Choosing a mask

[Steerpike58]

Thanks for the info! Your location indicates NorCal, and you mention Kaiser, so we may be referring to the same location - the Kaiser sleep center in Martinez. I'm curious - were you able to get masks from Kaiser AFTER they gave you a prescription for the machine, and you had your own machine at home? Was Crapria a factor with Kaiser, or do they have their own DME operation? I'm still in the 'investigation' mode, so I haven't been issued a machine yet.

Kaiser is a weird sort of bird. Kaiser is in reality your DME, and Crapria is the supplier. You have zero choice as far as suppliers. It's Crapria or nothing. 100% of the time the billing was wrong, and they often tried to substitute cheaper items for what was ordered, orders were wrong.
I once filed a greivance with Kaiser for a billing error, LOST the appeal, and 6 months later got a refund check because I was correct about the error.

The Kaiser sleep clinic in Santa Rosa was great. Right before I lost my coverage I went in for an appointment, and they HANDED me a brand new ResMed Autoset to take home with me--they apparently didn't wait for Crapria delivery anymore. I was NOT on Kaiser Advantage, had really good coverage, that paid for the machine outright. This was days before the last month on that insurance!

As for masks, they would always see me for mask fittings, let me keep the masks I tried on and give me extra pillows. But to get a mask from Crapria, Kaiser must specify the exact mask on your prescription, and they have a limited formulary. You can switch masks any time, but Kaiser must change your prescription every time.

It's been about 7 years since I lost coverage. I don't know if they are still operating the same way.

I don't intend to stay with Kaiser when I turn 65 in about a year. For one thing (there are many other reasons), they require "perpetual rental" of DME including CPAP machines on Kaiser Senior Advantage. No capped rental, you never own the machine. I'm not planning to play that game.

Interesting! I turn 65 in 2 months and will be medicare eligible Nov 1. Currently, I'm on a 'bronze' Kaiser plan through the 'healthcare exchanges' (covered California, since I'm in CA). Apparently I get ZERO coverage for a CPAP machine on this current insurance, but - once I become Medicare eligible, apparently they pay 80%. I was totally ready to bail on Kaiser because I just don't like their medical offices, their in-house pharmacy, and their in-house labs. So I was all set to go United Healthcare insurance+John Muir Health as the HMO. But then this 'sleep' issue arose, and now I'm deep in the middle of an ongoing 'trial' situation - already had the at-home sleep study, the take-home machine trial, and now I've just had the overnight in-lab study (part 1) and I'm waiting for part 2. So - if I bail on Kaiser now, I'm going to have to start the whole process from scratch with a new medical system. This (sleep issues) is pretty much my only medical condition.

So I'm reluctantly considering sticking with Kaiser and switching to Kaiser Advantage come Nov 1, and then seeing where I am in the 'sleep trial' come mid-December, which will be my next 'bail' point.

I wonder what will happen if I stick with Kaiser for a while, get a machine from them (on this 'perpetual rental' deal you mention), and then bail on them soon after getting the machine? I presume I'll either return the machine, or, be presented with some sort of a bill?

[ChicagoGranny]

... I get ZERO coverage for a CPAP machine on this current insurance ... I just don't like their medical offices, their in-house pharmacy, and their in-house labs.

Oh, is that all that is wrong with Kaiser?

[bwexler]

Steerpike58
First make sure you get hard copies of ALL of your sleep study results. That should be all you will need for a prescription from most PCPs/ medical services.
My original sleep study 13 years ago showed Mild sleep apnea with an AHI of 83.5. So far no one has questioned weather I need a PAP machine.
Once I go over the 2024 EOB I will decide if I am staying with my current Medicare Advantage program. Their cooperation in getting a new Rsemed Aircurve 10 ASV will either seal the deal or kill the deal.

[chunkyfrog]

Beware of Advantage plans. Less choice of where to go,
and you may pay forever on a simple cpap machine.

[SleepGeek]

So - if I bail on Kaiser now, I'm going to have to start the whole process from scratch with a new medical system.

Not so. Just be sure to get a copy of any sleep studies you have had.

just had the overnight in-lab study (part 1) and I'm waiting for part 2.

Have your doc order Split night sleep study. The 1st part is diagnostic - the 2nd the titration.

I was all set to go United Healthcare insurance+John Muir Health as the HMO.

afaik most DME's and many docs don't care for United Healthcare. Any HMO will severely limit your choices of docs, DMEs, equipment, and even medicines that you are using or taking now - they may not allow.

IMO you are much better off to go with straight Medicare and a Co-pay (if your retirement allows for it).

[bwexler]

Beware of Advantage plans. Less choice of where to go,
and you may pay forever on a simple cpap machine.

After 13 years on Advantage plans I am well aware of the pitfalls.
I paid put of pocket for my current ASV machine and I am currently weighing my choices for my next machine which is due by Christmas.
I also paid out of pocket for my hearing aids.
25 years ago when I was caring for my 90 year old inlaws I quickly discovered that with a bit of skillful shopping I could by DME for less than the copay.
It isn't easy, but am pretty good with a spread sheet and a calculator.

[Janknitz]

So I was all set to go United Healthcare insurance+John Muir Health as the HMO. But then this 'sleep' issue arose, and now I'm deep in the middle of an ongoing 'trial' situation - already had the at-home sleep study, the take-home machine trial, and now I've just had the overnight in-lab study (part 1) and I'm waiting for part 2.

The data from your sleep study should be enough to get qualified for CPAP regardless of which supplemental insurance plan you choose. I don't think you will need another sleep study. Just make sure you have copies of everything.

It's unusual for Kaiser to do in-lab sleep tests. They are really big on home testing unless you have a complex situation. The "take home machine trial" is your titration, but it sounds like in your case they will confirm in-lab again???

Yep, the Kaiser Covered California plans cover maybe a pair of crutches if you're lucky. You are SOL on CPAP machines and supplies. But to me that's been a boon--I hated dealing with crapria, but NOTE you can get a very good price from Crapria as a Kaiser member, IF they manage to supply the right device and supplies and watch them like a hawk for any billing. And NEVER, EVER give Crapria your credit card info for more than a single purchase at a time.

United Healthcare is also an HMO so they may also do perpetual rental (you can search for UHC's "Evidence of Coverage" which is the actual contract between you and an insurer that you never see unless you know to ask for it. That will tell you exactly what the CPAP coverage is). But a lot of people I know who aren't Kaiser have UHC around here and I haven't heard too many complaints. Kaiser is either love or hate, personally I'm on the hate side. But in my area there's not a lot of choice if you don't go with Kaiser--it can be impossible to find doctors accepting traditional Medicare, Sutter and Providence are pushing people into their own HMO's right now. I'm seriously considering a traditional Medicare plan plus a concierge doctor because I'm sick of doctor roulette at Kaiser. I'm technically without a primary care doctor right now for the fourth time (supposedly I've been assigned someone but I had no hand in choosing--I can change, but have no idea who to choose).

One thing to note is that you can't change supplemental insurers at will on Medicare, and you can't upgrade a traditional Medicare plan, you can only downgrade. You can only change during open enrollment, and once you have been with an Advantage plan for 3 months you cannot go back to a traditional Medicare supplement without underwriting--you now have a pre-existing condition. You can be on traditional Medicare WITHOUT a supplement, and sometimes that's not any more expensive, depending on your needs.

I suggest you talk to HICAP (Health Insurance Counseling and Advocacy) 800-434-0222 for FREE federally funded Medicare counseling on your supplement plan options https://cahealthadvocates.org/hicap/ They do not sell insurance and will help you evaluate options in your area.

[Steerpike58]

Steerpike58
First make sure you get hard copies of ALL of your sleep study results. That should be all you will need for a prescription from most PCPs/ medical services.
My original sleep study 13 years ago showed Mild sleep apnea with an AHI of 83.5. So far no one has questioned weather I need a PAP machine.
Once I go over the 2024 EOB I will decide if I am staying with my current Medicare Advantage program. Their cooperation in getting a new Rsemed Aircurve 10 ASV will either seal the deal or kill the deal.

Is there a typo there - I thought any AHI over 30 was 'severe', so 83.5 should be a bit more than 'Mild'.

[Steerpike58]

... I get ZERO coverage for a CPAP machine on this current insurance ... I just don't like their medical offices, their in-house pharmacy, and their in-house labs.

Oh, is that all that is wrong with Kaiser?

I'm not sure if you are being sarcastic or not, but I've been with the local John Muir Medical HMO group for 20+ years and I've always had good service (though - I've also been remarkably healthy, so mostly just checkups/blood work/etc, other than a heart-scare in 2021 where I got good attention). My PCP retired at the end of last year, and I knew I had only 10 months to go before Medicare, so I decided to see for myself what Kaiser was all about since I knew I could bail after 10 months (and their insurance premium was hundreds/month cheaper!).

Instead of going to a local, convenient, small medical office to see my PCP, I have to go to the big Kaiser Medical Center in town, parking in their massive multi-story parking lot, and being surrounded by a huge number of people (Covid got me less comfortable dealing with crowded spaces). For blood work (labs) I used to go to a tiny 'lab' and sit and wait with maybe 2 other people, but with Kaiser I have to go to their central lab and, 'take a number' along with maybe 40 other people in a crowded waiting room. Then, when I get an Rx, I have to stand in line for maybe 50 minutes at their massive central pharmacy (last time, I bailed on the line it was so long/slow, and opted for mail order) - compared to going to my local CVS or Walgreens and waiting for never more than 10 minutes. These aren't show-stoppers, but it's taking me 6 weeks to get new PCP appointments, and he's pretty 'cursory/dismissive' compared to my last PCP (this may be nothing to do with Kaiser as such, of course, just the luck of the draw with PCPs).

======================

So - if I bail on Kaiser now, I'm going to have to start the whole process from scratch with a new medical system.

Not so. Just be sure to get a copy of any sleep studies you have had.

I would hope that's the case; but who knows what wait-times they have, what their sleep clinic hours / practices are, etc. At least now I'm significantly into the process with Kaiser and know who I'm dealing with. Definitely a case of 'the devil you know' though - as I'm not thrilled with Kaiser!

just had the overnight in-lab study (part 1) and I'm waiting for part 2.

Have your doc order Split night sleep study. The 1st part is diagnostic - the 2nd the titration.

I was scheduled for a 'split' study - documented in this forum - but I slept so badly, I only got 2 hours sleep out of 8 in the lab, so they now need to get me back for 'part 2' (the titration bit). She said there's no need to re-do part 1 (whether I agree or not).

I was all set to go United Healthcare insurance+John Muir Health as the HMO.

afaik most DME's and many docs don't care for United Healthcare. Any HMO will severely limit your choices of docs, DMEs, equipment, and even medicines that you are using or taking now - they may not allow.

IMO you are much better off to go with straight Medicare and a Co-pay (if your retirement allows for it).

The two choices I'm considering are Medicare Advantage and Medigap. Premiums are roughly the same. But - as pointed out elsewhere - if I don't go with Medigap right away, I'm subject to 'pre-existing conditions' underwriting. My partner has been on Medicare Advantage with the same Medical Group / insurance company as I would be going onto, and she's had fantastic coverage so far - retina surgery, two cataract surgeries, emergency appendectomy, etc in just 2 years - no quibbles from insurance so far.

[Steerpike58]

So I was all set to go United Healthcare insurance+John Muir Health as the HMO. But then this 'sleep' issue arose, and now I'm deep in the middle of an ongoing 'trial' situation - already had the at-home sleep study, the take-home machine trial, and now I've just had the overnight in-lab study (part 1) and I'm waiting for part 2.

The data from your sleep study should be enough to get qualified for CPAP regardless of which supplemental insurance plan you choose. I don't think you will need another sleep study. Just make sure you have copies of everything.

The complication is - I was loaned a CPAP machine for 5 weeks and it didn't do much good (still showing 'centrals' around 15 per hour) so now they want to explore ASV and I'm waiting for that step. So I'm kind-of 'in the middle of things'.

It's unusual for Kaiser to do in-lab sleep tests. They are really big on home testing unless you have a complex situation. The "take home machine trial" is your titration, but it sounds like in your case they will confirm in-lab again???

I documented this in detail in another thread on the forum, but basically - I got the at-home Watchpat test which showed 31 unspecified Apneas per hour, then a 5-week loaner of a CPAP (resmed 10 airsense autoset), the results of which they didn't like (15 centrals per hour, which they further described as 'Treatment Emergent Centrals' - ie, caused by the CPAP therapy) so THEN they said, let's do an in-lab sleep study. They explained that this is the 'Kaiser way' - since most people who have Sleep Apnea are successful with CPAP, they prefer to do the at-home loaner program, and then, only if that doesn't work (my case), then they go to the trouble and expense of an in-lab study. In my case, they think I need an ASV but want to get me back in for an in-lab titration. She did say, if I REALLY didn't want to do the in-lab study, they would loan me an ASV, but I figured I'd at least give the in-lab study a try.

Yep, the Kaiser Covered California plans cover maybe a pair of crutches if you're lucky. You are SOL on CPAP machines and supplies. But to me that's been a boon--I hated dealing with crapria, but NOTE you can get a very good price from Crapria as a Kaiser member, IF they manage to supply the right device and supplies and watch them like a hawk for any billing. And NEVER, EVER give Crapria your credit card info for more than a single purchase at a time.

United Healthcare is also an HMO so they may also do perpetual rental (you can search for UHC's "Evidence of Coverage" which is the actual contract between you and an insurer that you never see unless you know to ask for it. That will tell you exactly what the CPAP coverage is). But a lot of people I know who aren't Kaiser have UHC around here and I haven't heard too many complaints. Kaiser is either love or hate, personally I'm on the hate side. But in my area there's not a lot of choice if you don't go with Kaiser--it can be impossible to find doctors accepting traditional Medicare, Sutter and Providence are pushing people into their own HMO's right now. I'm seriously considering a traditional Medicare plan plus a concierge doctor because I'm sick of doctor roulette at Kaiser. I'm technically without a primary care doctor right now for the fourth time (supposedly I've been assigned someone but I had no hand in choosing--I can change, but have no idea who to choose).

That's very interesting; Kaiser and UHC are pretty much the only games in town around here too (East Bay, CA). My last PCP 'retired' from his John Muir practice (where I was prior to going to Kaiser this year) but then set himself up as a 'concierge' service as you describe. He was always EXTREMELY thorough and detailed, and I'd like to stick with him but they want a $3,000 annual fee on top of all the insurance payments, and I'm not sure if it's worth it (plus he's already got a waitlist for signing up new patients!). My typical wait-times for my PCP with Kaiser is 6 weeks, which is terrible IMO, but - I'm hearing that's not so much Kaiser as it is 'the whole industry' - shortage of doctors, etc.
Edit To Add: I just called my old doctor's office; they said, if I switch back to them, it will be 6 months before I can get my first appt. with a PCP! I asked, what if I already have a condition and need a specialist referral; the guy couldn't give me a coherent answer. At first, he suggested I could get a referral from a doctor, but couldn't explain how I would see that doctor if the delay was 6 months, then he tried to tell me I could get a referral from my existing doctor, but my existing (Kaiser) doctor has no access to specialists in other medical groups. So I think I'm just going to suck it up with Kaiser until I get through this Sleep Apnea initial diagnosis ...

One thing to note is that you can't change supplemental insurers at will on Medicare, and you can't upgrade a traditional Medicare plan, you can only downgrade. You can only change during open enrollment, and once you have been with an Advantage plan for 3 months you cannot go back to a traditional Medicare supplement without underwriting--you now have a pre-existing condition. You can be on traditional Medicare WITHOUT a supplement, and sometimes that's not any more expensive, depending on your needs.

I suggest you talk to HICAP (Health Insurance Counseling and Advocacy) 800-434-0222 for FREE federally funded Medicare counseling on your supplement plan options https://cahealthadvocates.org/hicap/ They do not sell insurance and will help you evaluate options in your area.

I think I understand the basic 'Medicare Advantage' vs 'Medigap' (medicare supplement) plan issues, including the need for underwriting, but I'm not sure what you mean by ''can't upgrade a traditional Medicare plan, only downgrade". I'll be doing either Medigap or Medicare Advantage, most likely MA. I have called the HICAP folks and will discuss with them asap.

EDIT TO ADD: - update - I just spent 90 minutes on hold with Kaiser DME department to ask about the 'perpetual rental' details (I first called Kaiser's insurance people, they put me on to the DME dept). The lady I spoke to insisted that CPAPs are 'purchase' items, so you just pay the 20% copay and the machine is yours! She put me on hold and said she checked directly with Apria, and the Apria person confirmed, CPAPs are 'purchase items', not subject to rental. Totally contradicts what I'm reading here in the forums! I believe the forums, but I couldn't respond with anything concrete so had to leave it at that. I also asked if my Dr could specify the exact machine, she said no - you will be issued with whatever Apria has on hand at the time (which is typically Resmed Airsense 10 Autoset, but may be the '11' model). Doctor cannot specify make/model.

[Janknitz]

EDIT TO ADD: - update - I just spent 90 minutes on hold with Kaiser DME department to ask about the 'perpetual rental' details (I first called Kaiser's insurance people, they put me on to the DME dept). The lady I spoke to insisted that CPAPs are 'purchase' items, so you just pay the 20% copay and the machine is yours! She put me on hold and said she checked directly with Apria, and the Apria person confirmed, CPAPs are 'purchase items', not subject to rental. Totally contradicts what I'm reading here in the forums! I believe the forums, but I couldn't respond with anything concrete so had to leave it at that. I also asked if my Dr could specify the exact machine, she said no - you will be issued with whatever Apria has on hand at the time (which is typically Resmed Airsense 10 Autoset, but may be the '11' model). Doctor cannot specify make/model.

DME's lie like snakes. NEVER EVER EVER take their word for anything without checking. The "lady" may have been talking about NON-Advantage plans that have actual coverage for DME, not a Covered California plan and certainly not an Advantage plan (unless you also have some Employer Group Health Coverage Plans).

The Evidence of Coverage is the actual contract between you and your insurer, even though you never saw it or knew it existed. This is the RULE for how your insurance plan covers you, if it's in the book it must be followed, if it's not in the book it's not true.

Here's the Evidence of Coverage for Kaiser Senior Advantage in the Northern California Region for 2023 (2024 isn't up yet and may not be until January) :
https://healthy.kaiserpermanente.org/co ... e-ncal.pdf
Page 45 covers Durable Medical Equipment:

In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of our plan, however, you will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan, even if you made up to 12 consecutive payments for the DME item under Original Medicare before you joined our plan.

With respect to upgrading what you are calling a Medigap plan, they have various plans. For example on AARP's website they list A, B, C, F, G, N, L, K. https://www.aarpmedicaresupplement.com/?WT.mc_id=4NF G has the most comprehensive supplemental coverage, A has the least. (F and C are only available who had F and C by 2020). If you choose plan A initially with the least coverage --e.g. NO coninsurance coverage for the paid days in skilled nursing ($200 a day through day 20, then $400 a day through day 90 will cost a LOT out of pocket if you don't have that coinsurance coverage) or payment for Part A deductibles G, N, L, and K plans at different levels--you cannot upgrade to a better plan that has more coverage. You can always downgrade.

It's a jungle out there and Medicare coverage is a particularly thorny maze. Most people don't realize that a decision they make early on in their Medicare coverage will affect them the rest of their lives.

[booksfan]

Beware of Advantage plans. Less choice of where to go,
and you may pay forever on a simple cpap machine.

You just need to check carefully. My husband went on a Medicare Advantage plan in March (first timer) and was approved for his CPAP within weeks. Picked it up the beginning of April. Only waited that long because we were out of the country. Purchase after the 90-day compliance period. All his physicians are covered under that HMO plan. He IS switching, to the PPO Advantage plan I just started on today, only because neither of us needs drug coverage. I have coverage under my (free now) secondary coverage and his is under his previous employer secondary coverage. I scoured the coverage and, again, all our physicians, specialists, hospitals, etc. are covered, so we should be good. Fingers crossed, of course, because you never know with insurance!

edited to add: We are in NC, perhaps more and/or better choices here?

[Pugsy]

edited to add: We are in NC, perhaps more and/or better choices here?

Very possible that you have more/better options than CF does in Nebraska.
Medicare Advantage plans offered can and will vary by state and in some states even by county the person lives in.
They aren't all the same with what they cover or don't cover even between HMO plans or PPO plans or whatever plans.

Each person has to evaluate their own personal needs though because what one person needs may not work for the next person. There is homework involved that must be done.
If a person doesn't want to do their homework then they should just stick with straight Medicare and a traditional supplement and forget about the home work....but that supplement can sure be pricey and not always a good use of a person's dollars.

Last year I had 2 surgical procedures done and 2 specialist visits...out of pocket 220 for the spinal cord stimulator implant surgery and one specialist visit at 35 bucks....and a different procedure (another RFA) done by a different specialist that only cost me the 35 bucks for the specialist. So total out of pocket expense was 290 for the entire year.
This year....the only real out of pocket expense I have had is the Belsomra prescription and it is $47 because it is SOOOOOO expensive and tier 3 med. Given the cost of that RX without insurance...47 bucks is next to nothing and I only need it refilled maybe twice a year.

Blanket statements that "all Advantage plans are crap and full of ugly surprises" is simply not true and do a disservice to people.

Now since I don't plan on using my insurance to purchase a machine....don't really care if it is 13 month capped rental or perpetual rental....and they can change it each year anyway. Worry about that later if/when I need to cross that bridge.

I pay nothing for my Medicare Advantage plan. I have saved money (lots of money) using advantage plans compared to what a traditional supplement would have cost me over the years.
But then I did my homework and do it every fall when it's open enrollment time.

[ChicagoGranny]

There is homework involved that must be done.

People around me have used local brokers to do most of the homework. They say the results are good with some people being steered to Advantage Plans and others to traditional plans.

We have an Advantage plan. All three area hospital systems and their clinics are in network as are many doctors who are not with the hospitals. We have a good choice of insurance companies and plans.

[Steerpike58]

...

Here's the Evidence of Coverage for Kaiser Senior Advantage in the Northern California Region for 2023 (2024 isn't up yet and may not be until January) :
https://healthy.kaiserpermanente.org/co ... e-ncal.pdf
Page 45 covers Durable Medical Equipment:

In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of our plan, however, you will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan, even if you made up to 12 consecutive payments for the DME item under Original Medicare before you joined our plan.

...

Thanks for the EOC document link - interesting reading . I don't know if I can face working my way through the phone jungle to get back to that DME department - I don't even remember how I reached them now! Ideally I'd like to have them pull up that same document and have them explain how their position jives with that page! (UPDATE - I called the DME department again; on hold for 2.75 hours, then got disconnected ).

So circling back to the 'perpetual rental' issue - can you clarify with sample numbers, just to help me grasp this? Example - let's assume the DME (CPAP) is $1,000 and let's ignore supplies, etc. Insurance has a '20% copay'. So - 20% of $1,000 is $200. How much am I paying per month - $200/12 = $16.67/mo? And I pay that $16.67 per month, in perpetuity, as long as I am in possession of the machine ? So if I hold onto the machine for 5 years, I will have paid $1,000? So I would probably be better served by just getting the prescription from the doctor and finding a CPAP vendor independently - especially since that '$1,000' price is probably discounted by the vendor I choose.