Question for the insurance savy

Ok, I am going to be asking the doctor's opinion on this, but I thought I'd see if anyone had gone through a similar situation first. I had the initial sleep study, then a titration sleep study, and am now waiting for the results. The tech at the titration said the results from that study were great, so I'm assuming that I'll soon be having an appointment with my doctor to go over the results and probably get a prescription for a machine... My doctor is great and doesn't waste any time, so will probably happen within the next week.

Anyway, I am currently on BCBS with great coverage that includes 100% on durable medical equipment. I am only going to be on that insurance until the end of October, then switching to Aetna which will have a 20% copay on DME. Also, from friends that are on the Aetna plan I'll be going to I hear they are way worse than BCBS about choosing to not pay claims. Oh, and I am actually on COBRA with BCBS for this month and next, but that shouldn't factor in.

So, my question is how do insurance companies handle changeovers like this? More specifically, how would they handle it on something like a cpap prescription which usually has a 90 day compliance period? If the prescription is written and the order placed on BCBS are they required to fulfill it even after your policy is over with them? Or I am going to end up having to do the 20% copay and fight with Aetna the first day of November?

Has anyone got any suggestions here? I am going to explain it all to my doctor and see what his thoughts are, but I really doubt he has any way around the insurance companies' trial periods.

Oh, and anyone here have experience with Aetna in general on cpap claims?

Thank you!

Most insurance companies rent the equiptment until you have proven compliance (I think that it's 90 days). This means that when you switch carriers you will probably have to start the machine battle all over again.
If you are in a large city that has a major sleep clinic, you might be able to "borrow" a machine for a month if you explain the situation to the sleep clinic director. That's what I did.

Make sure that you get a "Letter of Medical Necessity" from your doctor. It will save you headaches in the future.

I am on Aetna and they paid immediately. No proof of compliance needed. UNderstand though that even with an insurance company, coverages may differ since there are different plans within a company.

Be sure to get your prescription and sleep study reports (lots of carriers won't approve the therapy until they review your reports). Your prescription is good for life.
Then, try to find out if they will either do an immediate purchase of your equipment or if you're in a position to purchase the stuff out-of-pocket, see it they'll reimburse you ASAP. It would be advantageous for YOU to get BCBS/COBRA to pay for it sooner than later (like long, drawn out monthly payments). It's been reported that BCBS is generally pretty good at doing the reimbursement.

Good luck,

Den

Here in Kansas BCBS purchases machines outright (without a rental period). There would be no issues if that is the case. The only problems I have had with Aetna insurance is they don't like to pay for replacement supplies.

By BCBS, do you mean Anthem? If so, is your plan Century Preferred or Blue Care? If Century Preferred, you're golden...they pay for everything. If Blue Care, they will pay for the machine but not any supplies (including the mask). Anthem does not go by the rental period thing, they buy outright. Given how you describe the two policies, I would try to keep everyone moving along at a good clip and try to get your stuff before you change policies.

As far as your question about which policy would pay at what time, it doesn't go by when the prescription is written, but rather by the date of service (when the prescription is filled). Whoever you are with when you actually get the equipment is the policy it would fall under. And you are correct, your doctor will not likely have any impact on changing the insurance companies coverage policies.

I'm not sure what Anthem is; never heard of it. When I say BCBS I'm referring to Blue Cross Blue Shield, and it is an HMO. But luckily it is one of the best covering HMO's available at least in Georgia. I guess I'll just have to wait and see what the doctor thinks. I hope that what KansasRt posted is correct about GA as well... Time will tell!

I was spoiled by the first sleep study results; they came the morning following the study. The titration is taking longer, and it bites waiting after seeing how much better sleep is with the cpap! Oh well...

At that sleep lab, mine was ready the next day. Get your pcp to call them. They can get it fast. Its probably done now.

Kevin

I have BCBS of Indiana which is considered a part of the Anthem plan with BCBS. They have at least for the plan that I am on a 10 month rental before they purchase the machine outright.

I was in the same situation when my employer switched insurance from BCBS of NC to Aetna. When I went to get may equipment, I explained my situation to the DME company and they change the form from the normal 3 month rental then purchase to a straight purchase. BCBS of NC paid with no problems but with my insurance I still had a 20% copay. Better than starting over with Aetna.

[quote="jaybee72"]I'm not sure what Anthem is; never heard of it. When I say BCBS I'm referring to Blue Cross Blue Shield, and it is an HMO. But luckily it is one of the best covering HMO's available at least in Georgia. I guess I'll just have to wait and see what the doctor thinks. I hope that what KansasRt posted is correct about GA as well... Time will tell!

I was spoiled by the first sleep study results; they came the morning following the study. The titration is taking longer, and it bites waiting after seeing how much better sleep is with the cpap! Oh well...

BCBS is an association of independent insurance companies. Each one decides for itself what it considers medically necessary, what plans to offer and what they cover. One common element other than the name is a national "blue card" network where in-network providers for one BCBS company are in-network for all.

But back to the main topic, Aetna and your BCBS company don't owe each other anything, so you're probably better off trying to wrap the whole thing up under BCBS if possible. Delays in getting things approved are common when switching carriers, you may need a new referral from Aetna, and your current docs may not even be in your new plan. A bird in the hand!