Insurance makes you CRAZY.

[DWaldman]

The world of insurance coverage is enough to drive anyone crazy. I have a good plan, in-network is 80/20 out of network is 60/40. Now you also have deductible, $.500.00 a calender year. So how do you figure out what you will pay beforehand? My research so far is in network works like Medicare, they bill insurance co. by code, get a set amount paid, and I pay 20%. For the machine, this is broken out over 13 months. Out of network , I find the best price, submit the bill to insurance and get 60% back. Sounds simple, right? Ha!
Try finding out what the Medicare pays by state.
Now remember, your monthly bill will go up to the Medicare full monthly rate at the first of the year, until your deductible is met. (My deductible is already met for this year.) Great if you start in January, Sucks starting in October.
The whole sytem is apples and oranges, though you have a hard time finding out the cost of the oranges.
Has anybody found an easy way to navigate all this?
Get my prescription on Tuesday, Would be nice to have this figured out by then.
The adventure continues... Oh, one thing I have learned is conventional DME's suck...

[MobileBasset]

With respect to agonizing over the Medicare yearly deductible and trying to schedule medical activity, I just don't. I'm going to end up paying it every year regardless of how I schedule things and the only thing that would vary is which medical provider ends up getting my deductible money. YMMV

[Moriarty]

Its a lot easier to work out in in Australia... If your insurance covers CPAP at all, it is to the tune of $500 towards the machine once every 5 years. Nothing on masks or consumables. (end sarcasm)

[Mike1953]

I really don't know why you bring Medicare into this discussion. If you were on Medicare and had a medigap policy along with your Medicare you would pay nothing every January. With the correct medigap policy your annual deductible would be paid by them.
As far as your insurance call them and ask them about the DME and what deal they have for costs.

[robertbuckley]

Medicare (original) with a supplemental (Medigap) is a very different set of hoops and payments then traditional insurance, so you need to tell us which you are under. Also Medicare Advantage is different.

If under Medicare you also need to determine if you are in a"service area" where they have contracted with low bidders to supply machines and supplies and you are restricted to using only that supplier - can't get re-imbursed if you use somebody else.

With traditional insurance every plan varies - while Medicare uses the 13 month payout, a 10 month payout is used by some insurers. They also will have a supplier list of "preferred" DME providers. Don't even try to make sense out of what they bill the insurance company, the insurance company will pay them what they have scheduled and you will pay your % copay of that.

I never thought I would ever think of supporting a single payer system, but having fought with United Health for years over all sorts of things and now under Medicare - I must tell you Medicare is far superior, except for the hassle of the part D drug plans - where you are back into fights over formulary - which isn't part of Medicare coverage.

[DWaldman]

Medicare (original) with a supplemental (Medigap) is a very different set of hoops and payments then traditional insurance, so you need to tell us which you are under. Also Medicare Advantage is different.

If under Medicare you also need to determine if you are in a"service area" where they have contracted with low bidders to supply machines and supplies and you are restricted to using only that supplier - can't get re-imbursed if you use somebody else.

With traditional insurance every plan varies - while Medicare uses the 13 month payout, a 10 month payout is used by some insurers. They also will have a supplier list of "preferred" DME providers. Don't even try to make sense out of what they bill the insurance company, the insurance company will pay them what they have scheduled and you will pay your % copay of that.

I never thought I would ever think of supporting a single payer system, but having fought with United Health for years over all sorts of things and now under Medicare - I must tell you Medicare is far superior, except for the hassle of the part D drug plans - where you are back into fights over formulary - which isn't part of Medicare coverage.

Not on Medicare, sorry for the confusion. I was stating that private insurance, which I have, (0nly 61 and still working.) follows medicare guidelines for reimbursement to the DME. That is why my deductible will roll over at the first of the year. That is what makes this difficult. Nobody gives you the full story. It is part medicare guidelines, part insurance company rules, and part DME policy.

[Mike1953]

Not all insurances follow Medicare guidelines. DME policy has nothing to do with payment. You have been listening to the wrong people. Also all deductibles roll over at the first of every year. You better call you insurance co. and get the story, not someone who doesn't know what they are talking about.

[SaldusMiegas]

Hi DWaldman,

I'm with the other guys on this point... don't worry about Medicare or the world of insurance, call the 800 number and talk to your insurance provider to determine specifically what your coverage will be.

The DME will spout all the Medicare stuff, and to be honest, lots of insurance providers adopt Medicare rules as their own policy. But many are less restrictive.

For example Medicare will require you demonstrate compliance with a machine and have a face to face followup with a doctor who must document both compliance and effectiveness of your compliant use of the machine before Medicare will buy it. Some insurance companies dispense with all that and take your sleep study results and doctor prescription as all you need to buy your equipment.

So you might be pleasantly surprised. Maybe your insurance plan will buy your machine outright on day one (mine did). That means no deferred purchase until documented compliance, and no 10/13 month "lease to own" period that will span plan years and cost you a second deductible to buy the same machine.

Don't rely blindly on the DME. Consider them a data point but you might end up knowing more than they are willing to tell you once you talk with your insurance plan provider.

Ask the DME lots of informed questions. They get big bucks above the cost of the equipment to train you, so don't be shy about asking all you need to know before YOU make the decision on what equipment YOU will decide to buy from them. If they have trouble remembering who the customer is, don't hesitate to call a different in-network DME who is willing to talk to you.

Tip: if you contact the DME by phone to answer all your questions versus go to their office, you might feel more freedom about calling someone else. Then when you make the appointment with a DME it will be to train you on the machine and fit you for a mask.

It might be useful for you to know what specific machine you want and at what type of mask you want (nasal pillows, nasal mask, full face mask, etc) before you call your insurance plan, before you get your prescription, certainly before you talk to the DME.

Lots of good info here --> http://www.apneaboard.com/wiki/index.php...ngle:Links

Also lots of good info and reviews of various mask products by googling <mask product name> demo fitting review

Don't despair. If you have a good insurance plan you may have more options and control over decisions than a DME will admit to you. Call your insurance provider for clarity.

Good luck, feel better.

Saldus Miegas

[DWaldman]

Not all insurances follow Medicare guidelines. DME policy has nothing to do with payment. You have been listening to the wrong people. Also all deductibles roll over at the first of every year. You better call you insurance co. and get the story, not someone who doesn't know what they are talking about.

Mine follows Medicare policy as far as Dme's in the network. Yes, all deductibles role over, I know that. That is why I said start in january is better. This is the first year I have met deductible, and next year will be the first I have a large monthly deductible payment. I have talked to my insurance company, they cannot give me concrete numbers until the bill is submitted. DME policy matters as to the type of machine they will provide. I have that first hand from an In-Network provider who said no way will they issue a S9 Autoset if insurance is involved. That is why I say this is crazy. I am shopping, to find the best provider who has a billing system that doesn't screw up, who will work with my insurance and doctor to provide the equipment I need and want. It shouldn't be this hard. I do not live in a large city, the major metropolitian areas are more than 150 miles away. The local reviews for our Apria and Lincare offices suck, the local non chain in-network provider wants to issue only the cheapest machine thay can get away with. I am leaning to buying on-line and accepting the 60% reimbusement instead of trying to deal with a difficult DME for an 80 % reimbursement. My insurance provides reimbursement without requireing

[SaldusMiegas]

Not on Medicare, sorry for the confusion. I was stating that private insurance, which I have, (0nly 61 and still working.) follows medicare guidelines for reimbursement to the DME. That is why my deductible will roll over at the first of the year. That is what makes this difficult. Nobody gives you the full story. It is part medicare guidelines, part insurance company rules, and part DME policy.

If you are getting fuzzy answers, maybe ask a more specific question:
i.e.

ResMed AirSense 10 AutoSet machine
F&P Simplus Mask or P-10 Nasal Pillows

.. what options do I have for buying the machine?
.. do I get to choose my machine (you want an automatic, data capable machine)
.. how often will the plan allow me to purchase new: masks (3 months?), hoses (3 months?), humidifier (6 months?), filters (monthly?), new machine (5 years?)?

If you only ask general questions they will give general "policy" type answers.

If you have a specfic bill of materials they can tell you much more...
Build yourself a list or get one from the DME then go over it with your insurance and they should be able to tell you very specifically what the costs will be.

If you must do a lease period, insist that the DME provide you with YOUR model machine (or your actual lease-to-own machine) during the lease period. Some people have reported that the DME provides a "loaner" class machine which is usually a "brick" (not data capable) during the compliance period, which is not what you want.

Saldus Miegas