DME info please?

Finally my doctor is going to give me a "home sleep study" which he expects will justify for him to prescribe a CPAP through their DME which my insurance uses. I am trying to get rid of my 7 year old Dreamstation which I have waited since August to get replaced.

This DME is called FMG.

I told him I would want the Resmed Autoset 11 if he could request it. He told me it won't matter what he requests, they will supply me with whatever they have in stock and i have no choice in the matter. So, it appears, other than me telling him I will NOT accept a Phillips, I don't have much say in the matter.

Does all this sound right to you guys? I have no experience with insurance dealings like this. For the past 22 years I have always bought my machines out of pocket. This will be the 1st time I am trying to go through with insurance.

Thanks for any advice.

Absolutely wrong, you can request whatever you want. You can also use whatever dme is under your insurance, the doctor legally can not choose the dme for you. You need a new doctor

bucko wrote: ↑

Mon Feb 28, 2022 6:08 pm

Finally my doctor is going to give me a "home sleep study" which he expects will justify for him to prescribe a CPAP through their DME which my insurance uses. I am trying to get rid of my 7 year old Dreamstation which I have waited since August to get replaced.

This DME is called FMG.

I told him I would want the Resmed Autoset 11 if he could request it. He told me it won't matter what he requests, they will supply me with whatever they have in stock and i have no choice in the matter. So, it appears, other than me telling him I will NOT accept a Phillips, I don't have much say in the matter.

Does all this sound right to you guys? I have no experience with insurance dealings like this. For the past 22 years I have always bought my machines out of pocket. This will be the 1st time I am trying to go through with insurance.

Thanks for any advice.

You don't have to accept something you don't want.

The doctor is not choosing my DME.
I have SCAN insurance (Medicare) in CA. He just said to me that the DME named FMG is the provider for my insurance company's durable medical goods.
That is who he must submit the prescription to. He said from there I do not have a choice to what I get. I may get a Resmed, but I cannot choose.

He also said he would write me a prescription if I want and I could buy it out of pocket from anyone.

Near as I can tell with a brief google search for SCAN and medicare and California....this SCAN plan is what we call a medicare advantage HMO type of plan.
HMOs can dictate who you get your equipment from and SCAN may or may not have other DMEs that they will considered to be approved to work within their system.

First thing you need to do is find out just how this SCAN HMO medicare advantage plan handles cpap machine equipment purchases....a lot of Medicare Advantage plans are going to a perpetual rental and they don't necessarily follow the usual Medicare way of purchasing cpap machines which is a 13 month capped rental.
You need to get a hold of the SCAN evidence of coverage information and see if they do a perpetual rental and you never own the machine or if they do a 13 month capped rental.
This is something you need to know (no matter what machine you get) because it might directly affect how much you pay as your co pay for the machine each month. With the perpetual rental there is a possibility that you will have to pay 20% of the approved amount for you machine forever. You want to know for sure your costs so that there are no ugly surprises down the road.

You can also try to find out if the SCAN plan has another DME in their network besides the FMG company you mention and if they do you can ask them if they would supply the machine you want.
You would have to ask the SCAN people if they will work with any other DME. They may or they may not.

You always have a choice but the choice may not be appealing to you. HMOs have their way of doing things and it is often their way or they highway. You can always buy what you want and pay for it yourself if you are in a position financially to do that. There are pros and cons to either so just make sure you fully understand your options.
I have a Medicare Advantage plan myself that is an HMO.....it also has a perpetual rental thing for cpap machines or any DME equipment.
I don't like the idea of paying 20% copay forever myself so I already know if I end up needing a new machine I will just buy my own and not even involve the insurance.

Do the Math....make sure you know what to expect...and you never have to accept something you don't want but it might involve your paying for something out of pocket. You do have options.

That is very good info Pugsy. I'll follow up with this through SCAN first and weigh my options.

In the past, I have always just bought it myself, but times are getting hard now for me.

I have been stuck in the US now for 2.5 years because I cannot return to my home in China. I got to the US 2 days prior to the shutdown Jan 2020 to attend to my Dad's death. So I am living out of a suitcase and paying outrageous rent, running through all my retirement $$ just to survive here.

Thanks

Pugsey, I think you mean co-insurance rather than co-pay, but the effect is the same.

Bucko, what you need to know is that Medicare Advantage plans tie you to into a network. You might be able to purchase equipment and services from suppliers or providers that are are out of network, however you will have to pay out-of-network co-insurance.

As example, in my area, one of the Medicare advantage plans will cover CPAP equipment with at 10% coinsurance if purchased at their designated in network provider. However, if you choose to purchase out-of-network, the coinsurance ( the % you pay) increases to 50%.

dataq1 wrote: ↑

Tue Mar 01, 2022 7:17 am

Pugsey, I think you mean co-insurance rather than co-pay, but the effect is the same.

No...I meant co pay...Medicare Advantage plans don't have another co insurance available that I have ever seen.
I have never seen a supplement to a Medicare Advantage plan being offered.
Medicare Advantage plans have a co pay involved. OP apparently has a Medicare Advantage plan and not traditional Medicare which of course there are Medicare supplement plans available which would be viewed as co insurance.
Not all Advantage plans have a provision for an out of network purchase with a higher co pay.
Mine doesn't. I either use the in network provider and get items covered at whatever rate there is for that service or I go out of network and get to foot the entire cost myself.

Perhaps we are talking past each other, and of course your experiences and area of the country may be different than mine.
Copayments are set fixed fees that are not a percentage of the amount charged. On the other hand, coinsurance is a not a fixed fee that is related to the amount charged. The industry considers co-insurance as a cost-sharing (cost of services) means with the patient.
Traditional Medicare has a 20% coinsurance (that is to say that the beneficiary is responsible to cover 20% of the Medicare allowable charge for that service). Optionally, people may purchase a Medicare supplement insurance to defray some or all of the 20% coinsurance. Those policies are generally referred to as secondary insurance.

In my zip code there are better than 40 different medicare advantage plans available. Some are HMOs others are PPOs and some are half-way in between. But the common thread is that the all rely on private networks.

Several of my neighbors have Medicare Advantage plans, And I have worked with about 5 different folks, all of which had MA plans through different insurers. How each plan approaches the concept of cost-sharing with participants differs considerably making it difficult to generalize. (Also makes it difficult to compare plans - what is probably considered to be a feature versus a bug !)

But back to what Bunko is inquiring about, he has w see whatever insurance he purchased, so he is stuck with whatever conditions that insurance policy imposes . Unfortunately, until he has a opportunity to change, it is what it is.

dataq1 wrote: ↑

Tue Mar 01, 2022 11:16 am

Traditional Medicare has a 20% coinsurance (that is to say that the beneficiary is responsible to cover 20% of the Medicare allowable charge for that service).

Perhaps it does depend on where one lives as to terminology....in my area my explanation of benefits says "co pay" for the 20 % I owe after the Medicare approved amount...even with an advantage plan.
It doesn't say "co insurance" anywhere. I don't recall ever seeing the term co-insurance on any of my paperwork.
To me "co insurance" means another insurance plan is in the works. Straight Medicare has the supplements which to me is "co-insurance". If someone doesn't have a supplement then they would have "co pay"....and I have never seen additional insurance available for any advantage plans.

BUT it's redundant....we all know that co pay or co insurance....it means the patient is responsible unless they have some sort of other additional insurance coverage that will pay their portion left after Medicare pays.

dataq1 wrote: ↑

Tue Mar 01, 2022 11:16 am

whatever insurance he purchased, so he is stuck with whatever conditions that insurance policy imposes . Unfortunately, until he has a opportunity to change, it is what it is.

On this we do agree. Up that proverbial creek without a paddle until open enrollment again next fall and then maybe change. Pros and cons to everything. We just have weigh each and decide what is more important to us.
If I was in the OPs shoes I would first figure out even if they would supply the machine I wanted would it be a capped rental or perpetual rental. That needs to be clear because if it is a perpetual rental then the potential to eventually spend a lot more out of pocket is always present and has to be factored into the dollars spent equations.
Then once I was okay with whatever it was (using insurance)...if they didn't/wouldn't supply the machine I wanted then I would try to find a supplier that would that also works with the insurance....and if no one was available I would make some sort of arrangement to get the machine that I wanted....either used or new or something because I refuse to pay for a machine that I don't want. I just wouldn't do it even if it was a capped rental.
But that is me and I have ways to find machines that end up costing me out of pocket less than my co-pay/co-insurance using insurance would cost me. My insurance has never ever bought me a machine because I buy my own and pay less and I don't have the hassle or headaches involved with using insurance. 13 years now...and I have never used my insurance and unless they drop the perpetual rental...I never will.

Now I do realize that I am fortunate and perhaps the OP here isn't so fortunate but there are options available and all I want is for the OP to understand the options and/or limitations so that there aren't any ugly surprises later....but I firmly believe that no one should have to accept any machine that they don't want for whatever reason they might have.
It's just down right unAmerican.

Pugsy wrote: ↑

Tue Mar 01, 2022 11:52 am

On this we do agree.

Oh, I'm quite sure we agree on much more than Bucko being "stuck" till next enrollment.
My only point was one of semantics, from Medicare.gov comes the topic " What are the Medicare premiums and coinsurance rates?" https://www.hhs.gov/answers/medicare-an ... index.html.

Regardless what this cost-sharing is called (co-pay or coinsurance) it represents payments to the provider by the patient.

I only have Medicare which costs me $145 a month everymonth. Now with my SCAN I pay 0$, the $145 is back in my pocket. Furthermore SCAN gives me.....
Standard Premium $0
Primary Care Office Visits $0
Specialist Office Visits $0
Inpatient Hospital $0 (Unlimited days)
Outpatient Surgery Ambulatory Surgical Center - $0
Hospital Facility - $225
Skilled Nursing Facility $0 (Days 1-20)
$100 (Days 21-100)
Durable Medical Equipment 20%
Emergency Care $90 ($0 if admitted immediately) - Worldwide
Urgent Care $0 - Worldwide
Ambulance $155
Maximum Out of Pocket $1,000
Diagnostic Radiology Services $0-$75
Prescription Drug Coverage
Prescription Tier 1 Preferred: $0

I am happy with this plan. I even get some dental free. I don't feel stuck in this plan.
However I just needed the good advice Pugsy gave explaining how this works for a CPAP. In the end, I will not "rent" anything. If I can't get what I want, or they want me to rent it, I will go buy it myself as I always have for the past 25 years.
Once I go back home, all this goes away anyway since I live in a foreign country. I just thought that since I am stuck here I would try to take advantage of my Medicare benefits I'm entitled to.

Here's how to find out which providers you can use under SCAN.

SCAN covers doctor-ordered durable medical equipment (DME) for use in your home. Examples of DME include hospital beds, oxygen equipment and blood sugar monitors.

For a list of DME, please call your primary care doctor or medical group (these phone numbers are on the back of your SCAN member ID card).

For questions about DME, call SCAN Member Services at (800) 559-3500 TTY: 711. SCAN Member Services hours are 8 a.m. to 8 p.m., seven days a week, from Oct. 1 to March 31. From April 1 to Sept. 30, Member Services hours are 8 a.m. to 8 p.m., Monday through Friday. Messages received on holidays and outside of regular business hours will be returned within one business day. You can also email us at MemberServices@scanhealthplan.com.

You can find out if the DME provider your doctor sent you to is the only provider for SCAN or not.

I have another HMO plan, Kaiser, and they absolutely do dictate which machines they will cover. Whether SCAN does this or not, I'm not certain, but when you call to find out about DME providers, ask this question:

Does Scan cover durable medical equipment by HCPCS d [billing] code, or is there a formulary for items like CPAP machines?

If they pay by HCPCS code, then SCAN doesn't care what brand or model of CPAP/APAP you get. But Kaiser, for example, specifies the brand and model--they have a formulary for DME and ONE and ONLY ONE DME provider you can get your DME from. Some DME's are having a hard time getting ResMed machines right now due to the dual issue of manufacturing delays because of covid and getting parts, and because ResMeds have been flying off shelves to replace the recalled Philips machines. So the price for ResMeds has gone up, and the DME may be unwilling to provide a machine that gives them less of a profit margin. You CAN refuse to accept anything but ResMed, but you may find the DME unwilling to get you a ResMed machine.

If you can go elsewhere under SCAN that's great, otherwise you may want to consider a gently used machine (pm our member lsat who scouts out good deals) if you are at an impasse with the DME.

Wow! Thanks for the great info Janknitz!

bucko wrote: ↑

Tue Mar 01, 2022 1:47 pm

I only have Medicare which costs me $145 a month every month.

Unless you are on a special low-earners help program, your 2022 premium should be 170.
148 was the rate for last year.

I am happy with this plan.

If you are satisfied with all your network providers and their limitations or restrictions, then you have found an ideal plan for yourself. That's great.

Some of us want or need the flexibility to choose our own doctors, specialists etc. Frankly, many of us will have to pay "extra" for that flexibility.

Best of luck to you.