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[Equipment] Finding what your insurance covers for DME
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DariaVader Offline
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Posts: 1,828
Joined: Nov 2014

Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

Other Comments: diabetes II, Thyroidectomized, Primary Immune Deficiency, and the list goes on :P

Sex: Female
Location: Oregon

Post: #1
Finding what your insurance covers for DME
I have looked all over every policy document I can find, and while it says that in-network DME is covered at 100% I cannot find any list of qualified DME. Obviously that doesn't cover just any old thing your doctor will give you a prescription for, or why did I pay out of pocket for my new Aeron chair Wink

The question arises, because when I picked up my CPAP equipment there was an estimated charge of just under $400. Seems high considering that 100% DME Coverage I am paying a fine monthly premium to get.
11-11-2014 06:48 PM
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PaulaO2 Offline
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Posts: 8,068
Joined: Feb 2012

Machine: S9 Autoset
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: H5i
CPAP Pressure: 14-20
CPAP Software: SleepyHead

Other Comments: Ehlers-Danlos Syndrome, Hypermobility Type; chronic sarcasm

Sex: Undisclosed
Location: western NC, USA

Post: #2
RE: Finding what your insurance covers for DME
Could be they pay 100% after a deductible?

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11-11-2014 08:43 PM
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me50 Offline

Advisory Members

Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA

Post: #3
RE: Finding what your insurance covers for DME
(11-11-2014 06:48 PM)DariaVader Wrote:  I have looked all over every policy document I can find, and while it says that in-network DME is covered at 100% I cannot find any list of qualified DME. Obviously that doesn't cover just any old thing your doctor will give you a prescription for, or why did I pay out of pocket for my new Aeron chair Wink

The question arises, because when I picked up my CPAP equipment there was an estimated charge of just under $400. Seems high considering that 100% DME Coverage I am paying a fine monthly premium to get.

Call the number on the back of your insurance card and ask them to explain the DME coverage. Coverage is different per insurance company but most insurances cover what Medicare covers as far as what DME equipment, supplies, etc., and replace supplies the same as Medicare allows.

I have only had one policy that paid 100% for all of my tests, supplies, office visits, prescriptions, etc. without a deductible and copay. Now, we have to pay 20% in network, 30% out of network except for prescriptions.
11-11-2014 09:28 PM
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DariaVader Offline
Apnea Board Facebook Editor
Monitors

Posts: 1,828
Joined: Nov 2014

Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

Other Comments: diabetes II, Thyroidectomized, Primary Immune Deficiency, and the list goes on :P

Sex: Female
Location: Oregon

Post: #4
RE: Finding what your insurance covers for DME
it's 100% in network and 80% out of net. There is no deductible. I do pay more for this premium package, but its worth it to me. The DME supplier did not offer much in the way of choice, they held a class with 6 participants and the equipment was all there waiting for us, with the only choice offered being mask style. They gave us enough stuff to sign that it felt like buying a mini house Tongue I sent them an email asking why there would be a $400 charge when I am covered at 100% but no response yet.
11-11-2014 11:32 PM
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me50 Offline

Advisory Members

Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA

Post: #5
RE: Finding what your insurance covers for DME
sounds like something Apria would do if it were me I would write down your information off of your machine and call ResMed and verify what kind of machine you have and when it was put into production somebody obviously have not checked your interests to see how it covers your supplies and equipment or call your insurance company if you can't get the DME to help I'm curious who your insurance provider is
11-12-2014 07:09 AM
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GeoffD Offline

Preferred Members-2

Posts: 194
Joined: Sep 2014

Machine: ResMed Airsense 10 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: ResMed AirFit P10
Humidifier: Integral + ClimateLine
CPAP Pressure: 14-17
CPAP Software: ResScan

Other Comments:

Sex: Male
Location: New England

Post: #6
RE: Finding what your insurance covers for DME
Your profile says you have an S9 AutoSet so you have the same best-of-breed CPAP machine I do. We all had to sign a bajillion forms. Welcome to health insurance and medical equipment bureaucracy. Smile

The DME doesn't know for sure what your insurance will pay and/or require for a copay until they bill it for the first time. I'm sure they have real world experience that what they're told over the phone when they get authorization for your equipment is different from what happens when they submit an invoice to the insurance company. If your insurance covers 100% of durable medical equipment, then you won't owe anything. I'd just tell the DME you want to wait until your insurance company has paid the first bill. They're likely going to be billing the insurance company monthly for machine rental and accessories like filters, nasal pillows, and the occasional hose, mask, & headgear. They can wait a few weeks for that first payment to see if you owe anything.
11-12-2014 07:11 AM
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DariaVader Offline
Apnea Board Facebook Editor
Monitors

Posts: 1,828
Joined: Nov 2014

Machine: Resmed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10 for Her
Humidifier: H5i humidifier with ClimateLine heated hose
CPAP Pressure: 8-15
CPAP Software: SleepyHead

Other Comments: diabetes II, Thyroidectomized, Primary Immune Deficiency, and the list goes on :P

Sex: Female
Location: Oregon

Post: #7
RE: Finding what your insurance covers for DME
(11-12-2014 07:09 AM)me50 Wrote:  sounds like something Apria would do if it were me I would write down your information off of your machine and call ResMed and verify what kind of machine you have and when it was put into production somebody obviously have not checked your interests to see how it covers your supplies and equipment or call your insurance company if you can't get the DME to help I'm curious who your insurance provider is

It's Cigna, and I pay extra for the "Premium" PMO plan offered at work. This makes sense because I am a diabetic (among other things) and my husband has other chronic issues. I don't think they make money on us Big Grin

(11-12-2014 07:11 AM)GeoffD Wrote:  Your profile says you have an S9 AutoSet so you have the same best-of-breed CPAP machine I do. We all had to sign a bajillion forms. Welcome to health insurance and medical equipment bureaucracy. Smile

The DME doesn't know for sure what your insurance will pay and/or require for a copay until they bill it for the first time. I'm sure they have real world experience that what they're told over the phone when they get authorization for your equipment is different from what happens when they submit an invoice to the insurance company. If your insurance covers 100% of durable medical equipment, then you won't owe anything. I'd just tell the DME you want to wait until your insurance company has paid the first bill. They're likely going to be billing the insurance company monthly for machine rental and accessories like filters, nasal pillows, and the occasional hose, mask, & headgear. They can wait a few weeks for that first payment to see if you owe anything.

Ok - I hope it is as you say. It does appear that the estimated amount is 20%. They haven't asked for any money yet, not from me, and not in on the MyCigna claims yet either.

now if I could get them to pay for one of those ozone cleaners!!! I do have a primary immune deficiency (unable to make antibodies to pneumococcus) clean is going to be extremely important for me.
11-12-2014 05:22 PM
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