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[Equipment] Ontario Canada insurance strategy
#1
Ontario Canada insurance strategy
Hoping there are others on this board who are from Ontario, or who are familiar with OHIP ADP and the private insurance situation.

I am newly diagnosed, will be getting a prescription for a CPAP (APAP) machine, a Resmed Airsense 10 Autoset for Her.  It will be prescribed to me in CPAP mode, but I have been given instructions to set it for 8-13 cm H2O when I get it home.

I also want to get a travel machine, the Resmed AirMini.

I have insurance through OHIP, which will cover most of the Airsense 10 machine itself.  The overage and accessories will be covered by my private insurer, which has a limit of $2500 every five years.

General plan is to buy the Airsense 10 through OHIP ADP, and pay the overage out of my pocket.  Then submit the AirMini to ADP and get it declined, then submit to the private insurer.

In this way, I hope to get two machines for around $200 out of my pocket.

Is that the best way to go about it?

Also, I want to burn as little of my $2500 insurance limit as possible. I am finding that the price of the Mini in the private market is $1399 at the high end, slightly cheaper online. All private suppliers are way higher than the price through OHIP ADP. Seems to be some gouging.
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#2
RE: Ontario Canada insurance strategy
I'm in Ontario and got a Resmed Airsense 10 AutoSet for Her via OHIP ADP program.

Right off the top, it's a good decision to get the AutoSet for Her, for some unknown reason the AutoSet for Her qualifies as a CPAP device under ADP even though it's an APAP device. Take advantage of it. 

As soon as I w pas the titration period I also changed from CPAP mode to APAP mode and improved my AHI from about 3.5 to 0.5.

My process was:
Purchase the machine ad initial supplies from my DME, the end cost had the ADP discount in place. I then submitted my invoice to my private insurance (SunLife) with covered 85% of the remaining cost. At the end of the year, I bought a spare humidifier tank, heated hose and mask from an online site, submitted the bill to insurance for 85% coverage again.

I really don't understand what you mean by "Then submit the AirMini to ADP and get it declined, then submit to the private insurer." All the ADP paperwork and submission was handled by the DME and I'm unsure why it's important to you to try to submit it to get it declined.

Though I'm not familiar with your private insurance, typically they only cover one machine every 5 years and often limitations on which machines are eligible. Travel machines aren't medically necessary and may not be covered.
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#3
RE: Ontario Canada insurance strategy
Nice AHI!  I am also in the 0.5 AHI range, with several nights in the past 30 days being zero point zero.  They gave me the machine set for 6-16 cm, which I changed myself to 9-16.  The doc told me this week that they generally go with the steady state level minus two and plus three, which for me is 8-13.

My doc told me that if I use the private insurance to pay the overage relative to ADP, that will count as one machine and I will be ineligible to get another one funded before five years.  So I think I need to pay that overage myself.  The second machine (the AirMini), will be submitted to ADP and declined (because I have already used the ADP program), and then Great West Life will pay 100% for that one.   My doc says I will be required to submit the AirMini to ADP, to be able to prove to Great West Life that it was declined.

But doctors do not actually know much about insurance in my experience, so I wanted to reach out to others.

I will need to look into whether the travel machine will be covered.  Usually there are no issues with that type of thing with Great West Life, but good to verify because I think I am looking at $1200+HST to get one.
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#4
RE: Ontario Canada insurance strategy
I'm not sure if any of these links are of benefit but take a look.

ADP Program overview:

http://www.health.gov.on.ca/en/pro/programs/adp/publications.aspx

Ontario ADP Respiratory information:
https://www.ontario.ca/page/respiratory-...d-supplies


Supported Respiratory Devices. 
APAP - Page 3
BPAP - Page 3
CPAP - Pages 3-4
http://www.health.gov.on.ca/en/pro/programs/adp/information_technology/docs/respiratory_devices_manual.pdf
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#5
RE: Ontario Canada insurance strategy
Thanks. Right there I can see that the AirMini does not qualify for the ADP program.    I sent an email to GWL to verify that it will be eligible for reimbursment.

I noticed that you have posted previously about the radio in the Airsense.  Do you know if it is on a daughter card that I can remove?  First thing I am doing when it gets home is to remove it or disable.  So creepy.
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#6
RE: Ontario Canada insurance strategy
(03-14-2019, 12:45 PM)Phasenoise Wrote: Thanks. Right there I can see that the AirMini does not qualify for the ADP program.    I sent an email to GWL to verify that it will be eligible for reimbursment.

I noticed that you have posted previously about the radio in the Airsense.  Do you know if it is on a daughter card that I can remove?  First thing I am doing when it gets home is to remove it or disable.  So creepy.

Here's a topic on how to Semi-permanently disable the modem in ResMed Airsense 10. I haven't done this myself, and can't comment on the ease or how easy it is to undo.


I linked to the post with pictures, instructions are earlier.

Some considerations:
  • Not sure if this voids warranty.
  • Disables OTA firmware updates, but there has been only one that I'm aware of and I don't see any happening on the AirSense 10 line in the near future
  • Won't be able to use ResMed MyAir app or webpage (no big deal)
  • Doctors or DMEs won't be able to remotely configure machine or see performance for appointments
  • In Canada, we don't have the same insurance compliance requirements as those in the US do, so insurance access to our data is not relevant

You may want to consider airplane mode initially, but aware turning airplane mode off will upload data, and display Airplane mode reminders.
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#7
RE: Ontario Canada insurance strategy
I'm with Sunlife and did an enquiry on submitting an invoice for a CPAP machine directly to them outside of our DME. I'm located in Manitoba where the province co-pays and I would pay only $500.00 every 5 years. Sunlife replied stating that I must go through the DME first and get subsidized by the province and then and only them will they cover the machine. My plan only covers a machine every 5 years and only for one machine. For our household it means any travel machines would be out of pocket.

Not sure if this would happen to those in Ontario and private insurance plans.
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#8
RE: Ontario Canada insurance strategy
I am an Ontario resident covered by both OHIP (the provincial plan) and an additional private plan, the Public Service Health care plan (PSHCP) which is administered by Sun Life. Each provincial plan is run differently. OHIP, under the ADP, only funds a basic machine that is needed to bring ahi levels below 5. They pay 80% of a fixed machine cost and the PSHCP plan pays 80% of the remainder. In addition the PSHCP will pay 80% of the first $300.00 spent annually for CPAP related "supplies" (which can include sleep pillows, hose cleaners / hangers, wipes, filters ...etc.). The CPAP machines must be purchased from an approved DME (not online) but supplies may come from any supplier.
After 3 years of cpap use (fixed pressure A10) I met with my sleep doc to discuss upgrading to an autosense A10. He mentioned that OHIP would fund a new machine (even after 5 years) only if I could no longer be successfully treated with my present machine or if it was in need of major repair - neither was the case. I would not be able to justify a new machine simply to optimise treatment. I decided to wait for a good buy online and pay out of pocket. Last August supplier 34 had the Autosense 10 (or Autosense 10 for her) for sale (with coupon) for under $600 C, including taxes and shipping which I am now using - my old machine is my spare / travel machine.
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#9
RE: Ontario Canada insurance strategy
As an FYI, most US insurance companies will not cover a travel style machine. Just wanted you to know that up front.
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#10
RE: Ontario Canada insurance strategy
Travel machines are not necessarily a good purchase.  I seem to recall complaints about noise and possibly lack of humidification .... possibly limited masks.  Before you jump in on the travel machine, read some of the threads about them.

When I first started XPAP I thought I would want one also, until I read the negative reviews.

It's not so bad travelling with a machine, you get a bag with it to pack everything and it doesn't count toward your carryon limit when flying.

Also, there are a lot of second hand travel machines machines available.

I don't think your extended health coverage will pick up the tab for a travel machine, but if they do your are in luck.  Let us know if they do, its good information to know.
Sleep-well
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