BCBS replacement schedule for supplies needed

I just got off the phone with a Customer Service person from Empire BCBS and I'm a very confused newbie CPAPer!

I've seen discussions here and other places about some insurance plans following the Medicare guidelines with respect to replacement of xpap equipment and supplies, with other insurance plans having different schedules. Members here talk about having backup machines, multiple masks, hoses, humidifier chambers, etc. I'm just a newbie, with my not-quite 2 month old cpap machine and humidifier, and only one mask, headgear, hose, humidifier chamber and filters.

On 11/1, 4 days after I started therapy, I switched masks to the one that I'm using currently, and my DME's RT said that BCBS only allowed for a replacement mask every 6 months. Today when I called about getting a longer hose, I was told that BCBS doesn't pay for replacement hoses and I would have to pay for it myself (they were out of stock on longer hoses both on 11/1 and today).

My current FFM is acceptable while I'm adjusting to therapy, but I'm having some issues like leaks and teeth pain. With a 6 foot hose the only way I can roll over from my left side to my right is by waking up and rearranging my body and the hose, and I've been finding that I've either woken up on my back snoring or the machine has been pulled off the nightstand -- usually loudly. I don't mind paying for a longer hose, but I'd like my insurer to pay for a new mask, and sooner rather than later.

I've found the Medicare replacement schedule, and masks can be replaced every 3 months and hoses every 30 days, which is different from what my DME told me. So I went to the payment source for me -- Empire BCBS. The Customer Service person said that there was NO schedule for replacement, just that they would pay when a specific item needed to be replaced! She could give me no guidelines whatsoever.

I can't believe that I can get any replacement item that my little heart desires whenever I believe that it needs to be replaced, and my insurance company will pay for it! Or is the gatekeeper to the candy store the DME who says no replacements except on THEIR schedule? Can someone here please give me some guidance, please? My first post-study appointment with my sleep doctor is next Tuesday, so I want to have as much information when I go as possible.

Thanks for any help you all can give!

A VERY confused Lyn

I also have BCBS, but mine is through Illinois. I called them to ask about my replacement schedule and they told me that I could get a mask when I needed it, as long as it wasn't excessive. I told them I was just starting CPAP and would like a nasal and full face mask since I have sinus issues on and off. They said that was fine. The DME told me that I could only have a new mask once every three months. I told them I had just spoken to my insurance and that was not their policy. I asked the DME to call my insurance and confirm. They did and then gladly sold me (and my insurance company) two masks and only charged the deductible on each. Ask your DME to call your insurance company and verify that you can get what you need when you need it, then they should comply. I think most DME's have a standard list of what BCBS will pay and that is what they go by unless told otherwise. We are lucky that our policy covers more!

I have BCBS of LA and Anthem. They replace as needed. I am glad you pursued the issue with your DME. I will be switching to Cigna next year...so who knows how they handle DME. I have to wait until I get the policy to see the details.

Thank you both for reassuring me. I'd be happier with some guidelines - at least to start, but flexible reimbursement as things need to be replaced is probably in my best interests, and most likely saves BCBS some money as well.

As I said, my first post-study appointment with my sleep doctor is next Tuesday. It's a 90 mile round trip to see him at the hospital where the sleep studies were performed, and the DME is another 20 miles further away from my house (40 miles round trip) from the hospital. It makes the most sense to me to combine both trips. I mailed my data card to the DME today and told the person I dealt with to order a longer hose. Hopefully they will contact me before next Tuesday and I will ask them to verify my specific coverage.

I'm making up my list of what I need to cover with my doctor, and I will definitely ask him about changing my mask and having backups of a few things. It's the season for a Santa list -- pulse-ox, maybe?

Lyn

msradar65 wrote:I have BCBS of LA and Anthem. They replace as needed. I am glad you pursued the issue with your DME. I will be switching to Cigna next year...so who knows how they handle DME. I have to wait until I get the policy to see the details.

check what they allow for a DME - ie vendor - not sure it is current but they had an exclusive contract with Apria for a while

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each policy varies and some require a new script each thing they pay for and others don't - some will never pay for DME and others will pay routinely - you need to get whatever you are told in writing

some of us have back up equipment and masks because we paid for it out of pocket

Rule of thumb:

NEVER, NEVER, NEVER, NEVER, I mean NEVER take a DME's word for what your insurance will cover. At the very least, there are many insurers and each has many insurance plans, and DME's cannot know the ins and outs of every single one. Beside that, many DME's lie like snakes when it is profitable for them to do so (e.g. "your insurance doesn't cover that more expensive mask").

So, as I said . . .

NEVER, NEVER, NEVER, NEVER, I mean NEVER take a DME's word for what your insurance will cover. Ever!

jules wrote:

msradar65 wrote:I have BCBS of LA and Anthem. They replace as needed. I am glad you pursued the issue with your DME. I will be switching to Cigna next year...so who knows how they handle DME. I have to wait until I get the policy to see the details.

check what they allow for a DME - ie vendor - not sure it is current but they had an exclusive contract with Apria for a while

--------------------

each policy varies and some require a new script each thing they pay for and others don't - some will never pay for DME and others will pay routinely - you need to get whatever you are told in writing

some of us have back up equipment and masks because we paid for it out of pocket

I checked with my DME provider and they are a CIGNA provider. When I learned my company was changing to to CIGNA I cringed. I really do not like them from past experiences. But I guess I will make do.

To the other posted. I have been purchasing back up supplies off of e-bay or one of the CPAP online places. Make sure you get a copy of your prescription and your sleep studies.

I know I will most likely just buy what I need myself, since I can get it cheaper than DME charges. I may even try filing a claim and seeing if they will reimburse me.