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Insurance - What you pay for you don't always get...
#1
Angry 
Insurance - What you pay for you don't always get...
Five years ago (Jan 28 2015) I had my sleep study done - the AHI were in to the 150 range... the polysomnologist told me that morning he was amazed I could even function - TBH, I was the walking-dead and really didn't know it... fall asleep standing up, like a pc in sleep mode..
Today I average less than 1 AHI and even have both AHI and RERA=0 once or twice a month! This has been a miracle in my life! 

Now I go to replace may current machine, it's five years old... and I find the following disaster:
Employer provided insurance is contracted in another state
I reside in a different state as does my DME

The insurance in either state requires a rental period - even for established patients!  Huh

Wait it gets worse...
- If I lived and worked in the company's state where the insurance is contracted AND I used a DME in that state then I only have to rent the unit for three months and prove compliance for the three months then I can convert to full purchase (of course, less deductible). 
- The insurance division for my state (the insurance company has different division for each state) now requires a 10 month rental period as of 7/1/2020 before I can convert to full purchase - of course, also, less deductible which will reset before the 10 months have elapsed - isn't that just wonderful! Bug-eyed 

Wait there's more!
- If I tried to purchase the unit at retail from the local DME - then the insurance will deny reimbursement if I submit because the DME is located in the division with the 10 month rent requirement
- If I try to purchase a unit in the company's state or thru one of the online CPAP supply DMEs then the insurance will deny reimbursement if I submit because my primary residence is located in the the division with the 10 month rent requirement.
- If the DME in the company's state or the online DME try to submit... wait for it... then the insurance will deny reimbursement if they submit because my primary residence is located in the the division with the 10 month rent requirement!

Hammer I have no right to appeal to the division in the state where I live because I am not a member of that division's group
Hammer I have no right to appeal to the division in the state where the employer contracted the insurance because they have (<direct quote>) "no control over that state division's contracts"
Hammer I have no right to appeal to my state's Board of Insurance because the insurance is technically self-funded and is incorporated in a different state; thus, my state's BOI has no jurisdiction over the contract or advocacy within my employer's state.
Hammer I have no right to appeal to my employer's state's Board of Insurance because the insurance division giving me grief is in my state; thus, the BOI in my employer's state does not have jurisdiction over the actions of a provider in a different state.
Hammer  finally the appeal to my employer falls on deaf ears - they say "... well.... we rely on the insurance company to oversee and manage the insurance benefits... there's nothing we can do to help you..."

Vomit So instead of only paying about $200 out of pocket (the family deductible is met for the year!) this unit is going to basically cost me just under the full retail price 

Thanks for letting me rant a bit
Sleep-well

Maybe for some APAP/CPAP are not "life sustaining devices;" however, for me without this device I would have most likely stroked out or just outright died in my sleep one night eeew
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#2
RE: Insurance - What you pay for you don't always get...
Might be a whole lot cheaper to look into lightly used at Supplier #2. If you have all that cash being taken out of your pocket, might as well get what you want. And it may be cheaper overall and less of a headache. And to top it off, insurance isn't looking over your shoulder.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Insurance - What you pay for you don't always get...
Retail price is lower online and a lightly used auto CPAP can be downright cheap. Just look at Craigslist for someone that failed to fall in love, and it might be less than your deductible. That does not make the insurance non-coverage right. There is nearly no other area where insurance companies work harder to transfer costs onto the patient than sleep apnea. You might want to escalate your concern through your company HR and see if anyone actually cares. Meanwhile, if you want some help finding a deal, maybe we can help. Hopefully you will get supplies covered, but based on your use of a pretty dated Quattro FX mask, I'm not sure..
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Insurance - What you pay for you don't always get...
I had a problem with my insurance also. I had to have another sleep study (would be my 5th) even though I have been on Cpap Since 89. Then 250 deductible and my old machine was not controlling my problems and was damaged and could not be repaired. Anyway I purchased an VAUTO USED (265 hours) for 800$. Great machine great company great service. Oh forgot they were not sure when I could get the sleep study because of COVID.
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#5
RE: Insurance - What you pay for you don't always get...
Thanks You guys are so kind!

+ Working with my DME today, with the new tubes humidifier etc... we're breaking the subparts out so that most of it will fall under this year's plan deductible and the main unit will go for the 10 months and they're going to take the 10 months as payment in full. The final price will still be more than if we could put the entire thing under this year's deductible but about the same as new-out-of-box from the online suppliers (we've been checking pricing the last few days - but number2 does have lower pricing... tempting!). And, the local DME has a 24/7-emergency line - they'll bring out a loaner at 3am Easter Sunday morning during a white-out blizzard if yours breaks - hard to beat the small town "you're family" service and I'll pay a little bit more to support that ethic!

+ Looking on Craig's list - the nearest to me for sale today is over a 6 hour drive but that's the Midwest for you -- I've called the grocery store to check on in-stock items and had them held before driving into town for years before this curbside delivery stuff started! However, I've been watching the list for a little while to get a "backup/travel-unit." Amazing how little some of these units have been used - found one was still in the box but they wanted full retail price (not).

+ The mask, Quattro FX, still able to get it without any issues... the major gripe I have about it is that the neoprene stretches out so quickly, I'm needing a new set long before insurance will cover it. "Redunculous" how much the replacement costs from the local DME - but I've seen them online for about 1/2 price

I've been tempted to try one of the gel-cushion styles as the QFX will occasionally fart in my face at night even with a new cushion (at 14cmH2O it's quite unpleasant) - I'm a heavy mouth breather an my allergies act up something horrible so the nasal styles just don't work - tried, don't like them, cannot breath when the sinuses clog, at least I didn't have to pay to try them out!

+ Is there a thread where the reliability of the various merchants in the Suppliers List is discussed? I've tried the search; however, either there's not one or I just haven't found the right keywords to search on... or would we say that in general the suppliers on the list are reasonably reliable?


Sleep-well
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#6
RE: Insurance - What you pay for you don't always get...
(07-15-2020, 10:21 PM)staceyburke Wrote: I had a problem with my insurance also. I had to have another sleep study (would be my 5th) even though I have been on Cpap Since 89. Then 250 deductible and my old machine was not controlling my problems and was damaged and could not be repaired. Anyway I purchased an VAUTO USED (265 hours) for 800$. Great machine great company great service. Oh forgot they were not sure when I could get the sleep study because of COVID.

Apology-2 Oh My - and I thought I had it bad... my sleep study once it was all done and paid was several thousand dollars out of pocket even after the deductable was met! To go thru that five times is almost criminal!

I hear you about the COVID thing... the pulmonologist office pushed me off about a month past the year date so my prescription for supplies expired - at least when I called my insurance they agreed to wave the requirement for coverage until I could get in to the office - I bet that changed on 7/1
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#7
RE: Insurance - What you pay for you don't always get...
request a prescription for your mask and supplies to state no-expiration or 999 months and get a copy of it.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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