Insurance Annual Deductible and CPAP Parts

I am likely getting a CPAP/APAP this week sometime. Never had one before and need some advice.

I have Blue Cross and they have a $500 annual deductible. I have met this year's deductible with some other things so I'm good for now with them paying for the machine and the initial supplies.

But I'm worried about next year and the years after that.

How does insurance treat replacement parts for existing DME/CPAPs? Do you have to pay a whole new year's deductible before they start covering the parts?

So if I get a mask(s) now, and its covered for 2012, if/when I need new cushions for the mask in 2013 or hoses or filoters do I have to spend another $500 before the replacement parts will be covered? Ugh that would be awful. I don't think I would even go through that much in cushions, tubing, etc in a year. It would almost be like the insurance was useless in regards to keeping the CPAP after the initial purchase.

I know that they have a clause in the policy where they will carry-over the prior year's deductible for costs incurred in the first three months of a new year, so hopefully I can get at least one or two new items in 2013 using the 2012 deductible, but still I am worried about these CPAP parts costs in the many years thereafter.

Can I order a lifetime supply of replacement parts in the first six months window I [may] have? Or does insurance simply not count replacement CPAP parts against one's standard annual DME deductible once one has bought the original equipment in a prior year.....

I'm afraid I might know what the answer will be but worth a shot.....

Thanks!!!!

The cpap machine and any equipment are subject to any deductible requirements just like any other medical supplies or services.
Check with your insurance to make sure that you aren't going to be "renting to own" the machine past the start of the calendar year or you may have an ugly surprise with the machine costs as well.

You can stock up on some supplies but only within the allowable replacement schedule. You would need to check directly with your insurance company because replacement schedules vary between companies as well as between different plans in the same insurance company. They aren't going to let you buy a lifetime's worth of supplies between now and the end of the year.

On the plus side of things. CPAP supplies will help you meet your deductible next year.

You should have mask trial window with your DME so you can at least try multiple masks. You will need to check with them to see what their policy is. Most of the mask manufacturers offer a 30 day trial for each mask but often the DME sets their own in house rules.

Pugsy wrote:The cpap machine and any equipment are subject to any deductible requirements just like any other medical supplies or services.
Check with your insurance to make sure that you aren't going to be "renting to own" the machine past the start of the calendar year or you may have an ugly surprise with the machine costs as well.

You can stock up on some supplies but only within the allowable replacement schedule. You would need to check directly with your insurance company because replacement schedules vary between companies as well as between different plans in the same insurance company. They aren't going to let you buy a lifetime's worth of supplies between now and the end of the year.

On the plus side of things. CPAP supplies will help you meet your deductible next year.

You should have mask trial window with your DME so you can at least try multiple masks. You will need to check with them to see what their policy is. Most of the mask manufacturers offer a 30 day trial for each mask but often the DME sets their own in house rules.

Ughhhh thats what I was afraid of. This will make things pretty costly. I was hoping that replacement parts for existing DME wouldn't fall under the annual deductible, but I guess thats the way it is. Welcome to US healthcare. So then I'll have to totally max out the replacement schedule with costly replacement gear to clear the $500, keep what I need and sell the rest on craigslist to recoup as much as I can for the deductible. It's frustrating paying so much each month for insurance, but in reality to use the benefits you have to spend hundreds more before the coverage even kicks in. And my deductible is pretty low compared to some people's policies.

The replacement schedule is spread out enough that there's a good chance you will need everything they will cover.
(Your mileage may vary.) Don't sell anything until you are sure you won't need it.
Dealing with insurance is indeed an exercise in frustration.

Ughhhh thats what I was afraid of. This will make things pretty costly. I was hoping that replacement parts for existing DME wouldn't fall under the annual deductible, but I guess thats the way it is. Welcome to US healthcare. So then I'll have to totally max out the replacement schedule with costly replacement gear to clear the $500, keep what I need and sell the rest on craigslist to recoup as much as I can for the deductible. It's frustrating paying so much each month for insurance, but in reality to use the benefits you have to spend hundreds more before the coverage even kicks in. And my deductible is pretty low compared to some people's policies.

Why not just buy what you need when you need it? It could very well be less than $500 for the year. Or you may have doctor appointments that satisfy the deductible. Why would you have to buy extra stuff to complete the deductible and then sell it off? Why get something if you don't want or need it?

I would be thrilled if I could have a year where I don't have to go through my deductible. I used to have years like that. This year and last year blew it out of the water. I went to the emergency room twice in one week last September. The first time in an ambulance. I wiped out 3 years of my health account in less than 2 hours. Then had to pay the deductible. My insurance covered most of it after that, though I still had some bills. This year, I used most of the deductible with repeat doctor visits. The second half went to the first part of my sleep study. My insurance paid over $5,000 of the $6,000 bill, as well as 85% of my cpap machine and supplies. It will also be paying 85% of my cardiologist appointment and probably another stress test (last one was 4 years ago). So, I would say the insurance is paying off. I won't mind paying my deductible again next year since I know it will be paying for most everything else. For years, I barely used my insurance. I went some years without a single doctor appointment. Now, I am using it a lot. That's how insurance works. We hope we never have to use it, and we're grateful that it's there when we need it.

Don't forget to use your flexible spending account, if your company has it.

Sheriff

Sheriff Buford wrote:Don't forget to use your flexible spending account, if your company has it.

Sheriff

Nope -- no company alas....

On my own paying for private BCBS insurance each month.... Ugh.

Recently I had to order a new FFM, my plan runs on our fiscal year July 1 to June 30, so I had just started the plan year. My deductible is $200 so I pay it to the first provider that gets their bill in. This year it was to my DME.

Oh well, now I am on my 80 / 20 pay until I reach my family out of pocket of $3000. Which is not too bad.

If paying your medical bills is an issue - check with your hospital group/medical provider, for me Ohio Health is a Methodist based care system and between the extensive care requirements of my wife and my recent surgeries, I actually qualified at getting a 50% reduction of the patient portions of my bills. It never hurts to ask if they have a financial assistance program. I never thought to ask until a recent visit to the hospital, as I thought I would not qualify as I make decent money. But with 2 kids and a wife that is disabled we did qualify for some assistance which is a great relief.

My DME told me that my ins (BCBS of NE) covers mask cushions every two weeks, handed me six to cover me for the three months ... One will probably last me over three months! So I have quite a stock pile ... Of course if you have to pay deductible, and it is near the end of the year ... There are lots of places that sell the supplies much cheaper than the DME !! Try cpap.com . . .

My deductible is $690 for the year ...Already used up!

Even if you haven't met your deductible, buying through your insurance through an in-network DME gets you the insurance price, not the fantasy ripoff billing price most of the medical mafia charges these days.

You may still find things are cheaper online.

However, consider the finances carefully. If you're eventually going to meet your deductible during the year, you should make all your medical spending decisions as if you had already met your deductible. Any extra money you pay before the deductible is met comes back later in the year because you will meet your deductible sooner.

You DO have to come up with the money now rather than later, but at the end of the year, you will spend the same amount of money whether you make the purchase before or after you meet your deductible.

archangle wrote:Even if you haven't met your deductible, buying through your insurance through an in-network DME gets you the insurance price, not the fantasy ripoff billing price most of the medical mafia charges these days.

You may still find things are cheaper online.

However, consider the finances carefully. If you're eventually going to meet your deductible during the year, you should make all your medical spending decisions as if you had already met your deductible. Any extra money you pay before the deductible is met comes back later in the year because you will meet your deductible sooner.

You DO have to come up with the money now rather than later, but at the end of the year, you will spend the same amount of money whether you make the purchase before or after you meet your deductible.

I would, but the deductible for out of network (1000), reimbursement rates are so low (50%) you are forced to use a network provider. I absolutely hate taking financial assistance, but if it means getting the care I need for me, my wife, and kids, I will grin and bear it. I choose to use a provider that will help me out.

retrodave15 wrote:

archangle wrote:Even if you haven't met your deductible, buying through your insurance through an in-network DME gets you the insurance price, not the fantasy ripoff billing price most of the medical mafia charges these days.

You may still find things are cheaper online.

However, consider the finances carefully. If you're eventually going to meet your deductible during the year, you should make all your medical spending decisions as if you had already met your deductible. Any extra money you pay before the deductible is met comes back later in the year because you will meet your deductible sooner.

You DO have to come up with the money now rather than later, but at the end of the year, you will spend the same amount of money whether you make the purchase before or after you meet your deductible.

I would, but the deductible for out of network (1000), reimbursement rates are so low (50%) you are forced to use a network provider. I absolutely hate taking financial assistance, but if it means getting the care I need for me, my wife, and kids, I will grin and bear it. I choose to use a provider that will help me out.

It defies logic how the private insurance companies would rather force their insureds to use higher (padded) cost 'in-network' DMEs and the insurer pay more for X-piece of equipment, than pay less for the same item purchased cheaper from another vendor! My BCBS IL pays about $1,000 for a CPAP/APAP at their negotiated rate with contracted, in-network DME vendors. I pay 20% after my deductible. It does not matter what brand or model machine it is. The DME gets the same reimbursement. If I buy the same machine cheaper over the internet or wherever, but out of network, and give BCBS the invoice, my deductible jumps to over $1,000, and they only cover 50% after that. It's totally nuts. They should pay ME for finding a good deal on a CPAP machine and saving them money! Each in-network DME I have spoken with wants to charge far more for some machines than they cost online. (ie $1,000 for an Intellipap Auto). (Only follow-up home care can justify such pricing, which I'm not actually sure is included with the in-network DMEs initial costs).

It makes me laugh (cry...) when these bozos get on TV and say how great it will be to give grandma a voucher to go out and buy a private insurance policy in place of Medicare! Oh yeah that makes total sense! Because obviously sick old grandma can figure out the intricacies of modern healthcare.... and because the private insurers obviously have their stuff together to save costs.... Not! Exhibit A is how they handle DME.

It must be a great business to have a DME company -- the insurers pay you the same whether you give the patient an inexpensive 'brick' made in Taiwan, or an S9. My DME wanted me to go with the standard DeVilbiss APAP they usually give out (hundreds cheaper on retail) but I asked that they special order a PR1 60 (more bells and whistles) and got my doctor's script written that way. Needless to say they were not pleased....

Here is my invoice from my first visit to DME ... PRS1 60 w/heated hose, "misc" is a 12v power supply cord ... Mask is TrueBlue Gel


They billed the mask out at each individual part, even though it all came in one bag that I saw her open/unseal in front of me! Total cost $261! Cpap.com sells the same mask for $99! Even though I would like to give cpap.com the business ... The mask cost me $52.20 as I pay 20% after my premiums!

If I did buy from cpap.com I would have to pay the whole $99 as they have a higher deductible for out of network, and then once I met that (which I haven't yet) then I pay 40%

Spektor wrote:It defies logic how the private insurance companies would rather force their insureds to use higher (padded) cost 'in-network' DMEs and the insurer pay more for X-piece of equipment, than pay less for the same item purchased cheaper from another vendor!

True in one sense. However, if the insurance companies did decide to start allowing online purchases, they'd corrupt that and they'd have a bunch of "in network" online DMEs who would provide the same stunningly bad service that the current local brick and mortar DMEs provide, and probably at just as high of a price. It would all be driven by how to keep the insurance company happy, and get the most money of of the insurance. The customer would be the insurance company, not the patient.

It really depends on your plan. I have an Anthem BCBS plan that has a 50% DME benefit, but it doesn't cover "A" codes at all (most mask and accessory related items are "A" codes).