Newbie question on Insurance coverage/rentals

Hi

Looks like a great forum - thank god for the internet these days!

I have just been diagnosed with osa and have been doing as much research as possible before getting a machine. My sleep doctor has given me a presciption for:

"Auto cpap set at pressure of 8cm h2o to 15cm h2o & heated humidifier & memory card for leak & ahi. Swift lt nasal pillows & all cpap accessories including straps, tubing, headgear, filters etc."

He also gave me a list of local DMEs together with a couple of recommendations (sleepquest & somnihealth) & one 'avoid at all costs' (apria).

Aplogies if this has already been posted, but I did several searches on the forum and could not find answers to my questions.

I contacted my health insurance co. (Aetna) and unfortunately sleepquest and somnihealth are not in the network, so I will have to select another DME.

I asked them about cpap coverage & they explained that they pay for 90% of the rental of cpap machines & that I would be responsible for 10% of the monthly rent.

Couple of questions:

1. How much is it likely to cost me each month for my 10% share of the cpap rental (I live in SF Bay Area) ?

2. Do insurance companies only ever pay for rental, or do they sometimes pay a % of the cost of buying a cpap machine ?

(I can possibly see advantage of initially renting, to find a machine that you like, but from what I read about the DMEs, doesn't sound like you can try a few different machines anyway...)

3. If Insurance co. only pays for rental, will they continue just renting year after year, even if that far exceeds cost of buying a machine ?

4. If I find I can tolerate a cpap, I would obviously consider buying at some stage (even if I have to pay 100%) - would that also mean that I would have to pay for supplies myself, or would insurance co. poss pay for those, even if I bought my own machine ?

5. Any other questions I should be asking my insurance company before I proceed ?

Thanks
Mike

An in-network DME will have a contract with your insurance. Someone should be able (maybe not willing) to provide what the actual costs would be for the rental.

Most rentals convert to purchase at some predesignated time as long as compliance is there (sometimes even if it isn't there). You need to ask

What if my mask sucks - how are replacements handled?

How many months rental to convert to purchase? any way to convert earlier?

Does rental $$ count towards purchase?

What needs to happen for the rental to be converted? Is there a requirement of compliance? Who reads the card / machine to determine that? Can the sleep doc just write a letter? What constitutes compliance (what % of nights at 4 hours (4 is usual cut off)?

I am sure others can chime in on what other questions you need to ask and be sure to read the fine print on the contract before signing it.

Each insurance company, and insurance plan is different, and pays at different rates. So you will have to get specific in your questions to them. It is common for there to be a rental period for cpap machines, the theory being that they want to make sure you will actually use the machine. However, in my case no one checked, so it really did not matter. An extended or open ended rental period allows them to charge you and your insurance for more than the machine would cost if purchased outright.

It is important for you to know when your deductible comes due again. If you don't have one, thats fine, but if your insurance pays 90% after your deductible is met and you have a six month rental @ $100 per month and your deductible starts up again in the fourth month, then you will be responsible for the total rental that month, and every month until you meet your deductible for the year. My rental period was six months (they tried to bill me for a seventh) and at the end of it I owned the machine.

I don't know about your plan, but mine pays 80% for purchases from an "in network provider", like the local DME, and 60% for an out of network provider, such as our gracious host. So in other words, if I get a new hose from my local DME they charge $54 and I pay 20%, or just over $10. $10 is also the price listed for the same hose on CPAP.com. So if I buy it from them and fill out the re-imbursemnt forms myself I only pay $4 for a hose the DME was charging $54 for. So, depending on the prices your DME charges, you may well be better off buying "out of network". See if the three in your area will agree to giving you a price list so you can compare.

Also, a local DME may break up the different components and charge you for each one seperatly. For example, in my case, the DME charged me for the individual CPAP machine, the hose, the filters, the case when it all comes as a single unit from the company.

Be aware as well that you may have trouble getting exactly what you want. Your Dr. wrote you out a pretty good prescription, IMHO. But I have read some horror stories about the DME deciding that the patient didn't need all that stuff, that it was just more things that could break down and go wrong. Your RX entitles you to a Respironics M series with A-flex machine, one of their top models, or the Resmed equivalent top of the line model auto adjusting CPAP. Do not let them give you a cut rate model. Don't be mean or nasty, do be firm, polite and insistent. Explain that you have a prescription for an Auto that is fully data capable and that you will be leaving with that machine and that one only.

Please don't get the impression that I am just "DME bashing" here, I don't mean to be. In the first few months when you are learning how to get your therapy right they can be useful, with fittings, sizings, mask exchanges and demonstrating how to use the equipment. There are many who are staffed with kind, considerate and compassionate people (several in this catagory post here), many more who are just trying to run a business and may not have time for the personal attention the customer deserves. But lots of people here have had some bad experiances and if you can learn from them, great.

Each insurance company also has a set of guidelines for how often you can get new supplies, such as masks, cushion, filters, headgear, etc. Many companies follow Medicare guidlines. You should ask for a copy of your insurance companies replacement guidelines for:

Mask or interface
Nasal pillows or mask cushions
Headgear
Filters
Hoses
Cpap machines
Humidifiers

For me it is a new mask every three months, two cushions a month, new headgear every six months, two filters a month, new hose every six months. I think machines are expected to last for five years. Once they get the CPAP thing down, many people purchase a second machine for back up or travel purposes. Get a hard copy of your prescription, it is good for life and will be needed to buy a second machine if you decide you want one. If you do end up spending your own money, Cpapauction is a great site to get new/slightly used machines and equipment for great prices.

Its obvious that you do care about getting the right equipment and the right treatment. Kudos to you for that. Determine now that you absolutely will succeed at cpap therapy. There really isn't any alternative treatment for OSA. I hope this helps, and wish you the best of luck in your treatment.

The insurance plans, coverage, payment options, deductibles, co-pays, etc. are a "mine field" to navigate through.
Here's what I did.....in case you want to see if it'll work for you.....

.

* I did lots of research and pricing of the equipment on the Internet. (mostly on CPAP.COM)......between the time of my sleep study and before I had my prescription. (I was told at my sleep study that I did have sleep apnea)

* I visited the local DMEs to get their equipment options and prices. (before and after I had my prescription)

* I contacted my insurance provider to see if they would reimburse me for out-of-pocket DME purchases. They said they would and I would be reimbursed at the "in-network" rate.

* I "did the math". I calculated that considering the over-inflated prices of the local DMEs, my co-pay (20%) was going to be so close to what I could actually buy what I REALLY wanted from CPAP.COM and save my insurance provider and myself some money.

* I uploaded my prescription to CPAP.COM, ordered my equipment and charged it to my credit card.

* CPAP.COM shipped my equipment.

* I made out an invoice to my insurance provider with me as the billing party and them as the party being billed. They then sent me a check to reimburse me for my 80%.


It was a "win-win" for both of us.

Lots of other members of the forum have done the same thing.

Too many times, these DME/insurance payment plans (many of which will run for 10 months or more) can overlap the insurance provider's fiscal year-end and then the users will get hit for another deductible amount.

I was actually prepared to purchase ALL of my initial purchase out-of-pocket just to be able to get the equipment I wanted, so it was a bonus when my insurance provider was quite willing to reimburse me.
All of the other equipment and supplies I've purchased since then (April 2005) have been out-of-pocket.

Good luck.

Den

I agree with everyone's comments. Wulfman is 'right on' about doing the math. My experience with in-network DME:
--insurance says they pay 50% of cpap after deductible
--DME tells me my portion of cpap will cost me $758
--I look at cpap.com and the cpap I want costs $515ish
--I write insurance company and ask if they will pay if I purchase via cpap.com, since I 'assume' my 50% is $758 and insurance 50% is $758 and we both save $$
--lady at insurance calls me and says, Judy - I don't understand where you are getting $758 each because we have a contract with DME and get charged $950ish in total.
--lightbulb goes off in my head. $1,500ish total ($758*2) is 'retail' price. Insurance company only takes the discount based on the contract they have with the DME. They still charge me, the patient, 50% of the 'retail' price.

Best of luck and be sure to ask a lot of questions!!

thanks so much for the great responses - I will continue my research with Insurance, and visit several DMEs this week to gain more info.

Thanks
Mike