Information on Insurance Coverage - Where to Turn?

I am a new CPAP user (~6 months). I knew nothing when I was diagnosed. I was sent to the DME supplier and given no choice of CPAP units; I was simply given the Remstar Plus. I was given the choice of a couple of masks. I have been given many different answers about my insurance coverage for a new mask or supplies. Now that I have learned so much information from this website, I would like to get a unit that includes the ability to add software/card to monitor my breathing. I have been unable to get any answers about when my insurance (Aetna PPO) will provide a new unit. Any advice on where to turn for answers? Is there a good website that provides this information on coverage for CPAP units and supplies?
Thanks.

are you willing to pay for a new machine out of pocket? if so they get the one you want that will have software you might like - it seems like the respironics APAP or Pro 2 with encore pro might be the way to go as there seems to be a lot of fellow encore pro users in this forum

if you are expecting your insurance to buy something, well, you have to call them and ask.

if they are renting now they might buy but not what you want and you might have to pay the difference.

if they bought then a lot of insurances use 5 years before they buy a new machine.

whatever it is they are the ones who can answer that not the people here. people here can only say what their insurance did (or did not do) but does anyone here have the exact same insurance you do or do they have the same doc to deal with (such as some docs will script an auto easily but others won't).

for my insurance I found online a general statement by doing a search with google using insurance name and CPAP. however that doesn't mean that my particular group policy with them is exactly that but it gave me an idea.

there is a sister site here called billmyinsurance.com - contact them and they might find out answers for you on when you can buy something but they have to be able to work with your insurance and if not you are back to square one where you have to do the leg work yourself

I hope this helps some

I have Aetna insurance as well, but I am on the EPO plan. I found out from my DME, not Aetna that my equipment was rental for 2 months. Right now my DME is taking back my Remstar Pro2, and giving me a Remstar Auto with C-Flex, and it is not a problem since I am still under a rental agreement. If the DME had not been willing to do that, I would have given the equipment back and used another DME. I did call Aetna and they gave me a list of DME's they work with.

Unfortunately billmyinsurance does not work with Aetna, so we have to go through their DME's if we wan't coverage.

Bottom line: Find out if you are still under rental. If you are, make the DME take it back and replace it with better equipment, or have them take it back and use a different DME. Call Aetna for the list of DME's. If the rental has already been converted to a purchase you are out of luck.

Since we are on different plan's the above information may or may not apply to you.

Ahh, as they say ignorance is bliss! I was exactly where you are at just a few short months ago.

The good news is with some time and many phone calls to Aetna, all your questios will be answered before you make your purchase. I too have Aetna PPO insurance, so I would imagine a fair portion of what worked for me will work for you as well.

Of course different employers have different coverages and what not, but I would hope that the internal Aetna processes are similar regardless of group numbers and employers.

Here are some things I found out and you should confirm:

As another poster said, first find out if you have purchased or renting your current machine.

When I talked to Aetna I was told they only cared about two thing. The insurance billing code (E0601 for CPAP or APAP- both use same code), and if the charge was within their "allowable" amount.

If your Dr submitted the required info including diagnosis, statement that you would benefit from CPAP, and the diagnosis code (780.53 for OSA) then the claim would be paid.

My plan covers DME at 80/20 once my annual deductible is met.

I specificall asked about replacement periods for mask/hoses/filters all of these are essentially "consumables". I also asked how frequently machines could be purchased. The reply i recieved was that there was no set period. They would cover the equipment up to the maximum of my coverage.

I even gave them a "what if" scenario about have OCD and wanting a different machine for each day of the week or frequently traveling and wanting to keep a machine at the locations i frequent. Their answer was as long as I pay my 20% I am good to go.

I bought a Remstar Auto CPAP w/C-Flex as my main machine. Doc prescribed set pressure, but that could change so I wanted a machine that would do auto. Plus I wanted all the bells and whistles. Didn't want to buy a lesser machine and then a year later need something more. Remstar auto is an APAP machine, but it also has a standard CPAP setting. It is the same insurance billing code, and I was told billing code is all they look at. Make/model/features don't matter.

I reccommend the heated humidifier, it is a separate billing code and your Doc needs to put it on the scrip to be covered.

My doc had no problem changing the Rx to an auto machine when I explained to him my concerns. I would imagine that you could buy an APAP with a CPAP RX, they will just set it to CPAP mode. That would be a question for the CPAP.com people to answer.

I bought a second machine, Puritan Bennet 420G for when I travel, it is much smaller, is basic CPAP only and uses very little power. This is important because I do long distance motorcycle touring and sometimes camp while on the road. It can be powered from my bike battery, and the bike will still start in the morning.

I found no specific info on coverage on any of Aetna's website. You need to call the customer service number and ask them the specific questions. They will be vague initially, but when you pin them down, they should be able to answer. You just need to know how to ask.

1. What is my DME coverage? (likely 80/20)

2. I am preparing to purchase a CPAP/APAP, billing code E0601 along with a heated Humidifier, billing code K0531, is this covered and what is the allowable charge for zip code XXXXX ? (zip code of equipment provider, not your home address) note- sometimes these codes are appended with "RR" for rental or "NU" for new purchase- make sure they understand you are talking about purchase.

3. What documentation is needed from my Doctor to support the claim?
(probably need letter of necessity, maybe copy of sleep study, and diagnosis code.)

4. I recently rented/purchased a different unit that I am not happy with, will this cause any limitation on purchasing a different machine? (will likely be told that so long as documentaion is in order and you have satisfied your deductible, coverage will be provided)


Make sure you get the name of the person you talked too. This is important so if you need to clarify something or they come back and say different you are not just saying " I was told.." you can say "Bonnie told me when I called on 2/10 that..."

Then go to cpap.com, order your goodies and wait for the UPS guy!

My claim was paid with out any problems, took them about 3 weeks to process it and get me a check. Read my thread below for more info on my experience.

viewtopic.php?t=6925


Good luck!

Ritap1965 wrote:I have Aetna insurance as well...

Unfortunately billmyinsurance does not work with Aetna, so we have to go through their DME's if we wan't coverage.

True, billmyinsurance doesn't work with Aetna. but you don't HAVE to use an Aetna provider. You can use ANY provider, the difference is if you use a non-Aetna provider, you pay the DME supplier directly the full cost, then file a claim with Aetna for reimbursement for their portion. With an Aetna approved DME supplier, you just pay your cut up front and they bill Aetna for the difference.

There is lots of money to be saved by going the direct route. Companies sell for much lower prices when they don't have to do the insurance billing. that takes time and they have to pay someone to do it, if you do it yourself (and it is a simple form to fill out) you can save well over $100 AND get better equipment.

I bought my equipment from cpap.com (sister comapny of billmyinsurance.com), sent in the receipt, a claim form, Drs. letter and it was all taken care of, I got a check three weeks later reimbursing me for 80% of the cost.

Ritap1965 wrote:Call Aetna for the list of DME's. If the rental has already been converted to a purchase you are out of luck.

Aetna gave me three local DME's. Two had no idea what I was talking about, the third wouldn't tell me the machine price until I told them who my insurance was. The machine I bought at cpap.com for $630, they would charge over $900 for, because that was the "allowable" charge. Do you want to pay 20% of $630 or 20% of $900?

I was also told that Aetna *would* cover more than one machine, no limitations other than allowable charge for the zip code and billing code of the equipment, my deductible, my 20% portion, and allowable maximum lifetime benefits.

See my other thread about how they even covered the encore software, DC power cord and even paid 80% of the overnight shipping charge!

Ritap1965 wrote:Since we are on different plan's the above information may or may not apply to you.

VERY true- take the time, make the calls, be an INFORMED patient and customer!

WW

It's back to John need to call his insurance company and find out what they have paid for and what they will pay for. John needs to do some talking to people on the phone to get some answers.

cpap.com prices are cheaper than bill my insurance but you have to pay for it all up front and then hope for reimbursement

Yup, as it was said.

But now John has a lot more informatio so hopefully those calls will be more productive.

WW

very true and you have provided him with some ideas of what he should ask