Insurance Guidelines for Replacement of CPAP Consumables ?

Having had my Remstar Auto machine with humidifier for a little over a month, I thought I had better find out what guidelines my Insurance company (Aetna) has for replacing/reimbursing consumables (hoses, mask, filters etc).

I do remember that when I originally got my machine from my DME, they had a list of "recommended" replacement timeframes on the wall, but they also made it clear that it all depended on the individual Insurance company.

I called Aetna this afternoon to understand their policies on this & after much research they came back to me and send they have NO recommended guidelines or timeframes on replacing consumable items... is this common, or was I talking to somebody who just did not know ?

After researching, she told me that consumables would be covered AS NEEDED - so if that's true, who determines the definition of "as needed"... ?

I also asked what their reimbursement policy is if I purchase the consumables from an online store (such as cpap.com) rather than my DME - they said that would be ok, but just to remember that I would only be covered at the "Out of Network" rate for those purchases (which is what I expected).

I think I have seen several posts on here stating that it is cheaper to buy online with 70% reimbursement (out of n/w), than to buy through DME with a 90% reimbursement.

Even so, I will need to calculate everything out for the year based on a higher deductible for out-of-network.

IN-NETWORK reimbursed at 90%

OUT-OF-NETWORK reimbursed at 70% BUT with a $500/year deductible.

[ Yes I do have a $250 deductible for IN-Network, but I think that can probably be ignored because... like many folks on cpap I do have a couple of other medical issues - so, I'm going to have to pay my 2009 $250 In-Network deductible anyway, regardless of whether I have cpap or not ]

Does this make sense ? the way I see it, buying cpap supplies online would be my only OUT-of-network activity, so if I buy online, I'm essentially having to pay $500 deductible, which I would not have with DME.

If I know the replacement timelines, I'm guessing I just need to compare DME vs Online prices over the course of 12 months, and compare savings against the $500 deductible.

Any feedback or thoughts would be much appreciated.

Thx
Mike

Aetna doesn't have a problem with a new mask every six months and filters every month. The waiting period wouldn't apply if you need to go from nasal to full face or vice-versa. Hoses as you need them.

best thing to do is ask them to send this to you in writing. funny how suddenly those words set wheels in motion to get you the correct answer.

Insurance coverage varies by the plans that the employer has negotiated with the companies. It sounds like you've been doing some of the math. One of the things a person has to take into consideration is the dollar amount of the highly-inflated prices of the local (brick & mortar) DMEs when doing these calculations. I have a $750 annual deductible and for that kind of money, I can buy one helluva lot of "stuff" from the online suppliers (like CPAP.COM) and it's also easy to acquire extra masks from individuals and places like CPAPAUCTION.COM. I haven't had any medical expenses since 2005, so I've used my $750 each year to buy extra machines, masks, hoses, filters, etc.....out-of-pocket. I have absolutely no doubt that I have saved myself and my insurance provider a whole lot of money. In fact, I believe I'm stocked up with "stuff" for the rest of my life.
As a side note, my insurance provider will reimburse me for 75% of DME purchases and I AM considered "in-network" to them. However, I've never turned any of those extra purchases in to them for reimbursement as I probably didn't exceed the deductible and I'm sure they wouldn't have reimbursed me for the extra machines.


Den

Find out what the Medicare replacement schedule is, they have to follow that, on the phone they will mislead and tell you anything then deny it later.

When I checked with my former insurance company (the one I had when starting cpap) they said the same thing -- supplies were on an as needed basis. I asked who determines that and was told the doctor determines it. Meant I had to get a script for supplies when I needed them. I purchased filters, hoses, etc. out of pocket on cpapauction, ebay, and cpap.com so only needed a script for masks. My doctor is very accommodating and doesn't have a problem providing the scripts.

I haven't checked with my current carrier -- which I need to do.

mymontreal wrote:IN-NETWORK reimbursed at 90%

OUT-OF-NETWORK reimbursed at 70% BUT with a $500/year deductible.

[ Yes I do have a $250 deductible for IN-Network, but I think that can probably be ignored because... like many folks on cpap I do have a couple of other medical issues - so, I'm going to have to pay my 2009 $250 In-Network deductible anyway, regardless of whether I have cpap or not ]

Any feedback or thoughts would be much appreciated.

Thx
Mike

Mike, Even if you ignore that $500 deductible for out of network, with your 10% copay for innetwork (DME), and 30% copay outofnetwork (online), the online price has to be less than 1/3 that of the DME price before buying online becomes cheaper!! I do not think any DME would mark up 3 times the prices of the online ones, especialy significant items like machines or masks. For the items I have compared, the two DMEs I know charge about 25% to 40% higher than the online prices. So with a 10 / 30 copay ( in/out network), it is a no brainer to get it thru the dme. Am I missing something here?

feeling_better wrote:

mymontreal wrote:IN-NETWORK reimbursed at 90%

OUT-OF-NETWORK reimbursed at 70% BUT with a $500/year deductible.

[ Yes I do have a $250 deductible for IN-Network, but I think that can probably be ignored because... like many folks on cpap I do have a couple of other medical issues - so, I'm going to have to pay my 2009 $250 In-Network deductible anyway, regardless of whether I have cpap or not ]

Any feedback or thoughts would be much appreciated.

Thx
Mike

Mike, Even if you ignore that $500 deductible for out of network, with your 10% copay for innetwork (DME), and 30% copay outofnetwork (online), the online price has to be less than 1/3 that of the DME price before buying online becomes cheaper!! I do not think any DME would mark up 3 times the prices of the online ones, especialy significant items like machines or masks. For the items I have compared, the two DMEs I know charge about 25% to 40% higher than the online prices. So with a 10 / 30 copay ( in/out network), it is a no brainer to get it thru the dme. Am I missing something here?

The possibility/probability of a $250 deductible for "IN-network" DME purchases. Part of it depends on IF the insurance provider has "contracted pricing" with the DMEs.......and/or if they go by the Medicare/government guidelines. I've seen some pretty hefty DME-billed prices posted on the forum......like $400 or more for a mask (and no headgear).
Just remember, the insurance providers are NOT going to LOSE money.......they'll keep jacking up the premiums to compensate for the money they're "wasting" on the overpriced stuff you're getting supplied with. One way or the other, the money is going to come out of your pockets.......and everybody else's. That's what "insurance" is.....it spreads the costs out to everybody paying premiums.

Den

Wulfman wrote:Insurance coverage varies by the plans that the employer has negotiated with the companies. It sounds like you've been doing some of the math. One of the things a person has to take into consideration is the dollar amount of the highly-inflated prices of the local (brick & mortar) DMEs when doing these calculations. I have a $750 annual deductible and for that kind of money, I can buy one helluva lot of "stuff" from the online suppliers (like CPAP.COM) and it's also easy to acquire extra masks from individuals and places like CPAPAUCTION.COM. I haven't had any medical expenses since 2005, so I've used my $750 each year to buy extra machines, masks, hoses, filters, etc.....out-of-pocket. I have absolutely no doubt that I have saved myself and my insurance provider a whole lot of money. In fact, I believe I'm stocked up with "stuff" for the rest of my life.
As a side note, my insurance provider will reimburse me for 75% of DME purchases and I AM considered "in-network" to them. However, I've never turned any of those extra purchases in to them for reimbursement as I probably didn't exceed the deductible and I'm sure they wouldn't have reimbursed me for the extra machines.


Den

You did a GREAT JOB of explaining "My View" -I'm @ $250 per year BUT the DAM HIGH markup from the DME's they would get my deductible for three replacement filters and a hose!!!
I have spent my $$ at the CPAPAUCTION.com and think I'm WAY AHEAD and NOT lining some robbers pockets!!!

BERT
Need to login -- Updated FireFox and it forgot to auto login?? -OR- The OldFart is Loosing it!

Wulfman, Bert,

In the case of Mike, who is the one who posted the original question, he states that his deductibles have already been paid for the in network, AND FURTHER MORE he has $500 deductible still to pay up for out network. So does it make sense for him to go buy anything online, assuming the insurance covers the 10%/30% ?

Well< I guess I am one of the Lucky ones in the CPAP world. I have Medicare and BC/BS for Insurance and my DME is American Home Patient. I get a Replacement mask every Three Months along with Hose and Filters with No Deductable. Insurance pays for everything. And for everyone Dealing with Deductables, Bad DME's and Insurance Companies My Blessings go with you as you Fight to Survive in the world of CPAP.

I have had Aetna for a few years and they will not provide any sort of replacement schedule, they provide replacements as needed -- period. You do not need an additional prescription for anything, you just need to tell the DME that you need something. Apria called me every month and asked if I needed any supplies, and every six months they would specifically ask if I need a new mask.

With my previous employer, Aetna covered 100% of the supplies from Apria, and I got a new mask every six months, and a new hose and filters every month. They will also provide an additional mask if you need to change types. I didn't have a problem with Aetna getting stuff on that schedule, which was suggested by Apria.

I don't get stuff using Apria any more because the Aetna coverage through my new employer is HORRIBLE, I get it online and pay out of pocket.

feeling_better wrote:Wulfman, Bert,

In the case of Mike, who is the one who posted the original question, he states that his deductibles have already been paid for the in network, AND FURTHER MORE he has $500 deductible still to pay up for out network. So does it make sense for him to go buy anything online, assuming the insurance covers the 10%/30% ?

A person should ALWAYS "do the math" and determine that for themselves. Far too many people get a "surprise" when they get a bill or see their insurance statements.
It also depends on how much "stuff" a person needs. When I purchased my initial equipment (that my insurance provider reimbursed me for 80%), I bought EXTRA filters and hoses. And, I didn't go "eeney, meeney, miney, moe" with masks, either. I did a lot of investigating and pricing before settling on the one I started with and am (happily) still using. I never could get an answer out of my insurance provider on their policy for supplies and replacements and it's not in writing in their manual, either. SO.....I figured I'd better "do it right" in the beginning.
Another thing to determine is whether your doctor has to write a new prescription for every damn replacement supply you're going to get. If that's the case, then you have to take into consideration the $$$ for the doctor visits and gas to go "wherever" AND if your time is worth anything.


Den

DannyP wrote:Well< I guess I am one of the Lucky ones in the CPAP world. I have Medicare and BC/BS for Insurance and my DME is American Home Patient. I get a Replacement mask every Three Months along with Hose and Filters with No Deductable. Insurance pays for everything. And for everyone Dealing with Deductables, Bad DME's and Insurance Companies My Blessings go with you as you Fight to Survive in the world of CPAP.

DannyP, Would you kindly PM me or login and make a post so I can PM you? I have a couple of questions, since as a new cpap user, I would be going into Medicare soon. Thank you for your help!

My insurance pays 100% in-network with no co-pay. It pays 0% for out-of-network. Insurance policy says I get supplies as-needed. DME policy is new mask every 6-months. That's fine with me. I order new hose, filters, whatever I need when I order the new mask at 6 months.