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Insurance makes you CRAZY.
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DWaldman Offline

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Posts: 57
Joined: Sep 2015

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: InnoMed Aloha
Humidifier: Hi5
CPAP Pressure: 9-17
CPAP Software: SleepyHead

Other Comments: We rescue dogs... I am going to need LOTS of filters....

Sex: Male
Location: Atascadero Ca

Post: #11
RE: Insurance makes you CRAZY.
Insurance will buy outright, no lease required, at least that is what they have told me so far. Their rules seem simple, 80% in network, 60% out of network. The problem appears to be that the in-network providers will only allow a lease to own. So then I have the problems of deductible rollover, etc. Buying outright from an on-line supplier seems like the way to go, I will have to provide more up-front money, but the total cost out of pocket will be less, even though I get only a 60% reimbursement of my real cost.
10-11-2015 12:39 PM
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Mike1953 Offline

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Posts: 134
Joined: Aug 2014

Machine: Resmed S9 Escape Auto
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Resmed Hi5
CPAP Pressure: 12
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Kansas USA

Post: #12
RE: Insurance makes you CRAZY.
What ever your prescription reads that is what the DME must provide. If you want a certain type of machine have your Dr. write the prescription to those specifications. Then the DME must follow that prescription. I don't know why your making this so difficult.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
10-11-2015 04:14 PM
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PaulaO2 Offline
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Posts: 8,057
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: #13
RE: Insurance makes you CRAZY.
Let's keep the conversation civil or the thread will be closed.

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

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10-11-2015 05:25 PM
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DWaldman Offline

Preferred Members

Posts: 57
Joined: Sep 2015

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: InnoMed Aloha
Humidifier: Hi5
CPAP Pressure: 9-17
CPAP Software: SleepyHead

Other Comments: We rescue dogs... I am going to need LOTS of filters....

Sex: Male
Location: Atascadero Ca

Post: #14
RE: Insurance makes you CRAZY.
I am done with you guys... No help for a newcomer who is having problems... Tried to expain what info I have gotten so far, and you treat me like an idiot...
10-11-2015 05:45 PM
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SaldusMiegas Offline

Advisory Members

Posts: 227
Joined: Apr 2015

Machine: ResMed AirSense 10 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: P-10, F&P Simplus
Humidifier: integrated
CPAP Pressure: Rx:14, Set:Auto 8.0-15.0
CPAP Software: ResScan SleepyHead

Other Comments: Woot! P-10 pillows plus Ruby chinstrap for side-sleeping mouth breathers

Sex: Male
Location: Virginia

Post: #15
RE: Insurance makes you CRAZY.
(10-11-2015 12:39 PM)DWaldman Wrote:  Insurance will buy outright, no lease required, at least that is what they have told me so far. Their rules seem simple, 80% in network, 60% out of network. The problem appears to be that the in-network providers will only allow a lease to own. So then I have the problems of deductible rollover, etc. Buying outright from an on-line supplier seems like the way to go, I will have to provide more up-front money, but the total cost out of pocket will be less, even though I get only a 60% reimbursement of my real cost.

Sounds like you are closing in on it and you got it from here Smile

A few final thoughts to consider that might fill in any remaining gaps ...

My initial setup (Resmed A10 Auto CPAP machine, F-10 mask, heated hose, and filters) costed out at about $1300 from the DME.

Unknown what your in-network DME will charge you for non-auto machine, but let's say this is a ballpark number.

If you are trading off 80% versus 60% then the diff is 20% or approx $260.00.

If they rent-to-own there would probably some additional cost just for paying over time which might close the gap or even make the in-network more expensive to you.

The fact that your insurance will buy outright is a big deal. It likely means you won't have to deal with demonstrating compliance which is the primary reason for the rent-to-own options (ie if it doesn't work out the insurance can turn it back in for the cost of a few months lease versus being stuck for the entire cost of a machine that nobody will use). So you can pull that rug out from under the DME when they tell you they must do a rent-to-own.

If you look around you might be able to beat the in-network purchase cost by buying online, but maybe not since the in-network price will already be a discounted contract price not retail price.

Lot of other things might come into play here, such as a separate out of network deductible not counting against your in network deductible, out of network "reasonable and customary" limitations falling short of actual machine purchase price, etc.

If I were considering your options and I had the money to pay now and get reimbursed, I might pursue the following:

1. try and get the Dr to write the prescription specifically for the machine you want. If that makes your in-network DME have to give you the machine you want, then you should have some leverage to buy outright versus lease. At that point it's not hypothetical and they can agree to sell you a machine or they can walk away with nothing. Who knows what they will do, but at least you will be holding all the cards.

2. Failing that, look around online for an in-network provider you can order over the internet. IDK, but maybe there are DMEs in big city locations in your state that are in network to you who would be happy for the business and ship stuff to you.

3. Failing that go out of network for the machine. One place you might start is the suppliers list (see link at the top of the page). I don't think they are "endorsed" per se, but it's a starting point.

You will likely have to live with the machine you get for a 5 year service life. So a couple hundred dollars over five years is a small price to ensure you get a good data-capable, automatic machine you can live with for a long time. And as you said going out of network to buy might actually be cheaper out of pocket versus in network rent-to-own. all things considered.

I got the A10 but the S9 auto machine is preferred by some people on this forum, so what I'm suggesting is you might find the slightly older S9 model which they still sell brand new to be less expensive and yet fully capable. I don't know since I didn't compare them, just mentioning what I read in some discussions. Sounds like you might already be there since you mentioned a DME told you they wouldn't buy an S9 Auto.

Also, might make sense to buy your mask, hoses, and supplies in network even if you buy the machine itself out of network. That would knock that hypothetical $1300 down to under $1000 (actually the A10 is listed for $883 on Supplier #1 web site) making for a little smaller gap between 60% and 80%. And the in-network purchase of mask, hoses, and supplies will be a recurring cost so if you do the initial purchase out of network for simplicity, consider doing the recurring in network later on.

Sounds like the hassle factor is already getting beyond a couple hundred bucks by now.

Hope you can line up your strategies so you can execute quickly once you have the prescription and get to feeling better soonest.

Saldus Miegas
10-11-2015 06:29 PM
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DWaldman Offline

Preferred Members

Posts: 57
Joined: Sep 2015

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: InnoMed Aloha
Humidifier: Hi5
CPAP Pressure: 9-17
CPAP Software: SleepyHead

Other Comments: We rescue dogs... I am going to need LOTS of filters....

Sex: Male
Location: Atascadero Ca

Post: #16
RE: Insurance makes you CRAZY.
(10-11-2015 06:29 PM)SaldusMiegas Wrote:  
(10-11-2015 12:39 PM)DWaldman Wrote:  Insurance will buy outright, no lease required, at least that is what they have told me so far. Their rules seem simple, 80% in network, 60% out of network. The problem appears to be that the in-network providers will only allow a lease to own. So then I have the problems of deductible rollover, etc. Buying outright from an on-line supplier seems like the way to go, I will have to provide more up-front money, but the total cost out of pocket will be less, even though I get only a 60% reimbursement of my real cost.

Sounds like you are closing in on it and you got it from here Smile

A few final thoughts to consider that might fill in any remaining gaps ...

My initial setup (Resmed A10 Auto CPAP machine, F-10 mask, heated hose, and ``filters) costed out at about $1300 from the DME.

Unknown what your in-network DME will charge you for non-auto machine, but let's say this is a ballpark number.

If you are trading off 80% versus 60% then the diff is 20% or approx $260.00.

If they rent-to-own there would probably some additional cost just for paying over time which might close the gap or even make the in-network more expensive to you.

The fact that your insurance will buy outright is a big deal. It likely means you won't have to deal with demonstrating compliance which is the primary reason for the rent-to-own options (ie if it doesn't work out the insurance can turn it back in for the cost of a few months lease versus being stuck for the entire cost of a machine that nobody will use). So you can pull that rug out from under the DME when they tell you they must do a rent-to-own.

If you look around you might be able to beat the in-network purchase cost by buying online, but maybe not since the in-network price will already be a discounted contract price not retail price.

Lot of other things might come into play here, such as a separate out of network deductible not counting against your in network deductible, out of network "reasonable and customary" limitations falling short of actual machine purchase price, etc.

If I were considering your options and I had the money to pay now and get reimbursed, I might pursue the following:

1. try and get the Dr to write the prescription specifically for the machine you want. If that makes your in-network DME have to give you the machine you want, then you should have some leverage to buy outright versus lease. At that point it's not hypothetical and they can agree to sell you a machine or they can walk away with nothing. Who knows what they will do, but at least you will be holding all the cards.

2. Failing that, look around online for an in-network provider you can order over the internet. IDK, but maybe there are DMEs in big city locations in your state that are in network to you who would be happy for the business and ship stuff to you.

3. Failing that go out of network for the machine. One place you might start is the suppliers list (see link at the top of the page). I don't think they are "endorsed" per se, but it's a starting point.

You will likely have to live with the machine you get for a 5 year service life. So a couple hundred dollars over five years is a small price to ensure you get a good data-capable, automatic machine you can live with for a long time. And as you said going out of network to buy might actually be cheaper out of pocket versus in network rent-to-own. all things considered.

I got the A10 but the S9 auto machine is preferred by some people on this forum, so what I'm suggesting is you might find the slightly older S9 model which they still sell brand new to be less expensive and yet fully capable. I don't know since I didn't compare them, just mentioning what I read in some discussions. Sounds like you might already be there since you mentioned a DME told you they wouldn't buy an S9 Auto.

Also, might make sense to buy your mask, hoses, and supplies in network even if you buy the machine itself out of network. That would knock that hypothetical $1300 down to under $1000 (actually the A10 is listed for $883 on Supplier #1 web site) making for a little smaller gap between 60% and 80%. And the in-network purchase of mask, hoses, and supplies will be a recurring cost so if you do the initial purchase out of network for simplicity, consider doing the recurring in network later on.

Sounds like the hassle factor is already getting beyond a couple hundred bucks by now.

Hope you can line up your strategies so you can execute quickly once you have the prescription and get to feeling better soonest.

Saldus Miegas
Thanks foryour reply, it is the kindess and most informative response i have gotten. This is all new to me, I have not had any major health issues that have made me work out all the details like this. I call the insurance co. 3 times and get 3 different answers. Sorry if i have bothered all you who are old pro's at this.
10-11-2015 08:39 PM
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DariaVader Offline
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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: #17
RE: Insurance makes you CRAZY.
stick around, you will find the vast majority are here to be helpful, and there are only a couple who don't know how not to be condescending Bigwink

(and if u think that was about you... check if the shoe fits Tongue )

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
10-11-2015 09:27 PM
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OpalRose Offline

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Posts: 3,155
Joined: Nov 2014

Machine: PR System One REMstar Auto 560 with A Flex
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 For Her
Humidifier: REMStar heated humidifier with heated hose
CPAP Pressure: Auto Cpap 10-13 AFLEX 1
CPAP Software: SleepyHead EncoreBasic

Other Comments: Started CPAP Therapy October 23, 2014

Sex: Female
Location: Northeast Ohio, USA

Post: #18
RE: Insurance makes you CRAZY.
DWaldman,
If your not entirely stuck on buying a ResMed, you may want to check out the Phillips Respironics Series 60 APAP machines. They are discounted now to make way for a new model coming out. Check out the suppliers list at top of page.

Here is a link that may help you in choosing the right machine:

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

Good luck,

OpalRose
10-12-2015 07:31 AM
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robertbuckley Offline

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Posts: 99
Joined: Mar 2013

Machine: Resprionics BiPAP Auto SV Advanced
Mask Type: Full face mask
Mask Make & Model: ResMed AirFit F-10 Full Face
Humidifier: Resprionics System One
CPAP Pressure: EEP 15; PS 4 - 10
CPAP Software: SleepyHead EncoreBasic

Other Comments:

Sex: Male
Location: New York, NY

Post: #19
RE: Insurance makes you CRAZY.
I would second OpalRose - If you can up-front it get yourself a PR-60 APAP with A-flex and humidifier on sale from one of the non-network internet providers and then go with a DME for mask supply and hose. The 40% of sale price you have to pay will probably be less than the deductible and the 20% co-pay, and you get what you want. You need to be comfortable with setting it up yourself, though.

Just a reinforcement of some of what has been said above - if you go with an in-network provider, decide what equipment you want and have your doctor write the scrip for that machine with every bell and whistle you want, specified, and then have him/her write - Dispense as prescribed - no substitution on the scrip. Also, ANY MD can write the scrip for you.
10-15-2015 02:31 PM
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DWaldman Offline

Preferred Members

Posts: 57
Joined: Sep 2015

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: InnoMed Aloha
Humidifier: Hi5
CPAP Pressure: 9-17
CPAP Software: SleepyHead

Other Comments: We rescue dogs... I am going to need LOTS of filters....

Sex: Male
Location: Atascadero Ca

Post: #20
RE: Insurance makes you CRAZY.
(10-11-2015 09:27 PM)DariaVader Wrote:  stick around, you will find the vast majority are here to be helpful, and there are only a couple who don't know how not to be condescending Bigwink

(and if u think that was about you... check if the shoe fits Tongue )

Thanks for the info, it has helped a lot. Met with the Dr. on Tuesday, he is writing a Rx for a APAP, with data capability. I think I have found a good on-line provider, who will work with my insurance. Even at a 40% co-pay for going out of network, I will be money ahead in the long run. This forum has been great for learning about equipment, warning about DME's, and overall making this new adventure less intimidating. So, a big thank you to you all, and I will be here for the long haul. Look forward to sharing my triumphs and tribulations with people who have gone down this road before me.
10-15-2015 08:47 PM
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