Medicare and CPAP

I'm getting close to being Medicare-eligible and am trying to evaluate the multiple Medicare Part B alternatives.

Do CPAP machines, masks, etc. fall under the Part B Medical Services category, "Physician, outpatient supplies, and certain preventive care"? If so, what is the current Medicare-approved charge for CPAP machines, masks (and "headgear" if Medicare allows this unnecessary, extra charge)?

They pick up 80% of the allowed charge, you pay 20%. They pay more than they should for most stuff.

JeffH

My question relates to what is Medicare's allowed charge for CPAP machines and masks/headgear. If I knew this, I'd be better able to evaluate the alternative Plan B programs which have differing reimbursements for all or part of the remaining 20%.

Medicare pays the DME a very low amount. I can give you an examole of a recent purchase. I needed a new cushion for my Quattro mask. The retail on this item is $70...this is what the DME charged medicare. My explanation of benefits read as follows:

Billed Charges $70.00
Not allowed $40.35
Allowed $29.65
My Cost (20%) $ 5.93
Medicare Paid $23.72

There are many items that the DME loses money on when they deal with Medicare.

LSAT wrote:Medicare pays the DME a very low amount. I can give you an examole of a recent purchase. I needed a new cushion for my Quattro mask. The retail on this item is $70...this is what the DME charged medicare. My explanation of benefits read as follows:

Billed Charges $70.00
Not allowed $40.35
Allowed $29.65
My Cost (20%) $ 5.93
Medicare Paid $23.72

There are many items that the DME loses money on when they deal with Medicare.

Perhaps, the DME just overcharges a bit ... and they likely make up for these losses with overcharges on other items. CPAP.com only charges $54 for a new cushion https://www.cpap.com/productpage/resmed ... attro.html

In any case, I find it ironic that one who is against government healthcare actually uses it. Were you the one at one of those town hall meetings yelling "I don't want socialized healthcare ruining my Medicare benefits!"?

DreamStalker wrote:
In any case, I find it ironic that one who is against government healthcare actually uses it. Were you the one at one of those town hall meetings yelling "I don't want socialized healthcare ruining my Medicare benefits!"?

I hope you're not referring to me. I would have liked to see either a viable public option or medicare for all. I don't see insurance companies adding value. But that's another topic and I'd rather see this thread devoted to allowable charges.

greyhound wrote:

DreamStalker wrote:
In any case, I find it ironic that one who is against government healthcare actually uses it. Were you the one at one of those town hall meetings yelling "I don't want socialized healthcare ruining my Medicare benefits!"?

I hope you're not referring to me. I would have liked to see either a viable public option or medicare for all. I don't see insurance companies adding value. But that's another topic and I'd rather see this thread devoted to allowable charges.

Nope ... not referring to you greyhound. I quoted LSAT cuz that is who I was referring to ... he seems to be for Medicare for him but not for for all.

I do understand your concern regarding your thread, sorry.

I can't comment on your question from experience since I'm not on Medicare. However, it does appear that your cost would be 20% of Medicare allowable charges. As I understand it, most insurance uses the same Medicare allowable charges schedule. But someone I'm sure will correct me if not.

DreamStalker, the way I understand it Medicare actually "allows" MORE than most insurances contract w/the local DME providers for.

Greyhound, each year it seems Medicare reduces their reimbursement allowed amounts but here is the most recent breakdown I have quickly at hand for a bi-level PAP

3/25/2008 - DME Billed: $239.92 - Medicare allowed: $218.11 - Medicare paid: $174.49 - CoPay: $43.62 (This is a 13 month rental)

and for a mask but darned if I remember which one:

5/13/2008 - DME billed: $199.40 - Medicare allowed: $157.39 - Medicare paid: $125.91 - CoPay: $31.48
1 A7034 - Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Pressure Device, With Or Wi
2 A7035 - Headgear Used With Positive Airway Pressure Device

Hey Dreamstalker.......".I can tell that you are from Dreamland"....You mean by your comment that you will not accept Medicare when you are 65???????? People over 65 have no other choice but Medicare. I paid for my medicare over my 40 years of working and I am still paying for it...$96.50 per month for part B and $170 per month for a suppliment and $40 per month for a Drug Plan. That's $600 per month for my wife and I. I wish I was at one of those town hall meetings....I AM against many of the items in the new health care law".

In case you can't understand what I was saying, I'll spell it out more simply.... With a manufacturers suggested retail price of $70 and cpap.com's reduced price of $54....the Medicare System was only paying the DME $29.65. It doesn't matter what the DME "charges". The DME is not making any money at that rate. The DME's may make a lot on machines, but on many other items they actually lose.

LSAT wrote:Hey Dreamstalker.......".I can tell that you are from Dreamland"....You mean by your comment that you will not accept Medicare when you are 65???????? People over 65 have no other choice but Medicare. I paid for my medicare over my 40 years of working and I am still paying for it...$96.50 per month for part B and $170 per month for a suppliment and $40 per month for a Drug Plan. That's $600 per month for my wife and I. I wish I was at one of those town hall meetings....I AM against many of the items in the new health care law".

Oh no no! Sorry for the misunderstanding. I, like greyhound and most people are for a government run single-payer health cost/payment system ... a Medicare for ALL if you will (regardless of age). I had not realized you had changed your view. Welcome to our way of thinking.

I too am against the "new health care law" ... just an extension of what we already have plus a bailout for big pharma.

LSAT wrote:In case you can't understand what I was saying, I'll spell it out more simply.... With a manufacturers suggested retail price of $70 and cpap.com's reduced price of $54....the Medicare System was only paying the DME $29.65. It doesn't matter what the DME "charges". The DME is not making any money at that rate. The DME's may make a lot on machines, but on many other items they actually lose.

I understood your first post. I was just expanding on your comment that DME's make up for any losses by overcharging on many other items. So DME's do make money ... or they would not be in business ... simple enough right?

Again, welcome to the "socialist" health care club. Well, for me, I'm not eligible yet because of the current age 65 restriction ... but maybe someday.


So anyway, based on what slinky also contributed, Medicare seems to pay between 70% and 80% of Medicare approved price schedule.

greyhound wrote:I'm getting close to being Medicare-eligible and am trying to evaluate the multiple Medicare Part B alternatives.

Do CPAP machines, masks, etc. fall under the Part B Medical Services category, "Physician, outpatient supplies, and certain preventive care"? If so, what is the current Medicare-approved charge for CPAP machines, masks (and "headgear" if Medicare allows this unnecessary, extra charge)?

It's my understanding, from reading these in previous years, that it goes by states/regions.....and varies in costs. If you go to these sites, you will find a .zip file that you can download, unzip and there will be a couple of spreadsheets and other files that can be viewed. They show the states and codes.

http://www.cms.gov/home/medicare.asp

http://www.cms.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp

Link to download for 2010:

http://www.cms.gov/DMEPOSFeeSched/LSDME ... PerPage=10


Den

Dreamstalker......YOU misunderstand...I never said I was for....." a Medicare for ALL if you will (regardless of age)."I'M NOT!!!! I am for SOME of the features of the new plan. Stopping the Insurance companies from refusing coverage and giving help to those that can't afford to purchase insurance. I am for a free enterprise system.
Over 65 Medicare is great...people have paid for it all their working lives. Under 65 NO GOVERNMENT PLANS (Except for Medicaid). The plan is too dam expensive....We are in debt up to our eyeballs now.

HOWEVER....This is not the forum to discuss the healthcare bill.....this is about CPAP.

LSAT wrote:Dreamstalker......YOU misunderstand...I never said I was for....." a Medicare for ALL if you will (regardless of age)."I'M NOT!!!! I am for SOME of the features of the new plan. Stopping the Insurance companies from refusing coverage and giving help to those that can't afford to purchase insurance. I am for a free enterprise system.
Over 65 Medicare is great...people have paid for it all their working lives. Under 65 NO GOVERNMENT PLANS (Except for Medicaid). The plan is too dam expensive....We are in debt up to our eyeballs now.

HOWEVER....This is not the forum to discuss the healthcare bill.....this is about CPAP.

Uhhh ok. So then you still are for Medicare for you but not Medicare for everyone ... because now that you have yours, we are in too much debt for the rest of us to have it. I guess all that money that was taken out of my pay checks for all of my working life (since I was 16) was spent on something else .... oh well, we can't all be so lucky as you and your wife. Congrats!

I guess I stand uncorrected and misunderstood.

Back to CPAP! and Medicare.