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Just started Medicare have questions on how to go about this
#1
Just started on Medicare.  I'm on AARP Medicare Complete by United Health Care.  

This is all I know about it so far.  I pay 20% of cost.  I understand I need a script for all supplies.  I need prior authorization from doctor and from where I'm getting the supplies.  Apparently the supplier needs to submit claims to insurance or I need to submit for direct member reimbursement which could be helpful I suppose if I order on ebay which they said I could do. 

One question I asked my insurance company was how the script needs to be filled out.  They told me the doctor will know how to write script.  Knowing the clinic I go to and judging by the last script that was written awhile ago, I'm not so sure about that and had better have detailed info on this for my appointment on Tuesday.  Is there a generic script or do i have to have the brand, model, etc for mask, cushion, hose, filters, mask wipes, etc along with how often I can get replacements?

I was told I can order from online suppliers as well as places like ebay.

I am hoping that my doctor can simply write out the scripts needed and I'm set and that I don't have to have a sleep study first.  My first and last sleep study was in 2000.  If I need a sleep study it looks like I'll be paying out of pocket for this but don't know what the current requirements are at this time.

I hope what I've written makes some kind of sense because I'm in kind of a haze about  this and am not sure I know what questions to ask at the moment.
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#2
Medicare CPAP Qualifications

CPAP Qualifications (E0601) Patient must meet all the following criteria to qualify for an E0601 device (CPAP)

  • Patient has had a face-to-face clinical evaluation
    • by treating physician prior to sleep test.

  • Patient has had a sleep test which meets Medicare Requirements.
    • that meets either of the following criteria:
      • AHI/RDI3 is ≥ 15 events per hour with minimum of 30 events; or,
      • AHI/RDI is ≥ 5 and ≤ 14 events per hour with minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke. See back for additional information.
  • Diagnosed with OSA (ICD-9 code of 327.23)
  • Patient and/or caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.
Bottom line You must have a sleep test, though it can be an older one if it shows need.
And you MUST see a Dr.
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#3
(05-14-2017, 12:55 AM)Lanco Wrote: One question I asked my insurance company was how the script needs to be filled out.  They told me the doctor will know how to write script.  Knowing the clinic I go to and judging by the last script that was written awhile ago, I'm not so sure about that and had better have detailed info on this for my appointment on Tuesday.  Is there a generic script or do i have to have the brand, model, etc for mask, cushion, hose, filters, mask wipes, etc along with how often I can get replacements?

I was told I can order from online suppliers as well as places like ebay.

I am hoping that my doctor can simply write out the scripts needed and I'm set and that I don't have to have a sleep study first.  My first and last sleep study was in 2000.  If I need a sleep study it looks like I'll be paying out of pocket for this but don't know what the current requirements are at this time.

Other than the machine itself and the mask, most replacement items (hoses, filters, small mask parts like cushions) do not require a prescription. I know of no insurance company that covers cleaning supplies and comfort items such as mask wipes. I asked my physician to write a generic prescription without a date. It contains my diagnosis, the diagnosis codes, and the codes required for reimbursement. The description reads "replacement/consumable CPAP supplies including masks, cushions, hoses, filters, and parts." Scan it into a pdf for email attachments or fax it to any vendor that requires it -- and leave it to them to check with your doctor if they need confirmation. The only party that appears to have a genuine need for the sleep study is the DME that will be providing the machine itself and monitoring compliance during the 13-month Medicare monitoring period.

Now that I am on Medicare and use United Healthcare's Plan F, my machine and supplies are covered at zero cost. The only glitch was that my original machine and supplies were supplied by Apria who lost the competitive bid in my area. That meant after 13 months, when the machine became mine, they could no longer provide the supplies per the Medicare schedule. Apria made arrangements for another company who won the competitive bid to provide the supplies.

I found that the best way to get a definitive answer to most insurance questions is to ask for the insurance company's ombudsman and document each encounter with date, time, employee, and a summary of the discussion. Many of the vendors on the Supplier list in the forum header are extremely knowledgeable about the policies and the reimbursement rates because that's the core of their business.

Best of luck with your quest ... and please post your follow-up for others who are similarly situated and might be facing the same situation.
"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius
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#4
If you have received the Medicare handbook for 2017 (more like a catalog) look up what it says about sleep apnea. They may require that you have a new sleep study to verify your need for the equipment. I had no problems with Medicare through the DME provider. Medicare has a set schedule for replacement hoses, masks, pillows and cushions, etc, and are pretty generous with their replacement dates. I'm fortunate that my secondary insurance is TriCare4Life (military) and picks up my whole 20% Medicare deductible.
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#5
I went on medicare 3 years after my sleep study and start of CPAP use. A new sleep study was not required. What was required was documentation of a "face to face" meeting with my Dr. within the 6 month period before I requested the first supplies covered by medicare to confirm the continued need and that I did benefit from the therapy. I simply called my Dr.'s office and they supplied the necessary confirmation to my DME. I did not need to deal with medicare directly.

I see the Medicare 13 month monitoring period mentioned frequently. I think the 13 month period only applies to the machine itself, after which you own it.  I believe compliance must continue to be demonstrated in order to have supplies covered after the 13 month period.  I have worked with two DMEs and they have continued to require confirmation of compliance every time I order medicare covered supplies even though my machine was completely payed for and over three years old.

I got a new machine in January after being on Medicare for 7 years and 10 years after my sleep study. A new sleep study was not required, just the "face to face" mentioned above. I must, of course, continue to demonstrate compliance and a meeting with my Dr. within 30 to 90 days after receiving the new machine was required.

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#6
Lanco, most of the qualifications listed are for those getting a machine. You have one already. You just need supplies. Realize that you can only get supplies for a single machine even if you take one with you traveling on business. My experience with 2 DMEs says that you should stick with the heated hose if you want a quality hose. If you have the doc list Slimline, that boils down to generic and you will likely be unhappy. Also want hypoallergenic filters if you have allergy issues at all. You will generally get knockoff filters. Mask - ask for patient choice or you will have to keep going back to doc to change.

To Sum up:
Supplies for Resmed S9 machine - Heated wire tubing, hypoallergenic filters, water chamber
Mask - patient choice - to include headgear and cushion replacements
Chinstrap (if you use one).

Length of need - try for 99 years, but at least once per year.
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#7
Thank you for the info Thanks
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