Question for Canadians

jabberwock · Post by **jabberwock** » Sat May 12, 2007 12:13 pm

I was appalled to recently find out that my health insurance plan through work covers CPAP and mask only every five years. Obviously, it is totally inadequate for mask replacement.

My disappointment turned to outrage when I realized that my plan does cover up to $500 PER YEAR for Viagra !! It seems to be that coverage should be better for life-saving medical equipment than it is for life-enhancing medications

I will be contacting the plan administrator to let them know what I think about their coverage, but I would like to go in with some ammunition; i.e. examples of what other Canadian medical insurance plans cover with regard to CPAP equipment, maximum $$ entitlement and replacement times.

Please let me know how your coverage compares.

Thanks.

Bonnie

Guest · Post by **Guest** » Sat May 12, 2007 2:20 pm

wow thats amazing cconsidering that for some males, impotence can be a result of OSA, please don't jump on the band wagon everyone, I only said Can be!!!!
once CPAP treatment start, things get better, or maybe it's where they're putting the mask!!!!!!

Elle · Post by **Elle** » Sat May 12, 2007 2:59 pm

My plan (blue cross) will cover whatever my doctor prescribes it will take to keep me compliant with treatment. They expect the machines to last about 5 years however but they will cover masks as often as they are needed. I have been on cpap since last August and have had two masks covered and mask parts...including a part from cpap.com. and filters for the machine. I think you should check the coverage again on the mask replacement. My brother in law is in Ontario and he can get masks whenever he needs them. Good luck.

Elle · Post by **Elle** » Sat May 12, 2007 3:04 pm

I forgot to add the percentage. My coverage is 80% until I have reached a certain yearly used amount (I forget what that is) and then it is 100%. Luckily I was at that amount when I got the machine and first mask so they were covered totally but for the 2nd mask (just recently had) it was only 80%. Masks are way cheaper on cpap.com BTW

Guest · Post by **Guest** » Sat May 12, 2007 8:33 pm

Ohip covers 75% of the cost of a basic system every five years(cpap + hum +hose + basic mask) if you use a adp vendor. The vendor can not charge more than 1040 (or 1080 I don't remember) for the basic system which ohip covers 75%. Private insurance should cover more

jabberwock · Post by **jabberwock** » Sat May 12, 2007 9:37 pm

Thanks to those who have replied. My insurance paid 80% of the amount OHIP did not cover for the initial setup. I just think it's really poor that they do not cover a replacement mask. The next time I am entitled to anything through my private insurance is when I can get a whole new setup when the five year period is up.

I am soooooo writing a long, nasty letter...

rhowald · Post by **rhowald** » Sat May 12, 2007 10:44 pm

Doublecheck that with your provider... Most providers are 5 years for the machines, but 2 masks a year.

Robert

Julie · Post by **Julie** » Sun May 13, 2007 2:20 am

Yes to what Rhowald said - I think you might have misunderstood (or spoken to someone who misunderstood your question). It's 5 yrs for the machine, but twice a year for masks.

jabberwock · Post by **jabberwock** » Sun May 13, 2007 8:24 am

Rhowald and Julie, do you mind me asking who your insurance providers are? I will call mine again tomorrow, since I know that you can sometimes get different answers to the same questions.

Bonnie

Doodeedoo · Post by **Doodeedoo** » Sun May 13, 2007 9:25 am

My insurance (through work) covers a machine every 5 years and no limit in the number of masks (as frequent as necessary). The coverage is for "reasonable cost" and so far has been 100%.

jvoisin · Post by **jvoisin** » Sun May 13, 2007 10:20 am

I have insurance through sunlife and this is what they told me via email.. I think they are pretty standard..

Under the terms of your contract, the purchase of a CPAP machine, a compressor unit that blows air into collapsed airway passages to aid patients while they sleep, is eligible at 100% and is subject or considered up to the Reasonable and Customary cost which is $2,000.00. A CPAP machine is eligible once per 5 years per individual. A note or letter of recommendation from the claimant's doctor indicating the level of sleep apnea (i.e. mild, moderate, severe, etc.) is required. There is no deductible applicable.

If the CPAP is approved by a provincial plan, we will pick up the balance and above information will not be requested.

We will review if sleep apnea is moderate to severe. We will not consider for mild sleep apnea, or for snoring.

The following supplies are eligible and included in the Reasonable and Customary for the initial purchase/rental:

- Battery
- Filter
- Humidifier
- Mask
- Mouthpiece
- Nasal seal kit
- Tubing OR headgear OR chin strap
- 12 VDC adapter

The following supplies are eligible for replacement at 100%:

- Filter (once every 12 months)
- Humidifier (as needed)
- Mask (once every 12 months)
- Nasal pillow --- examples of brand names: Mirage Activa Cushion (once every 12 months)
- Mouthpiece (once every 12 months)
- Tubing/headgear/chin strap (once every 12 months)
- Gel cushion for mask (once every 12 months)

The Reasonable and Customary cost for the mask is $400.00.

The following item are ineligible and will not be considered by the provincial plan, or Sun Life Financial:

- Extended warranty
- Yearly pressure checks
- Calibrations or pressure adjustments
- Patient instruction manual
- Battery cable adaptor
- Battery case
- Battery charger

If the provincial plan such as ADP paid a portion, the statement from ADP is required and in this case a doctor’s prescription is not required. If not, we need a letter of recommendation from the claimant's doctor, before we can consider this expense.

Sudsy · Post by **Sudsy** » Sun May 13, 2007 10:46 am

Hello

I live in Manitoba and right now Manitoba health pays for everything.

They allow 2 masks and headgear and tubing every six months. I do not know how often they change out cpap machines

sudsy

jabberwock · Post by **jabberwock** » Sun May 13, 2007 12:33 pm

Thanks to everyone who replied. Your responses will be very helpful to me in trying to convince my employer that their health coverage is way out of sync with the majority of health plans in Canada.

Bonnie

Elle · Post by **Elle** » Sun May 13, 2007 12:41 pm

Most of the insurers have websites. If you check there you might get more accurate info. I have called my insurer and got different answers depending on who I talk to.

cpapernewbie · Post by **cpapernewbie** » Sun May 13, 2007 1:12 pm

[quote="Sudsy"]Hello

I live in Manitoba and right now Manitoba health pays for everything.

They allow 2 masks and headgear and tubing every six months. I do not know how often they change out cpap machines

sudsy

Mask

Additional Comments: Pressure: 8

Mask

Additional Comments: Pressure: 8

Mask

Additional Comments: Pressure: 8

Mask

Additional Comments: Pressure: 8