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Medicare changed coverage for ResMed masks
#1
Money 
After trying numerous CPAP masks from different companies over the years, I finally found one that fits and doesn't leak: ResMed AirFit full face mask.
Medicare and AARP covered the cost with no copay by me.
However, when I went to get my 3-months replacement, my Medical Equipment supplier told me that Medicare no longer covers so-called Premium masks. Starting now, I would have to pay the full cost to the supplier who then would file the claim for me and in due time Medicare would send me a check for the amount they covered.
According to the supplier it would amount to a net cost to me of about $80 where I paid nothing before.

However, the supplier had the 3B Elara Full Face CPAP mask which would be fully covered by Medicare/AARP without any cost to me.
A look at the mask shows the flimsy construction and trying it for several nights, I cannot get a proper seal no matter what I try.

My question is: Did Medicare in fact made changes in the last 3 months regarding coverage of CPAP masks by classifying ResMed and other well known brands as Premium masks?
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#2
They're making up a story.

Medicare did another round of competitive bids for DME suppliers. Many lost their Medicare contracts; including mine.
Things changed on 01 July 2016. I can find no mention of so called premium masks. I am however, finding it difficult to find a new supplier.

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#3
Sounds like a tall tale to me, I would report them to Medicare.
I am not a Medical professional and I don't play one on the internet.
Started CPAP Therapy April 5, 2016
I'd Rather Be Sleeping
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#4
I just had an order filled 2 weeks ago for the F-10 under Medicare with no problem. Sounds like that the Elara is the mask the supplier wants to supply to you because they will make more. Which DME supplier do you use? You know what you like, and if you are not in the "rental" period anymore, just switch DMEs. You really don't even need one that is local, so long as they have a contract to service your area. You call, they fill. Mark your calendar for 3 months out, and call again. Even Apria does this with no hassles.
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#5
(08-21-2016, 02:08 PM)robertbuckley Wrote: I just had an order filled 2 weeks ago for the F-10 under Medicare with no problem. Sounds like that the Elara is the mask the supplier wants to supply to you because they will make more. Which DME supplier do you use? You know what you like, and if you are not in the "rental" period anymore, just switch DMEs. You really don't even need one that is local, so long as they have a contract to service your area. You call, they fill. Mark your calendar for 3 months out, and call again. Even Apria does this with no hassles.

Here in Westlake Village, California, APRIA is no longer the Medicare Supplier according to the latest round of bidding. However, they appear to be grandfathered into the program as long as I am in my "rental period" and then I may need to switch vendors. There does not appear to be any restriction on ResMed products when checking their on-line ordering site.

Considering the actual costs of the masks vs. retail, one might suspect that the DME is being incentivized to sell a particular mask. I would contact the DME and ask for a supervisor. Get their name, time, and date of the conversation. Get them to repeat the story. And then ask them if there is any reason you should not call the Medicare FraudTips Hotline at 1-800-447-8477. "Giving false information to any insurance company is fraud -- a crime that can result in criminal and civil penalties."
"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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#6
Looks like they make more money on that cheap mask which is $99 on the Internet.
I'll be looking around for another supplier.
No sense that I should be paying $80 out of my pocket with Medicare we
Hen I paid nothing 3 months ago
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#7
Hi Wildfire,
WELCOME! to the forum.!
Good luck to you with your CPAP therapy and with getting the situation with your supplies straightened out.
trish6hundred
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#8
Thanks everybody for answering my question. Obviously Medicare has no restrictions on ResMed and that Premium BS is the supplier's own invention.
They are not the only ones in this area; I'll be looking for more consumer friendly folks.
In the meantime I have the 3B Elara to test some more while I continue using my full face ResMed AirFit a little longer.



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#9
Medicare covers my F10s at 80% rate and that only leaves a small amount to pay. (as of 7/2016)
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#10
My supplier, Choice Medical, told me that when Medicare cut the reimbursement rate for masks by a large %, all the manufacturers EXCEPT Resmed cut their price; Resmed refused, thus making the Resmed masks a loss item under the medicare contracts. I have explored this with Choice and with Stanford Sleep Clinic and the story is consistent. When you look at prices on line now for direct purchase, all the current Resmed masks are significantly more  expensive than the other brands.

So far I have tried 5 different nasal pillow systems not Resmed and 100% of them result in less sleep, many falling off during the sleep, discomfort etc. I have used the Resmed nasal pillows - the Swift Fx (and maybe a predecessor) and then the Airfit P10 since 1998 without any issues. The current situation with medicare and Resmed is untenable. Clearly Resmed can make a nice profit with a reduced price - they just are too arrogant to do that. Or just too greedy.
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