Re: CPAP and BCBS
Posted: Wed Sep 29, 2010 7:51 pm
I don't think you can judge what BCBS will pay in your case from others' experiences because EVERY PLAN (even within the same insurer) is different.
But here's a little bit of basic insurance 101:
You stated your insurer has preferrd-providers. That means that BCBS has a contract with those providers to provide machines and equipment to you AT A CONTRACTE PRICE. BCBS will pay 70% of that contracted price, you pay the remaining 30% plus any deductibles.
The price the DME charges, and the price they are contracted to provide the machine to BCBS insureds are two different animals. The price you can buy the equipment for yourself online hs NOTHING to do with this BCBS-DME contract.
You need to call BCBS and ask, for YOUR plan, the following:
1. Does BCBS specify different rates for differnt CPAP/APAP machines or do they allow a set fee for ANY machine within the E0601 HCPCs code (billing code for CPAP/APAP)? Most insurances will pay a set amount no matter what machine you get within that E0601 code, BUT some insurances--particularly HMO's--pay only for a particular machine.
2. Ask how much the allowable fee is. that will permit you to calculate your 30% copay (alternatively, you can ask "what is my out of pocket cost going to be?") Remember the DME will charge the machine, humidifier, hose, and mask (and sometimes each component of the mask!) separately. Some insurers (and Medicare) insist that you rent your machine on a capped rental basis, but you buy the rest (humidifier, hose, mask) outright.
Now you have some homework to do. Calculate your out of pocket cost for deductibles (remember, you may have a second deductible to meet in the new calendar or fiscal year) and co-pays, and whehter or not you will have a choice of machines (if the insurer pays by HCPC's code you will, but the DME may pretend you don't). Then decide if it's even worth having your insurance pay if you can buy your choice of machine out of pocket more cheaply. You might also consider "letting" the insurance pay 70% of the humidifier and buying the machine online if that works better for you financially.
But here's a little bit of basic insurance 101:
You stated your insurer has preferrd-providers. That means that BCBS has a contract with those providers to provide machines and equipment to you AT A CONTRACTE PRICE. BCBS will pay 70% of that contracted price, you pay the remaining 30% plus any deductibles.
The price the DME charges, and the price they are contracted to provide the machine to BCBS insureds are two different animals. The price you can buy the equipment for yourself online hs NOTHING to do with this BCBS-DME contract.
You need to call BCBS and ask, for YOUR plan, the following:
1. Does BCBS specify different rates for differnt CPAP/APAP machines or do they allow a set fee for ANY machine within the E0601 HCPCs code (billing code for CPAP/APAP)? Most insurances will pay a set amount no matter what machine you get within that E0601 code, BUT some insurances--particularly HMO's--pay only for a particular machine.
2. Ask how much the allowable fee is. that will permit you to calculate your 30% copay (alternatively, you can ask "what is my out of pocket cost going to be?") Remember the DME will charge the machine, humidifier, hose, and mask (and sometimes each component of the mask!) separately. Some insurers (and Medicare) insist that you rent your machine on a capped rental basis, but you buy the rest (humidifier, hose, mask) outright.
Now you have some homework to do. Calculate your out of pocket cost for deductibles (remember, you may have a second deductible to meet in the new calendar or fiscal year) and co-pays, and whehter or not you will have a choice of machines (if the insurer pays by HCPC's code you will, but the DME may pretend you don't). Then decide if it's even worth having your insurance pay if you can buy your choice of machine out of pocket more cheaply. You might also consider "letting" the insurance pay 70% of the humidifier and buying the machine online if that works better for you financially.