Medicare Advantage and Apria Problem

I have a medicare Advantage plan administered by Aetna. I got my Resmed S8 Autoset from Apria. It was to be a 13 month rental after which I would own the machine. The 13 months are up, and Apria wants me to continue the monthly copay. When we contacted Aetna, their response was:

"The continuous airway pressure (CPAP) device is a continuous rental. The definitions for continuous rentals are items that require frequent and substantial servicing in order to avoid risk to the patients health: Ventilators, Continuous passive motion devices, Oxygen and oxygen equipment, includes stationary and portable gaseous and liquid sytems and the oxygen itself. "

"The 13 month option refers to a purchase option after 13 months. This item does not have a purchase option. You are responsible for a 20% durable medical copayment while renting this equipment."

Just before I got the machine, I got a phone call from someone from Apria telling me about the 13 month plan, the co-pays, etc. I was never able to get Apria to provide me with this information in writing. In retrospect, I shouldn't have accepted the machine without an official copy of the financial plan. Live and learn, I guess.

Does my CPAP fall under the insurance company's definition? Does anyone have to rent their machine forever?

Any feedback would be appreciated.

Irene

Is Medicare your pirmary insurance?

I believe that Medicare is considered the primary insurance, but Aetna just handles it.

Sorry i posted a little too quickly and should have been more clear. Do you have any other insurance besides Medicare? Like a retirement plan (if your retired), or a Medicare supplement?

Medicare Advantage (also called Medicare Part C) is an HMO plan. Kind of like signing your Medicare over to Kaiser. There's no primary or secondary here. Aetna is the payor for all of your care. If you go outside Aetna's network, they don't have to pay and Medicare WON'T pay either since you've signed all of your Medicare benefits over to Aetna.

This is different from a Medicare supplement or Medigap plan where Medicare is your primary insurnace and your Medigap pays the 20% Medicare doesn't pay.

I'm afraid you are stuck with Apria unless Aetna has another in-network provider you can go to.

However, I am not sure about the rental thing. Under Medicare, a CPAP machine is a "capped rental". That means Medicare pays for 13 months and then it's yours--no more copays. I'm not sure that Aetna and Apria can overstep that and force you to keep renting the machine indefinitely, as Aetna is obligated by federal law to provide the same services you would get on traditional Medicare.

Start with Aetna. Talk to their patient services about this. If you still have questions, go to http://www.medicare.gov and see if you can find your state's FREE health insurance/ Medicare counseling program (called HICAP in California and SHIP in many other states. It may also be on the back of your 2010 Medicare and You booklet. Call them and see if they can find out whether Apria and Aetna can force you to continue renting the machine beyond the capped rental period.

My advantage plan is not an HMO. It's an open plan. I can go to any doctor, any DME, anyone who will accept Medicare.

I don't have a supplement, just the prescription drug coverage.

I believe I'll get off the computer and try calling Aetna. All of our previous correspondence has been by E-mail.

Apria is well known around these parts for being particularly troublesome to deal with. Good luck!

I have talked with a very nice lady at Aetna, who asked me to call back later this week after they get a clarification from the claims dept. She agreed with me that cpap doesn't fit into the category mentioned in the e-mail I received and that rental should be capped at 13 months, after which I own the machine.

I have a friend on medicare, and also has health insurance from Kaiser. He had residences in California and Hawaii. When he joined the ranks as a hose head he got an XPAP in California which had a $50 per month rental fee. A few months later he got the same XPAP in Hawaii at no cost, no monthly rental fee's. He returned the machine from California, thus eliminating the monthly rental fee's.

Seems that under certain conditions the fee's charged can vary by state. I wouldn't trust Apria, I would check with my insurance about the rental fee's.

A few months later he got the same XPAP in Hawaii at no cost, no monthly rental fee's. He returned the machine from California, thus eliminating the monthly rental fee's.

I don't think this is a Medicare thing. Medicare's allowable monthly rental fee for CPAP in Hawaii is one of the highest at 102.90 per month, compared to $95.26 in California. On traditional Medicare, your friend would have to pay 20% of that fee.

It may be that Kaiser Medicare Advantage in Hawaii covers DME at 100%, while they do not in California. Different region, different plan.

Except to see things like that go away beginning next year. Since the Clinton administration, HMO's have been subsidized by Medicare, receiving a higher per capita rate than traditional Medi-gap insurers. That will disappear in 2011, and you can expect to see higher rates for Advantage plans and a drastic reduction in "extras" like DME coverage, dental and vision coverage. It's not going to be pretty.

Thanks for the clarification, not looking forward to higher costs such as DME costs rising.

Our insurance coverage just changed, my wife is primary and her work just downgraded her to a very cheap plan. We upgraded which is costing us over $17K per year out of pocket, this is over and above what her work now contributes. Previously my sleep apnea equipment was covered 100%. Starting April this year, DME covers 50%, this is with the better insurance upgrade we pay out of pocket.

As luck would have it, yesterday I discovered my XPAP was putting out a pressure of 22 when it's set for 15. It's an auto, now I'm wondering what the true max pressure really is when it's putting out 22 at a minimum setting of 15.

I picked up a new XPAP today but it's final cost is pending insurance approval. Today I was told sometimes insurance will require and old out of warranty machine (such as my 5 year old XPAP) be sent out to determine the cost for repair. The insurance company will have the XPAP repaired if the cost is less than the cost of a new machine.

In few days I will find out if I pay out of pocket for the total cost or 50% of the cost. I agreed to paying 50% pending insurance approval so I could bring home new working machine today.

I'm be keeping my fingers crossed for luck the next few days.

I have had some experience with Apria and their equipment. Generally once your contract is up they want you to pay maintainence for the equipment. If that is what they are really saying you might ask what that charge covers. I pay maintainence on a couple of DME devices through them, but I got my C-PAP from a different company. I would however have to agree that Apria is not my favorite company to deal with. Thus the change for my C-PAP.

Good luck.

Irene P. wrote:I have a medicare Advantage plan administered by Aetna. I got my Resmed S8 Autoset from Apria. It was to be a 13 month rental after which I would own the machine. The 13 months are up, and Apria wants me to continue the monthly copay. When we contacted Aetna, their response was:

"The continuous airway pressure (CPAP) device is a continuous rental. The definitions for continuous rentals are items that require frequent and substantial servicing in order to avoid risk to the patients health: Ventilators, Continuous passive motion devices, Oxygen and oxygen equipment, includes stationary and portable gaseous and liquid sytems and the oxygen itself. "

"The 13 month option refers to a purchase option after 13 months. This item does not have a purchase option. You are responsible for a 20% durable medical copayment while renting this equipment."

Just before I got the machine, I got a phone call from someone from Apria telling me about the 13 month plan, the co-pays, etc. I was never able to get Apria to provide me with this information in writing. In retrospect, I shouldn't have accepted the machine without an official copy of the financial plan. Live and learn, I guess.

Does my CPAP fall under the insurance company's definition? Does anyone have to rent their machine forever?

Any feedback would be appreciated.

Irene

I'm just guessing they're trying some sneaky way to get you to keep paying beyond the 13 month period. If they never gave you a copy of the agreement, then (I would think) they should have a copy of that agreement in their files. Make them produce it. (along with checking with the Medicare folks) After all, if they DON'T have a copy to prove their assertions, they would have no legal leg to stand on if you quit making payments and kept the machine. "Machine? What machine?"

On the other hand, I seem to recall some discussions on the forum in the past about "perpetual rentals".


Den

4 years ago Apria insisted I pay a 20% co-pay. I questioned this as my insurance covered 100%, Apria responded my insurance coverage changed. To make a long story short. I phoned my insurance to verify coverage, insurance stated nothing had changed, coverage was still 100%

For the next 4 years Apria phoned me after every order I placed stating they would not ship my supplies until I paid a 20% co-pay. My wife recently joined me as a hose head, Apria pulled this same 20% co-pay on her. It's been very frustrating having to fight Apria over every order. I had my insurance provide me with a statement of benefit which I gave to Apria. It made no difference they still insisted I had to pay this bogus 20% co-pay.

I would highly recommend checking with your insurance company, make sure these charges are legit.

In April this year our insurance changed, DME is now a 50% co-pay. I recently paid the 50% Apria said was owed, later discovering Apria over charged me. Due to an insurance statement showing a lesser amount which was my responsibility to pay.

Based on my previous experience, I would trust Apria about as far as I can throw an Elephant, which isn't far, especially with my bad back.

Please check with your insurance.

Irene P. wrote:My advantage plan is not an HMO. It's an open plan. I can go to any doctor, any DME, anyone who will accept Medicare.

I don't have a supplement, just the prescription drug coverage.

I believe I'll get off the computer and try calling Aetna. All of our previous correspondence has been by E-mail.

Maybe its time to go to "any DME". Alright, past time.
I refuse to support businesses like this.