Kaiser insurance coverage

[blancobonzo]

Hey, I recently bought a AirCurve VAuto and seem to be having success with it. However, I wouldn't like to pay for additional xPAP supplies when I need to replace them periodically. I was wondering if anyone was familiar with Kaiser's coverage for CPAP. I had an AHI of around 1.8 on my sleep study if I recall correctly, and a rem AHI of 4.7 or so. I have read that Medicare is outdated in their understanding of AHI and UARS and requires an an AHI >=5 for coverage for a CPAP. I was wondering if Kaiser has a similar problem where my low AHI could be a problem in receiving coverage. Officially I'm waiting for my second polysomnography to see if I have a greater AHI while in REM sleep, as I didn't have any REM sleep during my first PSG, and haven't been treated at all. Does anyone have know anything about Kaiser's CPAP coverage or have any experience with having a AHI<5 at Kaiser? This isn't very urgent but would be helpful to know. Thanks for your help.

[staceyburke]

The greater tha 5 AHI is for Medicare. I would think IF your Dr prescribe it the insurance will pay minus your deductible.

[RayBee]

I have Kaiser, no MediCal or MediCare. I went down the rabbit hole of misinformation for months trying to find out if my ASV would be covered and paid for by Kaiser. Those who should have known the answer did not. I eventually contacted someone (sorry I can't be more specific as it was 3 years ago) who was well versed in the coverage that Kaiser provides for DME, and the answer was... Basically if it originates within the 4 walls of Kaiser, is is covered. If it doesn't, i.e. comes from April, then you are on your own.

Now that is my particular Kaiser plan, but I think this is the case with most or all plans on DME. If I can locate more information of who I contacted I will post later.

As far as consumables, I doubt it. I have been out of pocket for everything PAP related.

[JJJ]

Kaiser has various plans, but they vary on what percentage of the total costs they will pick up, not whether a procedure or therapy is covered. In my area (a city) there are three sleep centers, and at each one there is a physician's assistant in charge. There must be an MD behind the scenes, but I've never met the actual sleep 'doctor.' Then again, the PA who I see can write common prescriptions, and knows his business well. He seems to have some discretion, e.g., I complained that my Dreamstation APAP wouldn't go high enough (he knows I use OSCAR and can adjust things on my own), so he ordered a sleep study. After the study he said that I was on the edge between being able to get by with an APAP or I could use a BiPAP, and he left it up to me to decide. I went for the BiPAP, which cost me an additional co-pay, but I'm glad I did, even if it's now recalled.

Another thing to remember about Kaiser is that it is an HMO, so you get total care more or less under the same umbrella.

In your case I would just make an appointment with your local sleep center. I wouldn't be surprised if you end up getting another sleep study, with a follow-up appointment to discuss the results.

[LindanHotAir]

On the Kaiser Medicare Advantage plan they cover DME and supplies with no copay.

[RayBee]

Just found this on Kaiser's website for Northern California. Their CPAP machine and supplies (DME) coverage varies greatly depending on your plan.

Durable medical equipment in Northern California

Durable Medical Equipment (DME) includes, but is not limited to, canes, crutches, walkers, wheelchairs, hospital beds, nebulizers, oxygen and Positive Airway Pressure Machines (CPAP). DME items are provided when medically indicated for in home use. DME is available to Kaiser Permanente members through third-party suppliers in your region.

You must have a referral from your Kaiser Permanente Physician to obtain Durable Medical Equipment from a supplier on this list. Contact your doctor’s office to request a referral. Once the order has been received, provision of the item will be determined by your Health Plan benefit and clinical criteria. Some health plans may have limited coverage and/or a share of cost for DME items. Please contact your local Member Services for additional information.

Note: Durable Medical Equipment coverage is limited to the standard item of equipment that adequately meets your medical need. Kaiser Permanente will determine whether to rent or purchase the equipment, and select the supplier. For questions about Durable Medical Equipment, please call Member Services at 800-464-4000.

Durable Medical Equipment suppliers in Northern California

The continued availability and/or participation of any Durable Medical Equipment supplier cannot be guaranteed and are subject to change.

Note: These listings are for your information only. A referral from your primary care physician is required to obtain Durable Medical Equipment from a supplier on this list. Please do not contact the suppliers directly.

Ref:
https://healthy.kaiserpermanente.org/nor...-equipment

And a PDF titled:
Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP)

Ref:
https://healthy.kaiserpermanente.org/con...s-ncal.pdf
Search the PDF file for "DME".

I guess I need to get a little older to get on the Senior Advantage Plan.

[pyatrus]

On the Kaiser Medicare Advantage plan they cover DME and supplies with no copay.

One more data point: For Kaiser Senior Advantage, Southern California, there's a 20% co-pay for DME and supplies.

As others have mentioned, there are a lot of different Kaiser Permanente plans, esp. with variations geographically speaking.

[clownbell]

I believe the OPs question was regarding expendable supplies, not the machine itself. So let's look at that question.

I am a Kaiser patient on Senior Advantage, a Medicare Advantage plan whereby Kaiser contacts with Medicare to provide services per Medicare's normal process and subject to certain co-payments. If your machine is prescribed by Kaiser, they will cover the machine and expendable supplies per the Medicare guidelines and subject to a 20% copay just like Medicare typically requires. After you get your sleep study (at home via WatchPat or in lab), Kaiser prescribes and supplies the machine and notifies Apria of what supplies are covered and how often. I received (and presume you will too) a copy of Kaiser's letter to Apria telling them what is covered. When it's time to order, you call Apria (using Kaiser's dedicated line). Apria will supply only what Kaiser has ordered. The replacement schedule is shown at https://thrive.kaiserpermanente.org/care..._Guide.pdf

If Kaiser did NOT prescribe your machine, I think you may be on your own.

Talk to your local Kaiser sleep center.

I have been told that Kaiser functions as their own DME and Apria (or another) is the back room fulfillment center not the DME.

[mbernstone]

Kaiser uses April as the DME provider. The coverage is similar to Medicare.
I only get supplies from April that are partially reimbursed by Medicare.
Others supplies can be found online for less than April pricing

[hegel]

Yep, I/'m on Kaiser senior advantage too, and as stated, I bought an Airsense 10 for 20% from them. I didn't even realize how sweet that deal was until later. Masks and tubes and such are also a 20% co pay. I consider this a very good deal!