New to Medicare and questions

[KSMatthew]

I know there are a lot of international members here, but these questions are US specific:

I’m almost Medicare eligible and am looking at different options.  Basically my options are Advantage vs a supplement.

I currently pay for my CPAP and supplies out of pocket.  How does Medicare coverage work? Do I have to use specific DMEs or can I continue to use mail order and then turn in receipts?  Do I have to keep my PCP more in the loop by setting up regular sleep studies?  

I don’t know what I don’t know.

Any info will help.

Thanks.

[SarcasticDave94]

I'm on Medicare via Disability. I chose an Advantage plan through Highmark, a Distinct PPO. My plan does have an in-network list including the DME. I had to deal with the DME directly at least for initial dealings.

I am not certain but when switching to Medicare only when getting a new CPAP, they might ask either for a sleep study or the report. There would not be ongoing needs for sleep studies afterwards.

[Nightynite]

If you look up Kansas dept of insurance, you can make a one on one appointment with a Medicare consultant and get all your questions answered. I did something similar where I live and it made my choice very easy.

[car54]

When I retired I picked a supplement plan because after years of work, my body was falling apart and I knew that I had  surgeries in the future. It allowed me to pick any doctor in the USA. There was no network that I had to stay in and I would not need preauthorization. It cost slightly more than a advantage plan and I had to pay extra for a prescription plan and it does not include any dental plans.

All my cpap supplies are covered


I retired 6 years ago and I have had about 15 surgeries. 3 years ago I had a major hand injury which required 4 surgeries. My total billed amount for my hand was $790,000.00 of which I did not have to pay anything besides the monthly premiums.

I decided to get the supplement plan after consulting with a independent insurance company who was not pushing an agenda. That is the best thing that you can do and do not listen to the adds on TV.

[Nightynite]

Also, research the phrase “ step therapy “. If you need a certain medication an advantage plan may require you to do step therapy first.

[StratCat48]

I've found Youtube videos from 'Medicare School' particularly helpful. Below is linked one comparing supplemental/Medigap vs Advantage plans. Pay attention to switching plans. If you start out on an Advantage plan it may be difficult to switch to a supplement if you should want in the future. Some Advantage plans for CPAP machines are setup as continuous rental that may have a co-pay associated with it. The supplemental plan follows the Medicare rules of payments for 13 months and then you own it. The 13 months of payments for my CPAP  was paid by my supplement plan.
Browse through the other videos from 'Medicare School'. A lot of good info can be found there.

Medicare School
https://youtu.be/3bttIlCVMms

[KSMatthew]

I’ve been pretty thoroughly looking into the details of different plans. But that’s not really the focus of what I’m trying to learn.

I’m assuming Medicare B covers DME.

How does a bare “B” plan, no supplement, work for CPAPs and supplies? Copays, deductibles, and coinsurance is probably standard.

A supplement would then cover those expenses?

I hear people say, “It didn’t cost me anything…”. Is that because od a supplement?

Are you limited to particular machines or brands? I but what I want, when I want. Am I still able to do that?

[StratCat48]

Image below is a Medicare claim for supplies from a DME. If I didn't have a supplement plan the DME would likely bill me for the amount shown a 'Maximum You May be Billed'. On several of the items that Medicare paid $0, those amounts were applied towards my yearly deductible of $257. My Supplemental (BCBS MEDEX) will cover what Medicare does not pay. I will owe $0. My CPAP machine, back 5 years ago was paid for fully by the supplement as well. I didn't know much when I got the CPAP machine initially and took what they gave me, but I believe you can have your doctor specify on the prescript to the DME what machine you want so long as the DME carries or can get it.

[Nightynite]

I hear people say, “It didn’t cost me anything…”. Is that because od a supplement?

That’s because they probably don’t physically pay the cost of secondary insurance. some one else is paying for them )
Depending on the plan you choose, it will cost you more money.

My plan cost me about 3k extra a yr. Some plans can be less or more.

Medicare pays 80 % you pay 20% . Thus the need for secondary insurance.

[SarcasticDave94]

FWIW because I'm disabled and have food stamps with county assist, the state pays most of my Medicare Advantage premium. I pay $4.40 monthly. My plan includes dental, eyeglasses, prescription, medical.

Regarding CPAP, I would have a copay of 20% the machine 13 month rental with mask and humidifier parts being lump sum upfront. The ResMed VAuto I tried recently cost about $90 to me month one copay. Month 2 and up was about $40 copay I think.