F&P Brevida pillow mask

harrywr2
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Re: obtaining cpap rx from Kaiser

Post by harrywr2 » Fri Nov 19, 2021 9:41 am

Apria decided to raise the price of my CPAP machine after I already had paid in full. They stated that they could charge me whatever 'Kaiser' allowed regardless of what was agreed to in the sales agreement paperwork.
So I returned my CPAP to Apria and demanded a copy of the prescription from Kaiser.
Kaiser initially refused so I went to the clinic and explained loudly in reception that I needed a copy of my prescription because I was not going to do any more business with the 'criminals' at Apria.
They told me it wasn't available...so I offered to wait at the front of the line until it was...if they didn't like it they could have me forcibly removed from the premises.
Miraculously they managed to produce the prescription.