HELP MY INSURANCE WONT COVER MY MASK

hello everyone I just found out like 2 days ago that my bi-pap provider is sending me a whole different mask because my insurance wont cover it any longer I am currently using the air touch f20 full face mask and my insurance will only pay for the comfort gel full face mask. i have talked to my Dr about this. and they tell me and insurance will NOT cover the f20 full face mask because they have made cuts to the number of masks they will cover, they will cover 3 types of masks a nasal mask, a full face, mask and Nasal pillows. I really like the f20 because it has the memory foam around the mask cushion. the problem I have with the comfort gel is that it irritates my skin around my nose and mouth. I am thinking about having my Dr write a letter. to the insurance company explaining my situation. I highly Doubt that it will make a difference. but its worth a shot. do you folks have any other advice for me thanks. much appreciated also J&L medical is my provider for cpap supplies. they told me today that they are keeping their current medicaid customers BUT they are not taking any new customers who have medicaid for insurance. the whole thing is a bunch of bull shit because i need the current mask that I am using no ifs ands or buts

Have you got the denial straight from the insurance company's mouth or is this all third party?
Call up your insurance company and ask them if they pay by brand and model.
Most don't.
They pay by HCPCS billing code only.
And they pay the same for all full face masks no matter which brand and guess what...the mask they want to give you is one of the cheapest in terms of wholesale cost especially when compared to ResMed.

cpap.com sells the comfort gel for $75 and we all know they are making money on it.
https://www.cpap.com/productpage/pr-com ... -mask.html

ResMed masks cost more at the wholesale level...guess which one they make the most profit on when insurance pays the same no matter which brand?

It looks like that mask goes for somewhere around $150.

The question you have to ask is what is your time worth trying to figure out a way around this inconvenience. If it is going to take hours and hours it may be better to just bite the bullet and purchase one on your own.

I have looked at amazon .com for the mask parts and I can basically get a whole new mask for $142.50 cents thats way cheaper then buying from cpap.com or another cpap supplier of course I would only get a new mask like every six months because when my insurance was paying for it I was getting it every 3 months

Your provider is giving you a line of BS. The F20 is available, they just don't want to give it to you because they make little or no profit on it. I would check with your insurance to find out what other DMEs are in your network.

I use J&L medical services they serve all of Connecticut and they also told me that medicaid dropped them or vise versa

This sounds like another DME deciding only to sell the lower wholesale cost equipment and blaming it on the insurance because of profit margin.
Irritates the hell out of me. They should be at least honest about the whole deal.

If it was me...I would take my business elsewhere and go find a DME that accepts my insurance and will be happy to supply what I wanted. I wouldn't buy so much as a filter from some place like that.

When you call up your insurance company to ask them....also get a list of other DMEs they work with.
You can change suppliers if you wish.

Good idea to have your doctor write an order for the mask you want as a medical necessity for your particular circumstances. In addition, follow the previous suggestions about calling your insurance company for first hand information.

If Medicaid is your insurance they MAY have a limited formulary if masks. But I still would not believe it if your DME or doctor tell you this. Your DME often lies and your doctor is clueless (not dissing doctors. DME coverage issues are way out of their wheelhouse). So you need to see in black and white what Medicaid in your state covers.

Google “[your state] CPAP mask reimbursement”. You should dig up some written policy for CPAP mask coverage. If you can’t find anything, ask the DME to SHOW you the policy or formulary list from your state’s DME in writing. Otherwise file a written complaint against your DME for failure to follow the doctor’s written order.

The $142 is about normal for any mask. Some are more.... some are less.... do what Pugs said, try and fins another DME.

Sheriff

Medicaid opens up a whole new can of worms.
And it's a different can with each state. Each state does their own thing for what and how and how much it pays for something.
Usually a lot less than normal insurance or even medicare. All depends on the state.

Since it is usually a lot less that's why people who have state medicaid have trouble finding doctors willing to accept less and DMEs willing to accept less as full payment for goods and services.

It won't be as easy to find another supplier who is happy to accept the amounts that medicaid will pay for goods and services.
I didn't know about the insurance being medicaid when I said "find another supplier". I would still say try to find another one but knowing it won't be easy and there probably won't be many to choose from.

I agree with what Janknitz said to do. First find out for sure if it is medicaid or the DME blaming insurance for their own choice.
It wouldn't be impossible for medicaid to say "we will pay $80 for any cpap full face mask" and that $80 be less than what the DME might pay for a mask and then be unwilling to lose money on the deal. The numbers just an example...I have no idea what the medicaid payment schedule might be or wholesale costs of these masks.

I took Janknitz suggestion and looked up my state Medicaid reimbursement rates and found this statement. Per Budget Reduction - Effective 7/1/2015 C-PAPs are no longer covered for ages 21 and older. Not sure if this has changed since then but for sure each state has to deal with their own Medicaid issues in their own way.

To the OP, I would look for other mask options. The Memory Foam cushion doesn't last as long as some of the silicone ones and because of that is more expensive. If you like the F20 you might look at the one with the silicone cushion and see if they would switch to that one.