DME and Medicare

[Remember2Breathe]

I'm new to Apnea world.  I've narrowed my search down to 3 DME providers to choose from.   I have questions regarding Participating, Non-participating, and Opt out.

If they accept Medicare but not assignment, can they charge you whatever they want or is there a limiting charge (CA)? (Medicare 80%, Supplement 20% + more?)

Do you have to sign an ABN?  I would think not as CPAP is medically necessary.  

Read that Medicare does not allow automatic supplies.  Does that mean that you should not set up to receive supplies automatically (even if per medicare guidelines for replacement)? Or does that mean that you need a new prescription every time you need supplies?  or can you get around that by having original prescription state dispensable equipment needs to be replaced on a regular basis (and list pillows, mask, tubing, etc.)?

Think #2 below probably 1st choice but want to call/visit before I decide. Accepting assignment would be great but most DME that except assignment here get bad reviews and might be better to get DME that is easiest to work with and pay a bit extra.

1. Super Care - Large provider that accepts assignment. The local one gets good reviews for initial visit but horrible reviews of dealing with on regular basis for supplies since directed to call center.  And thus worry if might be hard to change mask.  Best reviews (Yelp, BBB)  of companies in Medicare's list that accept assignment; but still sounds like could be a pain to deal with on ongoing basis.

2.  CPAP Cloud - small provider, only does CPAP.  All 5 star reviews on Yelp - sounds like lots of personal attention re mask, etc.  On Medicare's list but not listed as accepting assignment.

3.  Harmony Healthcare Supply - small provider, only does CPAP.  All 4-5 star reviews on Yelp.  Has a huge sign in window stating Medicare accepted; but does not show up on Medicare's online list of suppliers.  Could be system glitch?  When I called Medicare they could not find places which I later found on their online list (such as #2 above).

Thanks for any input!

Remember2Breathe

[OpalRose]

It's hard to give you specific answers on coverage because it varies so much depending where you live and if you have just Medicare vs. a Medicare Advantage plan.  I feel the best practice is to call your insurance and try to nail down your exact coverage for Cpap and supplies.  Then select your DME. The following link may help.  Good Luck!

http://www.apneaboard.com/wiki/index.php...d_Medicare

[Sleeprider]

When a supplier is a participating provider and accepts assignment, you have no financial risk since they accept Medicare as payment in full. If you're not happy with the replacement schedule for supplies, you are free to go search any online supplier you want for the best deal. Your Supplier #2 seems to accept medicare but is not a participating provider and may or may not accept assignment. It's not that hard to ask them to you up front in writing what their current prices are that are not covered. If you're interested in using them, stop by or make an appointment to discuss their terms. You appear to know what you want, and you can ask what that will involve financially with Medicare coverage. If you don't have a plus plan, the most Medicare will cover is 80%, so you need to know what price they will charge and if you will own any portion of the price above assignment plus the deductible. You should compare any quotes with the convenience and price of Supplier #2 where you can just buy the Airsense 10 Autoset fir $529 including tubing and humidifier chamber. A highly rated company is unlikely to pull a fast one, but you do need to know the complete price, and not get spoofed into a partial quote of the itemized pieces that is the normal billing by a Medicare DME. A mask consists of frame, headgear and cushion, but you want the total net to you.

[Remember2Breathe]

Thanks, Sleeprider for your sound practical advice and breaking it down.
and
Thanks, OpalRose for the link which had some helpful info I missed on insurance and more, and the great SDB Video.

I actually have Medicare and Supplement Plan F, so hopefully most will be covered; but may be affected in large part by how medicare is billed by DME.

[GuyScharf]

If the DME is a participating provider, it doesn't matter how much they bill Medicare. Medicare will pay its standard amount for that code and the DME will accept it -- as a participating provider, they have to.  They may well bill Medicare 3x what they receive but it doesn't make any difference in the end, and nothing comes back to you.

Medicare + Plan F covers 100% of my CPAP machine and supplies.

[Remember2Breathe]

1 More Question:

I've seen the Medicare Replacement Schedule.  But do you know the rule regarding Mask replacement during first 30 or 90 days?  

Think I read somewhere that you can change 3 times during this period to find the right mask to begin therapy and then revert to regular Medicare Replacement Schedule.

Is that right?  and is it during first 30 days or 90 days?

Thx,

Remember2Breathe

[Remember2Breathe]

Got it, Guy!

Remember2Breathe

[OpalRose]

1 More Question:

I've seen the Medicare Replacement Schedule.  But do you know the rule regarding Mask replacement during first 30 or 90 days?  

Think I read somewhere that you can change 3 times during this period to find the right mask to begin therapy and then revert to regular Medicare Replacement Schedule.

Is that right?  and is it during first 30 days or 90 days?

Thx,

Remember2Breathe

Medicare's replacement schedule is usually very generous.  You may think you won't need everything they offer, but it would be to your benefit not to refuse supplies but to build a back up of supplies, like extra filters, an extra humidifier chamber, extra heated hose,  and mask cushions, etc.

Mask Replacement Schedule

Medicare allows for Pillow and Nasal mask cushion replacement twice (2) a month, Full-Face Mask cushion once a month, the mask frame every three (3) months, and the headgear every six (6) months. CPAP manufacturers and vendors suggest these replacement schedules as well. Most mask cushions begin to deteriorate after about a month of use. The silicone eventually becomes too soft to hold a seal and headgear straps must be tightened more and more to get the same quality seal. Replace cushions and pillows as soon as they start to soften. Air leaks may reduce the effectiveness of CPAP therapy and headgear that is too tight may cause facial sores at pressure points. You can also replace the headgear of your mask if it is stretched out or the Velcro worn out.


As far as your DME goes, ask questions about mask replacement.  Some DME's will allow you to switch out masks within the first 30 days.  That's not the same as Medicare being willing to pay for more than one mask at a time.  

Also, check the supplier list at top of page.  Some will allow you to order a mask and trial it for 30 days.  Not sure if your insurance would cover online suppliers though.

It doesn't sound like you will have trouble with compliance, but just in case you are not aware of this:

Compliance:
Medicare requires that a patient use CPAP for more than 4 hours per night on 70% of nights (21 nights) during a 30-day consecutive period any time in the first three months of use.

Patient must also have a face to face appointment with their doctor any time after the first 30 days, but before the 90 days expires.

[Sleeprider]

In addition to what Rose said, I think Medicare has moved to a 13 month lease plan where you could be required to return the machine for noncompliance. It's not a big deal to use the machine, but they are trying to squeeze out any instance where patients simply resell a CPAP they don't use.

[Homerec130]

While Medicare does not allow automatic replacement of supplies, most DME's (at least all the ones I have dealt with) will contact you with a reminder according to Medicare's replacement schedule. After all, they want the business. It is usually a simple response with this is what I need or no thanks. You always want to have at least one backup of everything especially hoses and humidifier reservoirs.