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Insurance coverage, DME vs Supplies? (Medica)
Insurance coverage, DME vs Supplies? (Medica)

Long time listener, first time caller…I started with CPAP for Apnea treatment last October, and wanted to ask everyone their thoughts/experiences with regard to how insurance handles their supplies claims.  I have a ResMed AirSense10 AutoSet, and when I got it set up for the first time I had a Medica PPO insurance plan with a deductible.  They do a 2 month rental with a compliance check, and then purchase in month 3.  My deductible was not met for the year, and they covered it like this:

E0601 - ResMed Device: DME, 75%/25% Coinsurance, just like the plan document states
R0652 - Humidifier: DME, 75%/25% Coinsurance, just like the plan document states

Then it gets weird for the rest of the claim.  For these items:

A0746 - Water Chamber
A0738 - Filters
A4604 - Tubing
A7034 - Nasal Interface (Swift FX)
A7035 - Headgear
A7032 - Nasal Cushions

These were not DME, but "medical supplies".  Deductible was not met, and I’m on the hook for this one 100%.  I thought to myself “well that sucks, but I do have that other “gold tier” plan at work, without a deductible, so I’ll just deal with it this year, and move to that other plan in 2018 so this stuff will all be covered.”

So I change plans, which has some more lucrative benefits (and higher monthly premium, but not so much it’s a wash to the cost of supplies).  Both of these are “MSI Medica Choice Passport ASO - PPO” Plans, just with a different marketing name our that our company uses.

I set up auto-ship with the DME, since it’s all going to be covered, and they dutifully ship out a replacement pair of nasal cushions about a month later.  When I get the EOB, I see there is a non-zero patient responsibility, and I get hit for the coinsurance amount of what the DME shipped, with the better 80%/20% coverage level for DME equipment.

After some back-and-forth with Medica, they are saying that both claims were processed correctly.  However, I’m feeling like I’m getting ripped off in one of the two plan years.  Both are PPO, “MIS Medica Choice Passport ASO” plans, so how is it in one year those items are medical supplies, and in the next year they become DME equipment?  After looking at the plan documentation it’s of course not cut-and-dry; I just would like some consistency as it sure seems like they are cherry-picking the claim method that best suits them, which leaves me with more cash out-of-pocket.

My questions for the group:

Are your disposable parts (billing codes above, or similar ones found on "ResMed CME Reimbursement HCPCS Reference Guide") considered “medical supplies” or “DME equipment” by your insurance company?  Is there some secret “DME supplies” category that allows them to flip/flop as they see fit?

Which billing method is more correct?  Or is it wholly dependent on the insurance carrier?  Of course I've love to see these classified as "medical supplies" instead of DME, which would result in no out-of pocket.  At this point apparently I have to file a 'formal appeal' if I want to take my case further; if anyone has ever done that with regard to coverage I'd love to hear about your experiences there too.

Side note - anyone with Medica have luck getting more detailed EOBs?  The ones that come from their website are super generic, have no codes (I had to get detail from the DME instead), and make it really hard for the consumer to understand what they’re actually paying for and getting covered.  I’ve been pretty blessed to have good health with the exception of sleep apnea, and this is my first foray in to medical billing…wow, people aren’t joking when they say dealing with insurance companies gets frustrating.

Thank you for reading!
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RE: Insurance coverage, DME vs Supplies? (Medica)
It all depends on what the insurance company says they cover. They should have a detailed book of what they cover and how much. Call and ask them for it. Each Insurance company sets they're own coverage policies.
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RE: Insurance coverage, DME vs Supplies? (Medica)
For many insurance plans, Durable Medical Equipment is not subject to the deductible, but supplies are. If you have a high deductible, you are better off cutting loose from the DME and getting your supplies from online UNLESS the DME is willing to cut you a deal and reasonably match the prices of an online supplier. Some folks have had good luck with that. For instance, paying $5 more than Supplier #1, but you don't have to pay for shipping is a boon. The advantage to the supplier is that they get paid immediately and don't have to deal with insurance. For things like filters, the copay is often more than if you just bought the suckers yourself since most send you knock-offs anyway.

Alas, for me, no local DMEs were willing to reasonably match prices, so they lost my business for extras, my neighbor's business and even my BIL's son's business. No way I'm paying $285 for a mask that I could get for $110 on line (and $78 at a recent sale).
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RE: Insurance coverage, DME vs Supplies? (Medica)
My plan is a Medicare Advantage plan which has copays for most services but none for DME and CPAP supplies. This plan is supposed to take care of everything covered by regular Medicare plus other things and I have a maximum out of pocket limit of $1,000 per calendar year. This has actually been a pretty sweet plan overall for my wife and me. The issues I have run into with DME and supplies is that the DME providers (DMEs) like to make their own rules. For example, a former DME would not provide interim replacement mask interfaces, only a new mask including interface every three months. My current DME provides a new mask plus a spare interface every three months. With some DMEs there are a lot of reasons to be disgruntled. I realize that there are differences in Medicare vs non Medicare situations but in both cases the more research you do and the more knowledge you have the better armed you are when dealing with DMEs and insurance companies.

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RE: Insurance coverage, DME vs Supplies? (Medica)
Let's just assume you bought all your equipment on Amazon. You could get your Airsense 10 Autoset for $665 including the humidifier chamber, filter, and heated hose. Since you are using a nasal mask, the Resmed Airfit P10 nasal pillows mask with all sizes (S, M, L) of nasal pillow cushions could be purchased for $68. If you went with Supplier #1 for Supplier#30 (they work with insurance), increase the total cost by $150 to $200.

I have no idea what you got ripped off for, but that is the current market, and you can reduce that by buying from a backdoor distributor.
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