Medicare reimbursement for direct purchase of CPAP

I am a newbie and found it daunting to find a post or response sting for my question. I have a 15 year old CPAP that I acquired after a sleep study in 1999. Now on Medicare which started in October 2016. Wish to purchase a new CPAP (ResMed AirSense™ 10 AutoSet™ with HumidAir) from a web provider direct. Have a prescription, issued in June 2016 from my doctor who oversaw the original sleep study, that states what I need for a replacement and the AirSense unit fulfills that. Reviewed what Medicare covers in Plan B and it states they MAY cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements. It appears I have to rent the device for 13 months from a DME supplier enrolled in Medicare.

Does anyone know if Medicare will reimburse you, 80/20, for a new CPAP device purchased outright from a supplier? Why is this process so difficult? I don't want to rent a device for 13 months, there is no logical reason to do that.

Please advise

When you rent the device under Medicare it's 80/20 for the rental...It may cost you $10-$15 monthly for 13 months...Then you own the machine. The humidifier is a one time charge 80/20 on the first month.

Medicare knows that over 50% of users drop out, so by renting it if you do not used it (fail with compliance) they then stop paying for it and you have to return it to your DME.

After 13 months of compliance you then own it.

Rich

NHGranite wrote:I am a newbie and found it daunting to find a post or response sting for my question. I have a 15 year old CPAP that I acquired after a sleep study in 1999. Now on Medicare which started in October 2016. Wish to purchase a new CPAP (ResMed AirSense™ 10 AutoSet™ with HumidAir) from a web provider direct. Have a prescription, issued in June 2016 from my doctor who oversaw the original sleep study, that states what I need for a replacement and the AirSense unit fulfills that. Reviewed what Medicare covers in Plan B and it states they MAY cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements. It appears I have to rent the device for 13 months from a DME supplier enrolled in Medicare.

Does anyone know if Medicare will reimburse you, 80/20, for a new CPAP device purchased outright from a supplier? Why is this process so difficult? I don't want to rent a device for 13 months, there is no logical reason to do that.

Please advise

Medicare has specific rules they require prior to reimbursement.
Do not purchase a device expecting reimbursement without prior approval.

You need to choose an online supplier that is Medicare approved for your geographic area.
Versus is one online supplier that you might be able to use.
Call them. They will tell you what they need in order to seek authorization for you through Medicare.

1-800-936-9648

versus healthcare

Medicare rules are difficult.
Versus follows Medicare rules.
,
"Requirements" In addition to a prescription may include things like a copy of your sleep study, and a medical record showing you continue to use Cpap with good response dated after becoming a Medicare beneficiary and within 6 months prior to the replacement request. I do not believe you are required to rent the device if you meet their specific "requirements".

NH Granite was mostly correct, but not this:

I do not believe you are required to rent the device if you meet their specific "requirements".

Under Medicare there is no outright purchase. They pay for a capped rental only. 13 months and then the machine is yours, the humidifier is an outright purchase. No such thing as buying a machine outright for you.

So you have several hoops to jump through:
1. Get a copy of your sleep study (you may need a new one)
2. Choose the machine and mask YOU want and ask the doctor to specify the exact machine you want on the prescription. If you don't do this, you will be stuck with a brick--a cheap machine that doesn't have efficacy data. Read "What you need to know before you meet your DME" in my blog below so you will be forewarned--machines listed are out of date, though).
3. Get a copy of the prescription.
4. Check with your supplemental insurer whether they have a list of in network providers and whether they will let you go with an online Medicare approved supplier.
5. Find a list of Medicare Approved online suppliers and also Medicare and Supplemental approved local providers (it's going to be the same cost-wise as Medicare fixes the cost).
6. Determine which one will give you the machine you want and the least hassle.

Before you even get to the point of trying to get a machine, make sure you have a face to face meeting documented with your doctor where sleep apnea was discussed before your first sleep study. When I started trying to get my machine, I ran into a problem where my sleep doctor at that time did not document a face to face meeting where we discussed sleep apnea. The meeting occurred between my initial sleep study and my titration study. The DME could not issue a machine to me since the initial meeting was not documented in the right order. I ended up going to a different sleep specialist who documented things correctly, and after repeating my sleep and titration studies, I was finally able to get a machine and start treatment.

Does anyone know if Medicare requires a new Sleep Study after 5 years to get a new machine. And do you have to fail APAP/CPAP to get a bi-level even if your current Rx is for a i-Level?

Janknitz wrote:NH Granite was mostly correct, but not this:

I do not believe you are required to rent the device if you meet their specific "requirements".

Under Medicare there is no outright purchase. They pay for a capped rental only. 13 months and then the machine is yours, the humidifier is an outright purchase. No such thing as buying a machine outright for you.

So you have several hoops to jump through:
1. Get a copy of your sleep study (you may need a new one)
2. Choose the machine and mask YOU want and ask the doctor to specify the exact machine you want on the prescription. If you don't do this, you will be stuck with a brick--a cheap machine that doesn't have efficacy data. Read "What you need to know before you meet your DME" in my blog below so you will be forewarned--machines listed are out of date, though).
3. Get a copy of the prescription.
4. Check with your supplemental insurer whether they have a list of in network providers and whether they will let you go with an online Medicare approved supplier.
5. Find a list of Medicare Approved online suppliers and also Medicare and Supplemental approved local providers (it's going to be the same cost-wise as Medicare fixes the cost).
6. Determine which one will give you the machine you want and the least hassle.

The current Medicare.gov site states: "If you had a CPAP machine before you got Medicare. Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements." Am I misinterpreting this statement or reading more into it than is there????
If so, I apologize for the confusion.

Thank you all for the information. The DME supplier who sold me my first CPAP in 1999 outlined what he requires to make a deal for a new one.

• Have copy of prescription from doctor, which I have from a reevaluation of my condition in June 2015.

• Since that prescription is over 6 months old I also need record of a new face to face meeting with my doctor to confirm I am using a CPAP and that it is a benefit to my health.

• The DME supplier can then give me quote, which he has.

• Told me the humidifier has to be purchased up front and will be reimbursed

• If I add up the numbers and factor in my deductible for next year has to be applied then I am ahead by $400.00 by benefiting with the Medicare 80/20 reimbursement versus buying the device direct. That's good for six nights out to dinner with one glass of wine and a mini desert!!!!!!!!!!!!

Thank you for all your collective help. As Arnold says, "I'll be back".

My PCP submitted Script, (w/my 2003 sleep study), for New APAP to my insurance. I received a letter saying I was approved. Letter was from Apria, stating no co-pay. A month latter I get a bill from Apria for $1700. I called my insurance, they said the bill hadn't been presented to them for payment. So, I jumps on my mobility scooter and grabs a bus to get to Apria. Showed them the letter they had sent me, and letting them know what the insurance company had told me. Counter clerk at Apria made copies of letter, insurance card, Drivers License. Submitted the claim to my insurance company. Going on two months now, I haven't heard a word. Can't believe I'm getting a new machine in a new insurance year, (deduct not met), without having to pay something for it.

Cheers,
otrpu

Any time I suspect an error has been in my favor, my decision to mention it to them
is governed by their own honesty in past dealings. Most of the time, I do the right thing,
but with some shady outfits, ummm, I tend to "not trust my own math."

chunkyfrog wrote:"not trust my own math."

*looks over your shoulder* "Are you sure you should carry the 2 right there?" *points*

The current Medicare.gov site states: "If you had a CPAP machine before you got Medicare. Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements." Am I misinterpreting this statement or reading more into it than is there????
If so, I apologize for the confusion.

No need to apologize, but no, they are not going to purchase outright. They will either complete the rental of an existing machine or start over with a new one on capped rental.