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Medicare changes--can't get mask--Youre next
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andora3 Offline

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Posts: 2
Joined: Feb 2014

Machine: resmed M
Mask Type: Nasal mask
Mask Make & Model: mirage swift II
Humidifier: unsure
CPAP Pressure: 8
CPAP Software: ResScan

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Sex: Female
Location:

Post: #1
Medicare changes--can't get mask--Youre next
In NY Medicare recently declared New York state a competitive bidding area for all sleep apnea products. They are slowly are expanding this across the country. When this happens you can access apnea supplies only from their designated suppliers.
What is happening in NY is that now that you are locked up with certain suppliers, Medicare has allowed the suppliers to severely restrict the type of masks they will supply. This month my supplier decided no more Resmed. Or at least now they are announcing it. Three month ago they told me I could not get my mirage swift and got me to agree to a substitution which did not fit and was useless. There are no companies within the NYC area that show my mask on the Medicare site. Apparently I will have to change to a distant company but only if I can get my current provider to send the volumes of information Medicare requires to the new company and if the company wants to accept me. When I called yesterday they were not enthusiastic about a new customer. I am at this point obtaining a prescription from my doctor and will have to order and pay myself while the red tape is straightened out. We should be writing to our congressmen and preventing this lack of access to reasonable life saving medical equipment from expanding.
02-18-2014 09:40 AM
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justMongo Offline

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Posts: 3,839
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #2
RE: Medicare changes--can't get mask--Youre next
I had the same problem a year ago with diabetic testing supplies. My area became a competitive bid area for Medicare testing supplies.
The people I was getting supplies from did not carry my preferred test strips. They said "choose a different meter." I told them to, "Go pound sand." They wish to supply strips that maximize their profit after they won a low-ball bid. I have written to my Congress critter on that issue. Don't expect that they will care.

After searching and calling I did find a bid winner willing to supply the strips I wanted.
Point is: there may be a competitive bid winner who will supply ResMed.
You may use a supplier anywhere in the country as long as they are a a competitive bid winner -- you are not limited to NY.

I will PM you with a suggestion.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
(This post was last modified: 02-18-2014 10:14 AM by justMongo.)
02-18-2014 10:13 AM
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me50 Offline

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Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

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Sex: Undisclosed
Location: USA

Post: #3
RE: Medicare changes--can't get mask--Youre next
(02-18-2014 09:40 AM)andora3 Wrote:  In NY Medicare recently declared New York state a competitive bidding area for all sleep apnea products. They are slowly are expanding this across the country. When this happens you can access apnea supplies only from their designated suppliers.
What is happening in NY is that now that you are locked up with certain suppliers, Medicare has allowed the suppliers to severely restrict the type of masks they will supply. This month my supplier decided no more Resmed. Or at least now they are announcing it. Three month ago they told me I could not get my mirage swift and got me to agree to a substitution which did not fit and was useless. There are no companies within the NYC area that show my mask on the Medicare site. Apparently I will have to change to a distant company but only if I can get my current provider to send the volumes of information Medicare requires to the new company and if the company wants to accept me. When I called yesterday they were not enthusiastic about a new customer. I am at this point obtaining a prescription from my doctor and will have to order and pay myself while the red tape is straightened out. We should be writing to our congressmen and preventing this lack of access to reasonable life saving medical equipment from expanding.

you could go to an out of network supplier and that would be less expensive than you paying the full price.

you could order from one of their mail suppliers

you could go to a medicare advantage plan if you are on straight medicare

you could ask your DME if they will order it even if they don't carry it.

even if you go to an out of network supplier, check with your insurance company and see what it requires for you to file the claim for out of network payment. any reimbursement is better than you paying 100%

just some ideas to explore
02-18-2014 10:15 AM
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trish6hundred Offline

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Posts: 6,429
Joined: May 2012

Machine: Resmed S9 AutoSet for Her
Mask Type: Full face mask
Mask Make & Model: Fisher & Paykel Simplus
Humidifier: H5i Heated Humidifier
CPAP Pressure: 10 - 7-20 Cm H2O
CPAP Software: Not using software

Other Comments: I started CPAP in 2008. Totally blind since birth.

Sex: Female
Location: Missouri, USA

Post: #4
RE: Medicare changes--can't get mask--Youre next
Hi andora3,
WELCOME! to the forum.!
Best of luck in getting your insurance problem straightened out.

trish6hundred
02-18-2014 10:38 AM
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Lukie Offline

Preferred Members-2

Posts: 352
Joined: Nov 2013

Machine: Resmed S9 Auto
Mask Type: Full face mask
Mask Make & Model: Airfit F 10
Humidifier: H I heated tubing resmed
CPAP Pressure: 6-16
CPAP Software: ResScan SleepyHead

Other Comments: Masks: Simplus, Air, Quattro fx, Nano, Eson, Swift fx and Activ

Sex: Female
Location: Vermont

Post: #5
RE: Medicare changes--can't get mask--Youre next
If everyone goes to their DME and says they are going to get their masks online, the law will be changed fast. The DME will become a thing of the past if they don't fight this. No longer can they suck and fleece the Medicare tit. They will have to compete in the open market.
(This post was last modified: 02-18-2014 04:48 PM by Lukie.)
02-18-2014 04:44 PM
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PollCat Offline
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Posts: 1,576
Joined: Feb 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: ResMed AirFit P10
Humidifier: H5i Cleanable with ClimateLine
CPAP Pressure: 10 - 18
CPAP Software: SleepyHead

Other Comments: CPAP-ing since 1995; Type 2 Diabetes; Chronic Asthma; Gout

Sex: Male
Location: Westfield, IN

Post: #6
RE: Medicare changes--can't get mask--Youre next
Indianapolis was one of the test-beds for this policy, so I've had to live with it since I retired and became eligible for Medicare in 2011. After playing games with both Medicare and my insurance company, I found a local DME who is on Medicare's approved list - but my supplies now cost Medicare more than if they'd let me continue using Supplier #1.

My insurance company will reimburse me 75% of the costs after we (Supplier #1 and I) jump through multiple hoops. In the end, I bit the bullet and pay for the supplies out-of-pocket as my patience is worth more to me than the cost of the supplies. I'm not looking forward to the time I need a new machine!!!! oldman


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA.
INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-18-2014 06:13 PM
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PaulaO2 Offline
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Posts: 8,062
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: #7
RE: Medicare changes--can't get mask--Youre next
Yeah, I'll just go to buying out of pocket or going on line. Don't like my DME anyway. Any doctor can write the script for the mask and the machine, it doesn't have to be a sleep doc.

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-18-2014 06:57 PM
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GrammaBear Offline

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Posts: 381
Joined: May 2012

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Air Fit P10
Humidifier: ResMed H5i heated humidifier
CPAP Pressure: 12.2 - 16.2
CPAP Software: SleepyHead

Other Comments: Type 1 diabetes - using Tandem T-slim insulin pump, Dexcom G4 CGM

Sex: Female
Location: northern Illinois

Post: #8
RE: Medicare changes--can't get mask--Youre next
(02-18-2014 06:57 PM)PaulaO2 Wrote:  Yeah, I'll just go to buying out of pocket or going on line. Don't like my DME anyway. Any doctor can write the script for the mask and the machine, it doesn't have to be a sleep doc.

I agree with you Paula. My current DME made a mistake on my last order and then had the nerve to tell me "Medicare will not allow us to fill your order until ?? because you already have a 'partial fill' - meaning they gave me two nasal pillows and NOT the rest of my order. Then when I got the EOB for the partial fill order, I was shocked at the price that they charged Medicare and my secondary insurance. It is just a lot less hassle to pay out of pocket and be able to get supplies when I need them. I did not know any Doctor could write the script for the mask and machine.
02-18-2014 07:09 PM
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me50 Offline

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Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

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Sex: Undisclosed
Location: USA

Post: #9
RE: Medicare changes--can't get mask--Youre next
(02-18-2014 07:09 PM)GrammaBear Wrote:  
(02-18-2014 06:57 PM)PaulaO2 Wrote:  Yeah, I'll just go to buying out of pocket or going on line. Don't like my DME anyway. Any doctor can write the script for the mask and the machine, it doesn't have to be a sleep doc.

I agree with you Paula. My current DME made a mistake on my last order and then had the nerve to tell me "Medicare will not allow us to fill your order until ?? because you already have a 'partial fill' - meaning they gave me two nasal pillows and NOT the rest of my order. Then when I got the EOB for the partial fill order, I was shocked at the price that they charged Medicare and my secondary insurance. It is just a lot less hassle to pay out of pocket and be able to get supplies when I need them. I did not know any Doctor could write the script for the mask and machine.

I think your DME is full of it. Medicare doesn't care if the order is done in 2 orders 3 orders 5 orders, etc., as long as you are eligible for the supplies. Your DME (RT) was probably too lazy to correct their error. JMHO
02-18-2014 07:14 PM
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PaulaO2 Offline
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Posts: 8,062
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: #10
RE: Medicare changes--can't get mask--Youre next
Medicare allows for X # of supplies every X months. I can never remember the schedule. So it could be what he was saying is you were still not eligible for the next set or something.

But it most likely is they are idiots and didn't want to help you.

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-18-2014 09:03 PM
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